Critical Responses Mount As Influential Medical Journal Downplays Conflicts of Interest

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The New England Journal of Medicine has generated controversy by publishing a three-part article and editorial suggesting that concerns about conflicts of interest in medicine and psychiatry are overblown. “Have stories about industry greed so permeated our collective consciousness that we have forgotten that industry and physicians often share a mission — to fight disease?” writes Lisa Rosenbaum in the NEJM.

“Having received industry money, the argument goes, even an acknowledged world expert can no longer provide untainted advice,” writes Jeffrey Drazen in the NEJM. “But is this divide between academic researchers and industry in our best interest? I think not — and I am not alone.”

Highly critical responses came from HeathNewsReview.org, Health Care Renewal, Forbes and others.

“Is Dr. Rosenbaum’s consciousness so clouded as to think that pharmaceutical companies don’t exist first and foremost to make money? That their primary responsibility is not to their shareholders?” responds Susan Molchan in HealthNewsReview.org. “It’s true that a means to this end is fighting disease, (including new ‘diseases,’ tailored to one’s drug), but this should not be confused or conflated with the primary mission of (hopefully most) physicians.”

In response to Drazen, Molchan links to a 2006 Wall Street Journal article about the tens of thousands of people estimated to have died from the now-withdrawn anti-inflammatory drug Vioxx. Molchan writes that “data concerning the number of heart attacks while on Vioxx in a pivotal study had been withheld by Merck, and the NEJM were aware that these data were missing from the submitted manuscript. Editors had also rejected letters pointing out the problem (Dr. Drazen was editor at the time).”

In Forbes, Larry Husten writes, “To use a highly imperfect analogy, Rosenbaum’s focus on the imperfections of industry critics without fully appreciating the full magnitude of industry influence is akin to focusing on the imperfections of the extreme anti-slavery abolitionists in the 19th century while ignoring the overwhelming tragedy of slavery.”

“It was more surprising, given the reach of this journal, that these articles featured a catalog of logical fallacies in support of their arguments,” states a post on Health Care Renewal. The post goes on to examine the alleged logical fallacies in detail, including, “Appeal to Authority: Important People and Organizations Agree with Us” and “Ad Hominem Fallacy: People who Advocate Increased Disclosure, Regulation, or Restriction of COIs are ‘Pharmascolds’,” and “Burden of Proof Fallacy: That All Physician-Industry Collaborations are Beneficial is Assumed, but Contentions that Financial Conflicts of Interest Affecting Physicians Must be Disclosed, Regulated or Banned Require Rigorous Proof.”

Drazen, Jeffrey M. “Revisiting the Commercial–Academic Interface.” New England Journal of Medicine 372, no. 19 (May 7, 2015): 1853–54. doi:10.1056/NEJMe1503623. (Full text)

Rosenbaum, Lisa. “Reconnecting the Dots — Reinterpreting Industry–Physician Relations.” New England Journal of Medicine 372, no. 19 (May 7, 2015): 1860–64. doi:10.1056/NEJMms1502493. (Full text – Part one)

Rosenbaum, Lisa. “Understanding Bias — The Case for Careful Study.” New England Journal of Medicine 372, no. 20 (May 14, 2015): 1959–63. doi:10.1056/NEJMms1502497. (Full text – Part two)

Rosenbaum, Lisa. “Beyond Moral Outrage — Weighing the Trade-Offs of COI Regulation.” New England Journal of Medicine 372, no. 21 (May 21, 2015): 2064–68. doi:10.1056/NEJMms1502498. (Full text – Part three)

Say It Ain’t So: Logical Fallacies in Defense of Conflicts of Interest … in the New England Journal of Medicine? (Health Care Renewal, May 21, 2015)

No, Pharmascolds Are Not Worse Than The Pervasive Conflicts Of Interest They Criticize (Forbes, May 21, 2015)

Criticism of NEJM’s defense of industry-physician relations (HealthNewsReview.org, May 14, 2015)

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2 COMMENTS

  1. “Have stories about industry greed so permeated our collective consciousness that we have forgotten that industry and physicians often share a mission — to fight disease?”

    How delusional do you have to be to believe that industry has a mission to fight disease? Industry has a mission to make ever more money – that’s its whole purpose. Stupid or evil – that’s the real question.

  2. Below are some of the comments I submitted at a conference on policing and racism last week. I see a good amount of overlap, even if some will prefer not to.
    My first arrest, in Los Angeles County, was nearly 30 years ago. The treatment I received, both at the time of the arrest, and in subsequent days resulted in my receiving a diagnosis of PTSD. I was collateral damage on the war on drugs. I went from working for a small computer company, with plans to start my own company, to being arrested several more time, becoming homeless and spending some time in various mental hospitals. I had approached police officers for help due to a medical condition, they mistook my medical condition for illegal drug use.
    The attorneys I encountered – both public defenders and those in private practice, seemed to be more interested in covering up the abuses I endured than arriving at the truth. The political leadership I was able to access – well, perhaps I can best categorize it as callously indifferent.
    Trauma is the first issue I wish to address. One of the effects of trauma is an unconscious desire to repeat the circumstances of the original trauma in an effort to achieve a better outcome. During the meetings of the Behavioral Health Commission which Gov. Sandoval set up last year, I gave testimony to this, as well as the sources. The commission seemed genuinely interested. Trauma can result in shrinkage of the hippocampus which is adjacent to the amygdala, and can be considered the emotional center of the brain. This shrinkage affects the communication between areas of the brain and is responsible for heightened fear and anger responses. (1)
    “Many mental health programs are not staffed with physicians practiced in medical diagnosis and thus are unprepared to detect a large proportion of physical diseases in their patients…California’s state mental health programs fail to detect many diseases that could be causing or exacerbating psychiatric disorders” (2)
    In 1995 a study found that from 5–40% of psychiatric patients have medical ailments that would adequately explain their symptoms. (3) The next year, in 1996, Sydney Walker III, M.D., a psychiatrist, in his book, A Dose of Sanity, claimed studies have shown that from 41% to 75% of individuals are initially misdiagnosed, often due to overlooked treatable conditions. (4) In 2009, it was found that up to 25% of mental health patients have medical conditions that exacerbate psychiatric symptoms. (5)
    The use of the Koran Algorithm would significantly reduce the number of individuals misdiagnosed, however utilizing other research done since would also reduce the number of people diagnosed with various mental illness and steer them into appropriate treatments.
    There are 4 reasons in the medical model for brain dysfunction 1: Anatomical abnormalities or damage. 2: Lack of oxygen or glucose 3: Electrolyte imbalance 4: Neurotransmitter deregulation: the imbalance of brain chemistry. (6)
    There are also at least three proven non-drug therapies on healing and preventing trauma and its effects, Somatic Experiencing (www.traumahealing.com), Eye Movement Desensitization and Reprocessing (http://www.emdria.org, establishes standards for EMDR while the EMDR Institute http://www.emdr.com provides a directory of trained EMDR clinicians), and Tension & Trauma Releasing Exercises (www.traumaprevention.com ) developed by David Berceli, Ph.D.
    Addressing trauma and its effects is part of the solution being sought. Tension & Trauma Releasing exercises, I believe, offers the best ‘bang for the buck’ in reducing trauma symptoms as well as effectively preventing trauma from imposing all its negative effects. Perhaps it should be added to police training programs, as well as being introduced to the community, especially to its youth.
    Another topic which needs to be recognized are U.S. Supreme Court decisions which, in my opinion, work to diminish trust between police and the greater community. Frazier v. Cupp (394 U.S. 731, 739, 1969) permits police to lie to the public just about any time they want. Each local community is free to decide how much and how often they lie to the public. The more lie and misinformation is given, the less trust exists. Imbler V Pachtman (424 U.S. 409, 1976), encourages malicious prosecutions. The more malicious or over-zealous prosecutions are used by the court, the less respect for the court results. Bordenkircher v. Hayes , (434 U.S. 357, 1978) permits the prosecutor to blackmail defendants into accepting plea ‘bargains’; even when defendants believe they are not guilty of the charges. Again, the more this technique is used, respect for the court diminishes. Then there are the many changes to police and criminal justice procedures which resulted due to Miranda V.Arizona (384 U.S. 436, 1966). I believe a number of these changes, including prosecutors using a flawed economic game theory instead of evidence and proofs – and done so to reduce costs, contributes to the problems this conference hopes to address.
    I go into each of these issues in my book Liberty & Mental Health – http://www.libertymentalhealth.com
    While there are psychiatrists who genuinely wish to help individuals, calling everything a disease which should be treated with drugs is disingenuous, at best.
    1. Does Stress Damage the Brain, by J. Douglas Bremmer MD, Biologivcal Psychiatry 1999; 45:797-805; Traumatic Amnesia, Repression, and Hippocampus Injury due to Emotional Stress, Cortisosteroids and Enkephalins by R. Joseph, Ph.D. Child Psychiatry Hum Dev. 1998 Winter;29(2):169-85
    2. A Medical Algorithm for Detecting Physical Disease in Psychiatric Patients, Hospital and Community Psychiatry Vol. 40 No. 12 Dec 1989, Pg. 1270
    3.Allen MH, Fauman MA, Morin SF. Emergency psychiatric evaluation of “organic” mental disorders. New Dir Mental Health Serv 1995;67:45-55.
    4. A Dose of Sanity by Sydney Walker III, M.D. 1996, pg 13/ Hoffman, Robert Science News, Vol. 122,
    September 11, 1982; Herringm M.M., Debate over ‘false positive schizophrenics’ Medicine Tribune,
    September 25, 1985. Pg 3; Koranyi, Erwin K., “Undiagnosed physical illness in psychiatric patients,”
    American Family Physician, Vol. 41, No. 4, April 1990
    5. Christensen RC, Grace GD, Byrd JC. Refer more patients for medical evaluation. Curr Psychiatr 2009;8:73-74.
    6. Biology and Human Behavior: The Neurological Origins of Individuality, Professor Robert Sapolsky, Stanford University, The Great Courses, The Teaching Company © 1996