PUBLISH OR PERISH

Getting favourable papers published in journals is seen as a sound marketing strategy by drug companies. Ghost written editorials and review papers to promote off-label use of drugs is commonplace.

“THE MEDIA and the public see publication in peer-reviewed journals as validation of the research,” wrote Edward W. Campion in an editorial in a recent issue of the New England Journal of Medicine. “Diligent reviewers and careful editors can identify mistakes, provide balance, and restrain over interpretation.”

Yet, when your doctor suggests that a drug meant to treat another disease will be of better help than the one you presently take and shows a scientific paper published in a journal to support his case, take his suggestion with a pinch of salt. You may exclaim that a paper published in a peer-reviewed journal carries with it a seal of authority and cite what Dr.Campion had mentioned in his editorial.

Hold on. The journal’s name matters.

What’s in a name; a journal is a journal is a journal, yes? More so, if it is peer-reviewed, right? Richard Horton, Editor of a most respected medical journal, the Lancet, begs to differ.

According to his oral evidence provided before the House of Commons select committee on health, there is a whole lot of “promotional” journals that sit at the bottom of the rung. The Lancet and the British Medical Journal, among others, come out as the best of the best followed by specialty journals.

The transcript of Dr. Horton’s oral evidence taken in public and reported to the U.K. House of Commons is available here
Documentation

Missing strengths
These journals are often very good places to get papers published that are clearly promotional. “(These journals) will not necessarily have the academic background and critical appraisal strengths to be able to discern which are strong and which are weak articles,” he explained.

And what ends up at the doctor’s table are the papers published in such journals. “That is what the drug representatives are there to do, to feed them (doctors) rubbish,” he added.

With diminishing returns from research and development investment, the focus has shifted to marketing. “And the problem we have at journals is that the great tools for marketing are the papers we publish,” Dr. Horton clarified. “So this has led to the swathe of ghost writing… Using the research that we publish as a marketing tool and not as an educational tool. We get caught in that vice.”

Ghost-written editorials
He had gone further to elaborate his point: “… If you look at the work that is put out under the mask of education, it is largely marketing dressed up as education.” Promoting the use of drugs for an ailment for which it is not actually meant through ghost-written editorials and review papers in journals is not uncommon.

“… It (paper) looks credible. The reprint has the imprint of the journal and the publisher attached to it. There is an authenticity given to what are often completely spurious views not owned by the author him or herself,” said Dr. Horton about the impact these papers have on doctors. Published under the pretext of research, it sort of encourages the doctor to try using the drugs to treat conditions they are not supposed to or for which the drug is not licensed to.

What in the first place makes the journals become promotional rather than objective and educational? Dr. Horton was quoted as saying how financial incentives could influence commercially run peer-reviewed journals to publish a particular paper. And when the very viability of many journals depends on reprint revenue, the relationship between the journals and sponsoring organisation, drug industry for instance, changes for worse.

According to Dr. Horton, many of the formal research papers published in the Lancet are reprinted and bought in bulk by drug companies. These reprints are in turn used by the companies to market their products.

Dr. Horton had also pointed out how financial incentives could influence commercially run peer-reviewed journals to publish a particular paper. If the content of a paper interests the editor, the investigator goes on to add, “… it is likely that the (pharmaceutical) company will want to buy several hundred thousand reprints (of the paper).” A reprint is a replica of the paper published in a journal and carries with it the name of the journal, the publisher and other details.

Casting a bait
Several hundred thousand reprints might translate into millions of dollars in revenue to the journal. “There is an implicit connection between the submission of a paper and the revenue that comes in to a journal,” Dr. Horton said. Enticing with money to get a paper published is just the beginning though.

“At various stages after a paper has been submitted there may be interventions by either the authors or the sponsors to try to move the peer review process in a direction that is less critical,” he pointed out. He recalled a recent episode when during peer-reviewing, the Lancet found a paper trying to over-interpret and play down the impact of adverse reactions.

“… As we were getting the paper right for publication, we received a call from the sponsor of the company saying: Stop. Pull back. Stop being overly critical because if you carry on like this we are going to pull the paper and if we pull the paper that means no re-print income for the journal,” he said recalling the way the sponsor was trying to arm-twist the Lancet.

But the Lancet did not buckle under pressure. It wanted the authors to make sure that the company did not interfere with the journal’s procedures and processes.

“… The company backed off; the authors were willing to change the way they had interpreted the paper and report more accurately the data in the paper,” Dr. Horton noted. There appears to be a constant continuing conflict of interest during the peer-reviewing process between the journals and the sponsors.

Researchers helpless
Very often authors find themselves caught between the pharmaceutical companies and journals. But why do researchers get themselves involved with studies involving drug companies? The answer is simple — funding.

“(Researchers) would not have this research done if it were not for industry. Then industry owns the message as a result and the authors fail to win the argument about how the research gets reported,” he pointed out.

In a particular case Dr. Horton recalled how the Lancet had published an editorial that was highly critical about a paper they had published. “That is often our only come-back, to run a critical editorial pointing out the weaknesses in the study design,” he said.

“I think journals have an enormous responsibility. We are seen as independent; we are seen as a source of evidence and yet we ourselves can be corrupted by this very perverse set of incentives that we are businesses in our own rights that we are often owned by publishers who have to make a profit,” he highlighted.