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Why we should care that many editors of top medical journals get healthcare industry payments

About half the editors at the most prestigious medical journals in the U.S. receive payments from the pharmaceutical or medical device industries.

But only 30 percent of these journals make it clear to readers what their policies are regarding such conflicts of interest.

Those are the findings of a Canadian study published last month in the BMJ. They raise major questions about the independence and objectivity of academic journals, which are a primary source of health care news.

Why should we be concerned about journal editors taking industry cash — as much as $1 million some instances?

How ‘payments’ were defined in the studies:

The Canadian study published in The BMJ primarily looked at industry payments to editors that were reported to Open Payments as consulting fees, speaker’s bureaus, and meal and travel reimbursement.

The University of Hawaii/UC-San Francisco study looked at the same payments (per above) but also included payments to the home institution of the editor.

Editors at these journals are the primary gatekeepers in determining which studies get published and, quite often, which studies will be covered by the media. If they are influenced by industry money–whether that be via direct cash payments, research funding, or money given to their home institution–then our health care news can be tainted at its source.

Other highlights of the University of Toronto study include:

  • Researchers estimated payments by looking at 2014 data from the Open Payments database and investigated 52 highly influential medical journals across 26 specialties.
  • Median general payment was $11 but the range was wide ($0 to nearly $3,000). Two editors received over $1 million.
  • Endocrinology, cardiology, gastroenterology, and rheumatology editors received the highest median payments.

Interestingly, six days before these results were published, researchers from Hawaii and San Francisco published an even more extensive study. It focused specifically on industry payments to physician editors and was published in PeerJ Preprints (therefore, not peer reviewed) with the following key findings:

  • Nearly two-thirds of physician editors (from 35 influential journals) received industry payments over the 41-month study period.
  • more than 1 in 7 received over $10,000 directly (not via their institution).
  • 44 percent of cardiology editors received over $10,000 in 2015.

Of note, both studies are retrospective and observational in design. This means neither study can definitively claim that industry payments clearly affect editorial decisions in a cause-and-effect way.

One physician editor’s perspective

José Merino, MD

As we’ve written about before, there is a growing body of evidence showing that medical industry largesse does affect healthcare providers. And even if it didn’t, there remains the issue of public perception and trust whenever and wherever there is a reluctance to be transparent.

Dr. José Merino is acutely aware of this. He is an assistant professor of neurology at the University of Maryland School of Medicine. He’s on committees with both the American Academy of Neurology and the American Heart Association because of his interest in the diagnosis and treatment of stroke. He’s also the US Research Editor at The BMJ.

“Editors have significant power because they decide what (and who) gets published,” says Merino, who adds he doesn’t take industry payments to avoid any real or potential conflicts of interest (COI) in his clinical, research, and editorial roles.

“So I think it’s reasonable to expect that editors should declare their actual and potential COI. At The BMJ, editors must fill out the same COI forms as the authors and these COI are listed on the website. Also, at the start of every manuscript meeting — where we discuss which papers may be accepted for publication — we ask editors to reveal financial and non-financial COI with the papers being discussed. If any exist, that editor does not participate in the discussion and may even leave the meeting.”

But given that the Canadian study found only 30 percent of journal websites disclosed their COI policy for editors, it’s hard to know how many journals are (or aren’t) as careful as The BMJ.

Thought leaders as a double-edged sword

Victoria S.S. Wong, MD

Many physician-editors at prestigious medical journals are considered “thought leaders” within their field. Their expertise, reputation, and influence make them highly sought after not just by the editorial boards of journals, but also by colleagues, professional societies, the press, and industry. Many, like Merino, also conduct research.

And this creates a dilemma, says Dr. Victoria Wong, lead author of the University of Hawaii/UC-San Francisco study. She points out that, on the one hand, “some physician-industry relationships are beneficial and can result in novel therapeutics or other medical contributions.”  But on the other hand, such thought leaders also are more likely to have multiple sources of funding that could pose real or perceived conflicts of interest. She elaborated on this in a recent interview with Retraction Watch:

“It would be ideal for most editors to have some significant research experience, but not at the expense of losing objectivity and transparency. The more funds that come from industry, the greater the likelihood that editorial decisions are not objective.

It is unfortunate that we’re discussing the incomes of the very people who are the gatekeepers of the medical research that drives health care policy and expenditure, yet our current system does not think it important enough to provide them them with a dedicated and unbiased source of income to do this job.”

What about the publishers of medical journals?

Michael L Callaham, MD

It’s worth noting that medical journals make considerable money from reprints and advertisements paid for by drug or device companies. Publishers rely on these lucrative arrangements as a major source of income. So does this add a third level of potential COI as we move upstream from authors, past editors, and up to publishers?

“Reprint and supplement payments to publishers could easily be a source of bias,” says Dr. Michael Callaham of UC-San Francisco, a co-author with Dr. Wong, who studies the peer review publication process.

“High-profile journals can make hundreds of thousands of dollars from Pharma or device manufacturers that way (by their purchase of reprints to distribute to physicians by their salespeople). As for supplements, they serve the same purpose, and in my experience they often don’t get the same rigor or objectivity of peer review as routine manuscripts.

“Publishers typically state that editors have full independence in choice of manuscripts, but if you believe a big reprint order will make your publisher happy (so that they value you and your journal more), that could influence editorial decision making. Also, some publisher contracts pay extra for ad revenue above a certain threshold, so some of those funds might trickle over to the editors and/or their projects. We don’t know how often this happens or if it happens at all.”

Callaham adds that, to the best of his knowledge, there are no regulations mandating that publishers disclose to their readers how much income they receive from reprints and supplements.

Some unanswered questions

The authors of both the Canadian and Hawaii/San Francisco studies see their results as a call for more transparent and accessible policies addressing conflicts of interest for editors. As The BMJ authors put it, “editors play a crucial role in research integrity; even an appearance of conflict can serve to undermine the clinical research enterprise.”

For now–even though professional organizations like the International Committee for Medical Journal Editors (ICMJE), Committee on Publication Ethics (COPE), and World Association of Medical Editors (WAME) all publish guidelines addressing COI–compliance remains voluntary.

That leaves me wondering: Will medical journals see complete transparency as in their best interest? If not, why?

Many journalists agree that it’s unethical to take gifts or payments that might impact their reporting. Even if they’ve convinced themselves they wouldn’t allow this to happen, ethical journalists recognize the possibility of a subconscious influence as enough of a slippery slope.

Is it too much to ask editors (and publishers) to do the same? And is it too much to ask that we replace the de rigueur “call for transparency” with what we’re really asking for … a call for honesty?

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Evan Jack