“Gifts” From Industry to MD Editors of Pathology Journals

Was there a “quid pro quo”? I do not know, but I am worried. Many years ago, when I was the editor in chief of the Journal of the American Medical Association (JAMA) and Vice President of Scientific Publications for the AMA, with responsibility for all AMA journals, I had the privilege of testifying before a US congressional committee that was investigating whether laws should be passed to regulate how medical journals functioned. The context and impetus were a sequence of public airings of fraud and fabrication in some medical publications that lead to errors in science and practice and harm to the public. Because I and others made the case that medical journals in the United States functioned under the best forms of professional supervision as well as introspective self- and peer criticism, they were already well governed in the public interest and there was no need for new laws. I cited the International Committee of Medical Journal Editors (ICMJE) as the best example. For medical journal authors (and later, peer reviewers, editors, publishers, sponsors, advertisers, and the public media) to understand and be guided by the appropriate ethics of medical editing writ large, in 1978 a small group of medical editors and librarians met in Vancouver, Canada, to compose what became “uniform requirements” for manuscript preparation for submission to medical journals. As the process evolved over decades, that “Vancouver Group” was enlarged (but still select and small) and renamed the ICMJE. The original requirements were broadened to cover many facets of medical research, funding, designation of sponsors, peer view, manuscript preparation and submission, revision, veracity, error, fraud and fabrication, and various conflicts of interest. The point is for all concerned to “get it right” because, at an elemental level, the credibility and integrity of medical literature forms the basis for human life and health. Later, the International Congress on Peer Review and Scientific Publication, the Committee on Publication Ethics (COPE), and the World Association of Medical Editors (WAME) came to bear. In action, the world’s medical journal community, as editors, publishers, funders, authors, reviewers, advertisers, sponsors, owners, and others reinforced each other, actuating self-governance and preventing the need for new laws or government regulation. It was helpful at that time for the National Library of Medicine to be headed by another friendly pathologist, Donald A. B. Lindberg, who supported the AMA position. The industry of American medicine is huge and exerts great power in the marketplace; in the government; in the public media; with the public; and, unfortunately, with the medical profession. Some of the power is direct and explicit; much is indirect and exercised through deft influence of the public relations and marketing fields as well as the political establishment. The decision-making power of medical journal editors, entrusted to serve the best interests of patients, the health of the public, scientific truth, and the profession—in that order—is also vast. Fortunately, physician editors have well-established principles and policies to guide them that reside in the codified ethics of the fields of medicine, journalism, business, and the medical journals themselves.1,2 Two books titled Money-Driven Medicine, one by Maggie Mahar and one by David K. Cundiff, both published in 2006, pretty well tell the story of modern American medicine. Medicine has always been both a business and a profession—Chaucer and George Bernard Shaw both wrote about that—but balance has always been the key. In JAMA in 1990, I invented the metaphor “medicine’s rocking horse” in an attempt to balance the 2 forces and declared that there was an imbalance toward business.3 That was 32 years ago. It has only gotten worse. Perhaps I am biased by my years of experience, but I have always held both pathology as a medical discipline and journal editing to be professional commitments. Because of the inordinate power of their decisions and the nature of the people who choose those roles, I hold them to a higher standard than I would the average physician. Because of the frailties of human nature, the extraordinary amount of money at stake, and the temptation to cheat on many things, the issue of conflicts of interest for all concerned in the scientific enterprise has taken center stage in this daily scientific and clinical drama. For major players to have no conflicts of interest would be preferable, but that is almost impossible. So, the next best thing—disclosure of actual or even potential conflicts of interest—has become the required rubric. A large body of literature exists about the influence of gifting on recipients’ actions. Money is a powerful motivator. For decades, the morality of the individual physician and the ethics of medical professional organizations were believed to be sufficient to control this practice in the best interest of patients. The amount of money in the American health care system, however, is so huge and so much of it comes from government that a “last-resort” federal law was enacted to attempt to control the behaviors of all such entities by shining the light of day on the practice, name by name. Thus, when the stakes are high and the public health and safety are at risk, government steps in. The Physician Payments Sunshine Act was enacted in 2010 to collect from “industry” the payments entities make to physicians, physician assistants, and teaching hospitals in the course of each year in a searchable database.4 It is beyond the scope of this brief editorial to explore whether that 2010 act has been successful, but even such public disclosure has proved imperfect, with some authors forgetting or even deliberately not disclosing to editors, reviewers, or readers. In her extraordinarily helpful 2017 book An American Sickness, Elizabeth Rosenthal made the point that in the US health care system, charges for products and services tend to be whatever the market will bear, and those people and institutions that compose the bills will charge anybody and anything as much as possible for each. So it should not be surprising that in this culture, physicians who are decision-making editors of major pathology journals may request and accept large amounts of money from those industries that are the subjects, authors, supporters, and beneficiaries of any articles published, as documented here in the American Journal of Clinical Pathology in the article by Jacobs et al.5 The stated intent of this study was to investigate whether gender disparity came into play in the flow of money from industry to MD editors of pathology journals. This issue, which the authors discuss in detail, is important and complex, but in this editorial, I have elected to focus on the larger issue of potential conflicts of interest that acceptance of these payments by journal editors generally create. The vast majority of “gifts to physicians from industry” involve clinicians who write prescriptions for pharmaceuticals. In some countries, pharmaceutical companies may actually pay physicians directly to prescribe certain drugs. In addition, surgeons such as orthopedic surgeons who implant devices have been reported to receive large financial incentives to use certain types of hardware. Interventionists who deploy devices such as arterial stents are another major target for industry’s use of such financial incentives. Decision-making medical journal editors could be prime targets for their decisions to publish reports or editorials that promote this or that drug, device, instrument, reagent, or other product for laboratory use. The eye-opener to me, however, was the sheer volume of moneys transferred to MD pathologist editors (not editorial board members—that would be another study) revealed by “sunshine” in this research paper. Did each of the 35 journals studied publish an easily found full conflict of interest disclosure list for all decision-making editors? I don’t know which 35 journals were studied. I looked through a convenience aliquot of pathology journals and found some statements of the policy guidelines they followed. The disclosures from authors seemed uneven. I found nothing about how those journal decision-making editors shield their decisions from the bias that may result from receiving related industry money. Jacobs et al5 deserve thanks and praise for their paper. It is exactly the kind of self-criticism that is expected from a learned profession that wishes to retain the honor and trust of self-governance. For next steps, the editors and publishers of those 35 pathology journals need to examine their own journal policies and practices, clean up anything that requires it, and let the sunshine do the rest by leveling with their readers about how they avoid conflicts of interest. They should provide transparency to prevent even the appearance of improper industry influence on their journal’s content. For best guidance, follow COPE conflicts of interest and disclosure statements for journal editors by establishing and following written policies.6 Also, use the procedures for internal disclosure and recusal from decisions where conflicts may exist.7 But mostly, rather than relying on disclosure, follow the WAME policies to identify and prevent conflicts of interest for editors.8 The goal is to continue to merit the trust of the public.

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