Transcript Is medicine corrupt?

Is medicine
corrupt?
Richard Smith
Editor, BMJ
www.bmj.com/talks
What I want to talk
about?
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What is corruption?
Evidence from medical students
Richard Horton story
The Banerjee case
Doctors and drug companies
Examples from medical publishing
Other possible areas of corruption
Why is this happening?
What might be done?
What is corruption?
• Corrupt (verb transitive): to
taint, destroy the purity of, to
pervert, to debase, to spoil, to
bribe
• Corrupt (verb intransitive): to
rot, go bad, to lose purity, spoil
What is corruption?
• Corrupt (adjective): defiled,
depraved, dishonest, venal, of
the nature of--or involving-bribery, bribed, not genuine or
pure, rotten, putrid, debased or
made very faulty in
transcription
Is medicine
corrupt?
Of course,
everything is
corrupt to some
degree
So the question is
“How corrupt is
medicine?”
Evidence from studies
on medical students
Are "tomorrow's doctors" honest?
Questionnaire study exploring medical
students' attitudes and reported behaviour
on academic misconduct
S C Rennie and J R Crosby
BMJ 2001; 322: 274-275.
676 students surveyed in
Dundee
471 responded (62%
response rate)
Survey of 461 medical
students
• Do you consider it misconduct
to write “Nervous system-examination normal” when it
hasn’t been done?
• Yes 75%
• Have you done it?
• Yes 32%
Survey of 461 medical
students
• Do you consider it misconduct
to forge a doctor’s signature on
a piece of work?
• Yes 93%
• Have you done it?
• Yes 9%
Survey of 461 medical
students
• Do you consider it misconduct
to copy text directly without
acknowledging the source?
• Yes 82%
• Have you done it?
• Yes 14%
Understanding the clinical dilemmas that shape
medical students' ethical development: questionnaire
survey and focus group study
Lisa K Hicks, Yulia Lin, David W Robertson, Deborah L Robinson, and
Sarah I Woodrow
BMJ 2001; 322: 709-710.
108 students in Toronto
90% response rate
47% had been asked to act
unethically
Survey of 103 medical
students in Toronto
• Conflict between medical
education and patient care (17)
• Patients asked to return to clinic for follow up visits
and not informed that the visits were entirely for
teaching purposes
• Students asked to perform pelvic examinations on
patients under general anaesthesia without patients'
prior consent
• House officer instructed a student to perform a
femoral puncture, for purely educational reasons, on a
comatose patient who did not need the procedure
Survey of 103 medical
students in Toronto
• Responsibility exceeding
student's capabilities (15)
• Student completed antenatal visits with patients
who were never seen by a doctor
• House officer refused to respond to student's
request for help in assessing an unstable patient
• Student and house officer left by teacher to close
wound, without knowing how to close it properly
• Student expected to give weekly psychotherapy
sessions without supervision
Survey of 103 medical
students in Toronto
• Involvement in care perceived
to be substandard (9)
• Patient requested a narcotic-free vaginal delivery
but given intravenous narcotics without her
knowledge
• Student witnessed house officer responding
inappropriately to patient's refusal to have joint
aspiration; consent form completed, but consent
not meaningfully given
• Student instructed by house officer to repair a
child's scalp laceration with inappropriate supplies
The ethics of intimate examinations:
teaching tomorrow's doctors
Yvette Coldicott, Catherine Pope, Clive Roberts
BMJ 2003; 326: 97-101.
452 students in Bristol
386 responded (85%
response rate)
Intimate examinations without
consent being recollected
Year of study
Intimate
examinations
32
No of
students
doing them
19
No consent
recollected
(%)
34
Second
Third
245
89
51
Fourth
1211
98
5
Total
1488
206
14
Medical students see that
academic misconduct is common
• Survey among 229 German
medical students
• 97% response rate
• Results are from 201 who had
completed their MD dissertation
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Eysenbach G. BMJ 2001; 322: 1307
Medical students see that
academic misconduct is common
Eysenbach G. BMJ 2001; 322: 1307
Survey among 229 German medical
students
97% response rate
Results are from 201 who had
completed their MD dissertation
Survey of 201 German
medical students
• 12 “completely agreed” that
“students have to deliver the
results expected by the
supervisor”
• 16 had been omitted from a
publication despite contributing
work
• 9 had been plagiarised
Survey of 201 German
medical students
• 5 had taken words or ideas from
others without credit
• 5 had presented results
selectively
• 7 had trimmed or falsified
results
Survey of 201 German medical
students: observations on others
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Selective reporting 43%
Trimming or falsifying results 36%
Wrong authorship attribution 25%
Multiple publication 18%
Wilfully misleading 14%
Plagiarism 14%
Institutional corruption
in medicine
Peter Wilmshurst
BMJ 2002; 325: 1232-5.
Anjan Kumar Banerjee
Banerjee’s story
• Awarded honours and distinction
in his final medical exams
• Won 24 undergraduate prizes
• Junior jobs at the Hammersmith
and Northwick Park
• Within a few years of graduating
had 49 publications and the first
part of his FRCS
Banerjee’s story
• Started research with Professor
Tim Peters
• 1988--doubts raised about his
research: included authors on his
papers who said that they had not
been involved; doubts that he
could have done the work
• Moved with Tim Peters to Kings
Banerjee’s story
• Received grants from charities and
pharmaceutical companies for research
into the effect of NSAIDs on the gut
• Colleagues said the work was fraudulent
• Banerjee confessed that it was--but it had
already been printed as an abstract in Gut
in 1990
• Gut was not notified until 2000 that the
work was fraudulent: the retracted it
Banerjee’s story
• 1990--full paper submitted to
Gut with Banerjee and Peters as
sole authors
• Retracted as fraudulent 10
years later
• 1990--widespead doubts about
Banerjee; Kings starts an
inquiry
Banerjee’s story
• July 1991: Inquiry completed.
Chairman writes to Peters and
school secretary: "Having carefully
examined the documentary evidence
which you sent me, I am totally
satisfied that much of the research
data reported by Dr Banerjee since
1988 is at best unreliable, and in
many cases spurious.”
Banerjee’s story
• The report disappeared
• Kings didn’t notify the MRC or Gut
• University of London awarded him
an MD degree based on the
fraudulent research; never retracted
• Royal College of Surgeons made him
a Hunterian professor based on his
(fraudulent) research
Banerjee’s story
• Early 90s Banerjee became a
consultant surgeon in Halifax
• 2000 resigned
• November 2000--found gulity of
serious professional misconduct for
falsifying research
• February 2001--Peters found guilty of
serious professional misconduct for
failing to act on Banerjee
Banerjee’s story
• September 2002: found guilty of
serious professional misconduct for
financial dishonesty: misled patients
about the length of NHS waiting lists
to induce patients to opt for private
treatment and sought payments for
treatments not performed. Concerns
were also expressed about clinical
skills.
Banerjee’s story
• More than 10 years elapsed between
there being clear evidence of fraud
and proper action being taken
• He flourished professionally despite
strong evidence of misconduct
• Many were harmed by his behaviour
• Many knew about his misconduct
• Documents were lost
• Whistleblowers were threatened
“For the triumph of evil it is only necessary for good
men to do nothing.” Edmund Burke
Institutional corruption
• No individual within an
institution wants misconduct to
flourish, but nobody is directly
responsible--so it does flourish.
Bristol: another
example?
Doctors and drug
companies. Too close
for comfort?
16 forms of entanglement between
doctors and drug companies
• Face to face visits from drug
company representatives
• Acceptance of direct gifts of
equipment, travel, or
accommodation (“Will you advertise
my drug on your person for a year if I
pay you 20p?”)
• Acceptance of indirect gifts, through
sponsorship of software or travel
16 forms of entanglement between
doctors and drug companies
• Attendance at sponsored dinners and
social or recreational events (“If they have
to pay the full whack they won’t come?”)
• Attendance at sponsored educational
events, continuing medical education,
workshops, or seminars (“Could you hurry
up so we can get to the vol au vents?”)
• Attendance at sponsored scientific
conferences (“Bugger Bognor, but the Gritti
Palace in Venice sounds good.”)
16 forms of entanglement between
doctors and drug companies
• Ownership of stock or equity holdings
• Conducting sponsored research (“It’s so
hard to get money from the MRC and £800
for registering a patient is not bad.”)
• Company funding for medical schools,
academic chairs, or lecture halls
• Membership of sponsored professional
societies and associations
• Advising a sponsored disease foundation
or patients' group
16 forms of entanglement between
doctors and drug companies
• Involvement with or use of sponsored
clinical guidelines
• Undertaking paid consultancy work for
companies (“A return flight on Concorde,
five nights at the Ritz Carlton, and 20
grand is not bad for two hours of blah.”)
• Membership of company advisory boards
of "thought leaders" or "speakers'
bureaux” (“Flattery and money: I can resist
everything except temptation.”)
16 forms of entanglement between
doctors and drug companies
•
Authoring "ghostwritten" scientific
articles (A critic on Naomi Campbell’s
autobiography: “If she can’t be bothered to
write it I can’t be bothered to read it.”)
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Medical journals' reliance on drug
company advertising, company purchased
reprints, and sponsored supplements (“It’s
a million quid and £800 000 profit for
reprints of a major trial. Without it I might
have to lay off staff. But we’re not
influenced in our decision making.”)
Does all this matter?
• Virtually all new drugs, which
have been so important for
medicine, have come from drug
companies
• Drug companies must have the
right to market their products
• Prescribing is influenced--often
to be unnecessarily expensive
Does all this matter?
• Information is biased
• Doctors are too dependent on
drug companies for both
education and information
• Companies spend more on
marketing than on research
• Costs are inflated
Corruption in medicine?
Evidence from medical
publishing
Corruption in medical
publishing
• Redundant publication occurs in
around a fifth of published papers
• About a fifth of authors of studies in
medical journals have done little or
nothing
• Most authors of studies in medical
journals have conflicts of interest,
yet they are declared in less than 5%
of cases
Conflict of interest: a
case study in poor
performance within
biomedicine
How common are competing
interests?
• 75 articles on calcium channel
anatagonists
• 89 authors
• 69 (80%) responded
• 45 (63%) had financial conflicts of interest
• Only 2 of 70 articles
disclosed the conflicts of
interest
•
Stelfox HT, Chua G, O'Rourke K, Detsky AS. Conflict of interest in the
debate over calcium channel antagonists. N Engl J Med 1998; 338: 101105
Why don’t authors declare
conflicts of interest?
• Some journals don’t require
disclosure
• The culture is one of not
disclosing
• Authors think that it’s somehow
“naughty”
• Authors are confident that they
are not affected by conflicts of
interest
Does conflict of interest
matter?
• Financial benefit makes doctors more likely to
refer patients for tests, operations, or hospital
admission, or to ask that drugs be stocked by
a hospital pharmacy.
• Original papers published in journal
supplements sponsored by pharmaceutical
companies are inferior to those published in
the parent journal.
• Reviews that acknowledge sponsorship by the
pharmaceutical or tobacco industry are more
likely to draw conclusions that are favourable
to the industry.
Does conflict of interest
matter?
• Is there a relationship between whether
authors are supportive of the use of
calcium channel antagonists and whether
they have a financial relationship with the
manufacturers of the drugs?
•
Stelfox HT, Chua G, O'Rourke K, Detsky AS. Conflict of interest in the
debate over calcium channel antagonists. N Engl J Med 1998; 338: 101105
Does conflict of interest
matter?
• 106 reviews, with 37% concluding that passive
smoking was not harmful and the rest that it was.
• Multiple regression analysis controlling for article
quality, peer review status, article topic, and year
of publication found that the only factor associated
with the review's conclusion was whether the
author was affiliated with the tobacco industry.
• Only 23% of reviews disclosed the sources of
funding for research.
•
Barnes DE, Bero LA. Why review articles on the health effects of passive
smoking reach different conclusions. JAMA 1998; 279: 1566-1570
Does conflict of interest matter?:
third generation contraceptive
pills
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At the end of 1998 three major studies without sponsoring from
the industry found a higher risk of venous thrombosis for third
generation contraceptives; three sponsored studies did not.
To date, of nine studies without sponsoring, one study found no
difference and the other eight found relative risks from 1.5 to 4.0
(summary relative risk 2.4); four sponsored studies found
relative risks between 0.8 and 1.5 (summary relative risk 1.1)
The sponsored study with a relative risk of 1.5 has been
reanalysed several times, yielding lower relative risks; after this
failed to convince, a new reanalysis was sponsored by another
company.
One sponsored study finding an increased risk has not been
published.
Vandenbroucke JP, Helmerhorst FM, Frits R Rosendaal FR. Competing
interests and controversy about third generation oral contraceptives.
BMJ 2000; 320: 381.
Other topics I might
have covered
• Private practice
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•
“X has had a heart attack. Who’ll do his on call?”
“Whover does it normally, when he’s doing his private
practice.”
• Merit awards
• Fundholding:
keeping prescribing deliberately
high in order to maximise next year’s budget
• Racism
• “Lucragrams”
Why do we have
corruption?
• Why wouldn’t we?
• Much of medicine operates on
trust
• Inadequate accountability
• Inadequate training
• Poor role models
• “Pressure to publish”
Why do we have
corruption?
• The main target of one of the
world’s richest industries
• Tribal loyalty
• “Under no circumstances would I shop
another doctor”
• “Not even if he was murdering his patients,
like Harold Shipman.”
• “Not even then. I know how hard it is to be
a doctor.”
Why do we have
corruption?
• “There but for the grace of God
go I.”
• “The bogus contract”
• Patient: “Modern medicine is wonderful. You can
see inside me, fix my problems”
• Doctor: “I’m more impressed with what medicine
can’t do than it can do. I can’t fix this. I’d better
keep quiet. My salary and my status comes from my
‘magical’ powers.”
What can be done about
corruption in medicine?
• Set high standards
• Increase transparency in
appointments, merit awards, private
practice
• Increase accountability: appraisal,
revalidation, CHAI, etc
• Interact more professionally with the
drug industry
Survey on bmj.com:
1479 responding
• Would you like doctors to stop seeing drug
company representatives, replacing them
with more independent sources of health
information?
• Yes 79%
• Would you like doctors to stop receiving all
forms of direct and indirect gifts from drug
companies?
• Yes 84%
Survey on bmj.com:
1479 responding
• Would you like industry-funded education
of doctors replaced by education funded
by more independent sources?
• Yes 84%
• Would you like all financial relationships
between doctors and drug companies
conducted with transparent contracts that
are disclosed to patients and the public?
• Yes 96%
What can be done about
corruption in medicine?
• Teaching/discussions on best
practice in relating to patients,
research, etc
• Leadership (“Tone at the top”)
Finally, recognise
something that I
didn’t recognise
until I was fifty and
three quarters
“Integrity is not
something you have
and hope not to
lose but something
you must work at
every day.”