Is medicine corrupt?

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Is medicine corrupt?

• Richard Smith
• Editor, BMJ
• www.bmj.com/talks

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What I want to talk about?

• 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?

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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

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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

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Is medicine corrupt?
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Of course, everything is corrupt to some degree
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So the question is How corrupt is medicine?
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Evidence from studies on medical students
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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)

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Survey of 461 medical students

• Do you consider it misconduct to write Nervous
  system--examination normal when it hasnt been
  done?
• Yes 75
• Have you done it?
• Yes 32

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Survey of 461 medical students

• Do you consider it misconduct to forge a doctors
  signature on a piece of work?
• Yes 93
• Have you done it?
• Yes 9

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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

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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

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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

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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

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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

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The ethics of intimate examinations teaching
tomorrow's doctorsYvette Coldicott, Catherine
Pope, Clive Roberts BMJ 2003 326 97-101.

• 452 students in Bristol
• 386 responded (85 response rate)

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Intimate examinations without consent being
recollected
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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
• Eysenbach G. BMJ 2001 322 1307

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Medical students see that academic misconduct is
commonEysenbach G. BMJ 2001 322 1307

• Survey among 229 German medical students
• 97 response rate
• Results are from 201 who had completed their MD
  dissertation

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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

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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

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Survey of 201 German medical students
observations on others

• Selective reporting 43
• Trimming or falsifying results 36
• Wrong authorship attribution 25
• Multiple publication 18
• Wilfully misleading 14
• Plagiarism 14

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Institutional corruption in medicine Peter
Wilmshurst BMJ 2002 325 1232-5.
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Anjan Kumar Banerjee
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Banerjees 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

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Banerjees 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

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Banerjees 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

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Banerjees 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

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Banerjees 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.

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Banerjees story

• The report disappeared
• Kings didnt 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

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Banerjees 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

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Banerjees 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.

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Banerjees 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

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For the triumph of evil it is only necessary
for good men to do nothing. Edmund Burke
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Institutional corruption

• No individual within an institution wants
  misconduct to flourish, but nobody is directly
  responsible--so it does flourish.

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Bristol another example?
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Doctors and drug companies. Too close for comfort?
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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

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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 wont 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.)

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16 forms of entanglement between doctors and drug
companies

• Ownership of stock or equity holdings
• Conducting sponsored research (Its 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

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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.)

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16 forms of entanglement between doctors and drug
companies

• Authoring "ghostwritten" scientific articles (A
  critic on Naomi Campbells autobiography If she
  cant be bothered to write it I cant be bothered
  to read it.)
• Medical journals' reliance on drug
  company advertising, company purchased reprints,
  and sponsored supplements (Its a million quid
  and 800 000 profit for reprints of a major
  trial. Without it I might have to lay off staff.
  But were not influenced in our decision making.)

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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

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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

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Corruption in medicine? Evidence from medical
publishing
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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

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Conflict of interest a case study in poor
performance within biomedicine
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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
  101-105

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Why dont authors declare conflicts of interest?

• Some journals dont require disclosure
• The culture is one of not disclosing
• Authors think that its somehow naughty
• Authors are confident that they are not affected
  by conflicts of interest

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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.

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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
  101-105

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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

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Does conflict of interest matter? third
generation contraceptive pills

• 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.

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Other topics I might have covered

• Private practice
• X has had a heart attack. Wholl do his on
  call?
• Whover does it normally, when hes doing his
  private practice.
• Merit awards
• Fundholding keeping prescribing deliberately
  high in order to maximise next years budget
• Racism
• Lucragrams

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Why do we have corruption?

• Why wouldnt we?
• Much of medicine operates on trust
• Inadequate accountability
• Inadequate training
• Poor role models
• Pressure to publish

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Why do we have corruption?

• The main target of one of the worlds 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.

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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 Im more impressed with what medicine
  cant do than it can do. I cant fix this. Id
  better keep quiet. My salary and my status comes
  from my magical powers.

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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

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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

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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

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What can be done about corruption in medicine?

• Teaching/discussions on best practice in relating
  to patients, research, etc
• Leadership (Tone at the top)

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Finally, recognise something that I didnt
recognise until I was fifty and three quarters
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Integrity is not something you have and hope
not to lose but something you must work at every
day.