Map of life expectancy at birth from Global Education Project.

Monday, October 01, 2007

Oh Canada!

I should have gotten around to this sooner, but as you may recall much of the staff of the Canadian Medical Journal quit last year in a dispute over editorial independence and integrity. Now, the new journal Open Medicine helps to keep Canada moving forward while its neighbor to the south keeps racing backwards toward the Dark Ages. As James Maskalyk explains on behalf of the editors of Open Medicine:

To attain their true worth, medical journals need to place the knowledge on their pages into as many capable hands as possible. In the past, this opportunity was limited mainly to those with a university library close by. Now, because of the Internet, one simply needs to be near a telephone line. The capacity of medical journals to disseminate knowledge has never been greater.

Unfortunately, physicians attempting to answer a clinical question are faced with two unappealing options: to navigate a sea of unedited pages of varying quality, or to pay for access to more carefully reviewed scholarly information. It seems an anathema to the spirit of medical research that, largely for economic reasons, the information it produces remains hidden from many potential users. Access is limited not only for health professionals in poorer countries, but also for health care providers in wealthy countries (most of whom do not have "free" access to information unless they work in universities), and for patients, who deserve the opportunity to become informed about research that affects their lives. The transformation of research findings and discussion of the results — the application of knowledge — is curtailed. Just as importantly, the debate over its merit is stifled before it can properly begin. . .

Traditional modes of medical journal publishing can also exact a price in other, less noticeable, ways. There is clear evidence of publication bias in medical journals predicated on financial conflicts, geography and poverty. There are also several important instances where information and debate have been stifled because of private and political concerns over making knowledge public. To an important degree, the impetus to launch Open Medicine arose from widespread dismay in the Canadian and international medical community over one such attempt to suppress open discussion and restrict the scope of health care discourse. Further, too much of the revenue that sustains medical journals comes from pharmaceutical advertising that attempts to influence physicians into making decisions based on brand recognition rather than on discerning scholarship.

So what does Open Medicine offer to you? How about butt kicking essay by Jerome Kassirer? A little taste:

Earlier this year the New York Times reported that in selecting drugs for cancer patients some American physicians took into account the profit the drugs would achieve for their medical practice.9 The same week a study in PLoS Medicine showed that pharmaceutical company sponsorship of controlled trials of statins was closely correlated with positive results of such trials, suggesting that the trials were deliberately biased.10 Early this summer, reporters disclosed that unqualified researchers who were receiving payments for enrolling patients in clinical trials were practising shabby research.11 This past spring we learned that physicians with financial ties to the company that makes Epogen were inappropriately represented on a US National Kidney Foundation committee that recommended potentially dangerous doses of the drug.12–15 These recent revelations are just a continuation of reports over the past 10 or so years;11,16–24 dozens more examples of serious financial conflicts are described in my recent book.1

Financial payments have swayed professional medical organizations to make inappropriate recommendations for use in practice by their members,25,26 influenced industry-paid speakers to recommend risky drugs, biased FDA panels,27,28 and yielded inappropriate behaviour by NIH scientists.29,30 Free drug samples encourage doctors to use the newest and most expensive drugs, and the samples themselves often get into the wrong hands.31 Drugs such as Natrecor, approved for use in acute heart failure only in hospital settings, have found widespread use in doctors’ offices for a variety of less serious conditions where they were unlikely to provide benefit, costing American taxpayers hundreds of millions of dollars.32

And what have leaders of the profession done to counter a trend in which the profession has become increasingly beholden to industry, at times to the detriment of the public? Not much. Policies of the American Medical Association, the American College of Physicians and many other physician organizations permit their members to receive gifts and meals, to serve as consultants on marketing issues, and to serve on pharmaceutical companies’ speaker’s bureaus.25 Most have no proscription against members’ involvement in developing or just signing off on educational materials for the companies. In fact, most American medical society rules are no more stringent than those of the Pharmaceutical Manufacturers Association.

So read the whole thing. Then enter your zip code in the little icon right under Chimpy and let your members of Congress know that you want something done about conflicts of interest in medicine and medical research.

And congratulations! You have won a free subscription to a leading medical journal. Now let's see whether JAMA and the New England Journal of Medicine have a future as exclusive clubs for the wealthy and well positioned. I say no.

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