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