Elite medical journals bash industry, offer little evidence to support favored policy recommendations.

I've been meaning to write about a recent letter - really a full blown article - published in Nature Biotechnology that examines the quality of the evidence - or rather dearth of it - in articles published in major medical journals that detail the supposed ills of industry engagement with physicians and academic medical centers and call for more stringent conflict of interest regulation at public and private institutions.

In their letter, Lesko, Scott, and Stossel point out that while extensive interaction between academic medical centers, physicians, and pharmaceutical and medical device companies has undoubtedly accelerated innovation and provided enormous benefits to patients, this has not prevented growing concerns about and criticism of such interactions. The ostensible concern is that:

...such relationships may degrade the performance and reporting of biomedical research and also induce physicians to behave in a manner inconsistent with cost-effective or ethical patient care--which are loosely defined under the operational term 'financial conflicts of interest' (COIs).

This is a legitimate concern, at least on its face. But it should be a testable hypothesis. So where is the evidence that such interactions result in actual harm - as opposed to theoretical harm?

The authors survey four major medical journals to assess "whether the positive and negative aspects of industry academic relationships were equally represented in top-tier medical journals but also to assess the weight of evidence in the COI literature that patient outcomes or public attitudes are indeed negatively affected by corporate interactions with academics and physicians."

This is certainly a fair question for medical journals that tout their professionalism and adherence to objective science. Still, Lesko et al found that out of 108 articles selected for analysis, nearly 90% "unambiguously emphasized" the risks of industry relationships (often in their titles: "Just how tainted has medicine become?") while presenting little quantitative evidence of such risks and downplaying potential benefits while calling for increased regulation of industry.

Here's the nut graph:

...it is clear that the preponderance of articles published in the four highest-impact medical journals that publish primary research focused on problems concerning COI relationships. These articles differed qualitatively from benefit-emphasizing academic-industry relationship papers. Most risk-emphasizing articles presented no evidence and many of the ones that did present evidence extrapolated that it had a bearing on patient outcomes or public attitudes.

The problem is that only presenting one side of an argument, often with little supporting evidence and without giving equal weight to opposing viewpoints, leads to a "conformity cascade" that shapes public policies that restrict industry interaction with the medical community to the point that innovation - and therefore patient health - may be affected.

In other words, it's like presenting a drug label that has 98 words about risk in bold print, and two words about benefits in small print. In that case, the patient is likely to avoid any treatment at all.

Ironically, the caricaturing of industry is likely to lead to the very jaundiced view of medical professionals and medicine that COI proponents say they want to prevent - since everyone has some conflict of interest (whether for tenure, publication, or in competition for grants or hawking their latest industry-bashing book), then no one can be trusted at all.

For a longer discussion of the growing thicket of COI regulations, and some practical solutions for managing conflicts that doesn't throw out the baby with the bathwater, see this Project FDA Report How Conflict-of-Interest Rules Endanger Medical Progress and Cures by Richard Epstein.

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