Survey or show trial?Reporters routinely troll The New England Journal of Medicine for what may be newsworthy in medical science. The Journal's April 26 issue contained research results concerning treatments for bipolar mental illness, dangerous cardiac side effects of widely used anti-AIDS drugs and novel insights into the mechanisms of a rare genetic disease.
Allegations that industry-physician ties corrupt medical practice may make headlines, but evidence is lacking
Thomas P. Stossel, M.D., Thomas S. Huddle, M.D., Ph.D.
Medical Progress Today
May 18, 2007
However, the media ignored these medically substantive stories to focus instead on "A national survey of physician–industry relationships." According to this survey, 94% of physicians have financial interactions with drug and device companies. The vast majority of these relationships involve accepting meals, product samples or small gifts from company salespersons, although some doctors also receive corporate research grants, consulting or speaking fees or subsidies for participation in professional meetings.
That this descriptive article with no obvious conclusions warranted precious space in a prestigious medical periodical and its hyping by the news media reflect how a prevalent and highly marketable obsession with money in medicine diverts attention from real medical science.
The promoters of this prurient interest are alarmists who argue that when physicians work with industry to develop medical products or when industry markets those products to physicians, the interactions are so likely to be corrupt or potentially corrupt that they deserve opprobrium, heavy regulation or complete prohibition. The code words for this corruption are "conflicts of interest."
Physicians and medical scientists with such conflicts allegedly consciously or unconsciously ignore or distort scientific evidence to stealth market inappropriate products to practicing physicians, and the corporate encumbrance of physicians endangers "evidence–based medicine." The authors of the national survey are of this persuasion, being on record for recommending the strict curtailment of medical product marketing to physicians and the collectivization of industry sponsorship of medical research and education in academic health centers.
Serious scholarship evaluating physician–industry relationships is desirable, as is vigorous prosecution of statutory violations, such as kickbacks or making marketing claims unapproved by the FDA. However, no rigorous evidence and certainly not this survey support the allegations or onerous new regulatory recommendations.
Nevertheless, the survey's authors and New England Journal colluded in biased stealth marketing of their own, pandering to the public's preference for juicy crime and corruption stories over drier and more difficult science. Advance, pre–publication content provided by The New England Journal to the media, embellished by reporters' interviews with the study's authors, conveyed that the study actually justified a case for severer regulation of doctors’ industry associations. One author, for example, compared such associations to baseball umpires getting free meals from team owners. To help readers interpret their survey, its authors referenced 25 articles, books and news reports that overwhelmingly emphasized the risks rather than the benefits of commercial contributions to medicine. Good scientific practice mandates that researchers reference articles on both sides of controversial issues. The failure to adhere to such practice, thereby imparting a distorted picture dismissive of the positive effects of companies on medicine, is a clear manifestation of bias. That The New England Journal’s editors failed to enforce balance suggests that they share the authors' views.
So what should we conclude from this survey? If, as the survey's authors imply, physicians' commercial involvements lead to inferior medical care, can we trust only 6% of the physician workforce to act in our best interests? On the other hand, perhaps the survey reports good news: we are within 6% of having every physician working with companies.
That steady advances in the quality of medical care have principally arisen from medical products contributed by private industry is an incontrovertible fact. The increasing involvement of physicians and medical researchers in medical product development is an adaptation to opportunities to address unmet medical needs.
Medical product marketing, like most activities, has harms and benefits in different circumstances; but on balance it affords the likely benefit that marketing these products to physicians gets them to the patients who need them. These realities are blatantly incompatible with the fantasy of critics that the intrusions of commerce into medicine must inevitably be an evil conspiracy.
No useful medical products arise from the media, from advocacy organizations or from medical journals. Activists and journalists, including editors of high–profile journals, are not promoting morality in the face of greed. Rather they are marketing their own product, sensationalism, in the face of reality.
Thomas P. Stossel, M.D., was educated at Princeton University and Harvard Medical School, trained in internal medicine at the Massachusetts General Hospital and in hematology at Boston Children's and Peter Bent Brigham Hospitals. He was head of Hematology and Oncology at Massachusetts General Hospital from 1976 until 1991, Co-Director of the Hematology Division at Brigham & Women's Hospital through 2006, and is currently Director of a new Division of Translational Medicine. He was President of the American Society for Clinical Investigation and Editor in Chief of its Journal of Clinical Investigation. He served as President of the American Society of Hematology and received its Dameshek and Thomas Awards. He is a member of The National Academy of Sciences, The American Academy of Arts and Sciences, and the Institute of Medicine. His policy interests concern physician and researcher interactions with private industry.
Thomas S. Huddle, M.D., Ph.D. is Associate Professor of Medicine in the University of Alabama at Birmingham (UAB) Division of General Internal Medicine. Dr. Huddle completed an M.D.–Ph.D. program at the University of Illinois College of Medicine at Urbana-Champaign, with a Ph.D. in the History of Medicine. He went on to complete internal medicine residency training at the University of Wisconsin Hospitals and Clinics in Madison, WI. After residency he completed a Robert Wood Johnson fellowship in general internal medicine with a focus on the history of medicine at the University of Pennsylvania before joining the faculty at UAB. Dr. Huddle presently combines internal medicine practice with teaching medicine to residents and medical students. His written work has ranged from the history of medical education to medical professionalism and the nature of medical knowledge and competence.