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Offline: The BMJ vs NEJM—lessons for us all
Comment
Offline: The BMJ vs NEJM—lessons for us all
Jerry Kassiner
BMJ
The Sydney Morning Herald/Getty Images
It’s hard to recall now, but there was a time in medicine’s recent past when interactions between physicians and the pharmaceutical industry were seen as positively virtuous. During medical school (a long time ago, 1980–86, at the University of Birmingham), most of our general medicine teaching was organised by the Department of Pharmacology and Therapeutics, led by the inspirational Martin Kendall. In weekly “roadshows”, 180 students would discuss clinical scenarios from a pharmacological perspective. Martin Kendall would lead the class through vignettes of patient management. He would do so by testing the students on stage, a ritual we all endured and enjoyed in equal part. An appreciation of, and respect for, the contribution of the pharmaceutical industry to clinical medicine was embedded in our training, and I think most of us felt better prepared for the practical aspects of subsequent ward work as a result. This mutuality extended to research. In 1985, I spent 3 months working at the Astra Laboratories in Mölndal, near Gothenburg, Sweden. At that time, the great Swedish cardiovascular physiologist, Björn Folkow, was at the University of Gothenburg. It was accepted (and encouraged) that senior faculty in Folkow’s department, together with post-docs and PhD students, would move seamlessly between university and industry. This symbiosis is hard to comprehend today. The conflict between those who see industry as an enemy to the values of medicine and those who see great possibilities from collaboration is exemplified by the recent argument between two great general medical journals, The New England Journal of Medicine and The BMJ. *
Marcia Angell
Writing in The BMJ this week, two former Editors-inChief of the NEJM, Jerry Kassirer and Marcia Angell, call three recent NEJM articles (by the journal’s national correspondent, Lisa Rosenbaum) and an editorial (by the journal’s current Editor-in-Chief, Jeff Drazen), “A seriously flawed and inflammatory attack” on financial, largely pharmaceutical and device manufacturer, conflicts of interest. “We find it sad”, they write, “that the medical journal that first called attention to the problem of financial conflicts of interest among physicians would now backtrack so dramatically, and indulge in ad hominem attacks on those who disagree”. They accuse the NEJM of downplaying the importance of conflicts of interest in 2238
medicine. They allege the journal has “little understanding of the meaning of the term”. They call Lisa Rosenbaum’s three essays “rambling”, “fanciful”, and “data-free”. They also attack Drazen, their successor, for weakening the NEJM’s conflict of interest policy. In an accompanying editorial, the BMJ’s Editor-in-Chief, Fiona Godlee, together with the journal’s heads of research and education, notes that they are “deeply troubled” by Drazen’s “possible retreat from policies that prevent experts with relevant commercial ties from authoring commentary or review articles”. “We don’t find much to agree with in NEJM’s anecdotal analysis…It is a mistake by NEJM to suggest that rigorous standards should be revisited.” There have been few such sharp rebukes by one journal editor against another. What led to this surprising assault? * Lisa Rosenbaum posed a series of questions that have upset those who believe in the inimical influence of industry in medicine. For example, Rosenbaum asked whether it was reasonable to conclude that a physician with industry ties is motivated by a desire for financial gain? To what extent are reactions to industry influenced by reason or emotion? Why do we not take non-financial conflicts as seriously as financial entanglements? What unanticipated negative consequences might accrue from a hunt for wrongdoing? Why are the benefits of industry–academic collaborations persistently ignored? It would seem within the spirit of scientific inquiry to pose questions that challenge received orthodoxies. Rosenbaum accepts that gifts to doctors can have unacceptable influence. She agrees that past wrongdoings should not be excused. She believes that oversight of industry should not be eliminated. And she discusses evidence that industry-sponsored studies are more likely to be positive. Therefore, I don’t agree with the NEJM’s critics that the Rosenbaum papers represent a reversal of policy by the NEJM. But while I don’t agree with these critics, I do think that the BMJ’s analysis should be welcomed. A clear division of opinion in this argument helpfully clarifies both positions. The truth is likely to lie somewhere between these extremes. It’s time we found it. Richard Horton [email protected]
www.thelancet.com Vol 385 June 6, 2015
Offline: The BMJ vs NEJM—lessons for us all
Jerry Kassiner
BMJ
The Sydney Morning Herald/Getty Images
It’s hard to recall now, but there was a time in medicine’s recent past when interactions between physicians and the pharmaceutical industry were seen as positively virtuous. During medical school (a long time ago, 1980–86, at the University of Birmingham), most of our general medicine teaching was organised by the Department of Pharmacology and Therapeutics, led by the inspirational Martin Kendall. In weekly “roadshows”, 180 students would discuss clinical scenarios from a pharmacological perspective. Martin Kendall would lead the class through vignettes of patient management. He would do so by testing the students on stage, a ritual we all endured and enjoyed in equal part. An appreciation of, and respect for, the contribution of the pharmaceutical industry to clinical medicine was embedded in our training, and I think most of us felt better prepared for the practical aspects of subsequent ward work as a result. This mutuality extended to research. In 1985, I spent 3 months working at the Astra Laboratories in Mölndal, near Gothenburg, Sweden. At that time, the great Swedish cardiovascular physiologist, Björn Folkow, was at the University of Gothenburg. It was accepted (and encouraged) that senior faculty in Folkow’s department, together with post-docs and PhD students, would move seamlessly between university and industry. This symbiosis is hard to comprehend today. The conflict between those who see industry as an enemy to the values of medicine and those who see great possibilities from collaboration is exemplified by the recent argument between two great general medical journals, The New England Journal of Medicine and The BMJ. *
Marcia Angell
Writing in The BMJ this week, two former Editors-inChief of the NEJM, Jerry Kassirer and Marcia Angell, call three recent NEJM articles (by the journal’s national correspondent, Lisa Rosenbaum) and an editorial (by the journal’s current Editor-in-Chief, Jeff Drazen), “A seriously flawed and inflammatory attack” on financial, largely pharmaceutical and device manufacturer, conflicts of interest. “We find it sad”, they write, “that the medical journal that first called attention to the problem of financial conflicts of interest among physicians would now backtrack so dramatically, and indulge in ad hominem attacks on those who disagree”. They accuse the NEJM of downplaying the importance of conflicts of interest in 2238
medicine. They allege the journal has “little understanding of the meaning of the term”. They call Lisa Rosenbaum’s three essays “rambling”, “fanciful”, and “data-free”. They also attack Drazen, their successor, for weakening the NEJM’s conflict of interest policy. In an accompanying editorial, the BMJ’s Editor-in-Chief, Fiona Godlee, together with the journal’s heads of research and education, notes that they are “deeply troubled” by Drazen’s “possible retreat from policies that prevent experts with relevant commercial ties from authoring commentary or review articles”. “We don’t find much to agree with in NEJM’s anecdotal analysis…It is a mistake by NEJM to suggest that rigorous standards should be revisited.” There have been few such sharp rebukes by one journal editor against another. What led to this surprising assault? * Lisa Rosenbaum posed a series of questions that have upset those who believe in the inimical influence of industry in medicine. For example, Rosenbaum asked whether it was reasonable to conclude that a physician with industry ties is motivated by a desire for financial gain? To what extent are reactions to industry influenced by reason or emotion? Why do we not take non-financial conflicts as seriously as financial entanglements? What unanticipated negative consequences might accrue from a hunt for wrongdoing? Why are the benefits of industry–academic collaborations persistently ignored? It would seem within the spirit of scientific inquiry to pose questions that challenge received orthodoxies. Rosenbaum accepts that gifts to doctors can have unacceptable influence. She agrees that past wrongdoings should not be excused. She believes that oversight of industry should not be eliminated. And she discusses evidence that industry-sponsored studies are more likely to be positive. Therefore, I don’t agree with the NEJM’s critics that the Rosenbaum papers represent a reversal of policy by the NEJM. But while I don’t agree with these critics, I do think that the BMJ’s analysis should be welcomed. A clear division of opinion in this argument helpfully clarifies both positions. The truth is likely to lie somewhere between these extremes. It’s time we found it. Richard Horton [email protected]
www.thelancet.com Vol 385 June 6, 2015