Naming Names: Is There an (Unbiased) Doctor in the House?

Journalists often forget that conflicts of interest may bias the opinions of their expert sources. Jeanne Lenzer and Shannon Brownlee explain how, in an attempt to disentangle commercial messages from science, they have compiled a list of nearly 100 independent medical experts to whom reporters can turn.

Ho hum, another medical scandal in the news. Earlier this month US Senator Chuck Grassley announced his intention to investigate Alan Schatzberg, chairman of the psychiatry department at Stanford University and the incoming president of the American Psychiatric Association, about his multimillion dollar interest in Corcept Therapeutics, a company that is seeking to market a drug that Dr Schatzberg is researching with federal funding, and the extent to which he disclosed and was required to disclose that interest to Stanford.¹ In June the New York Times broke a front page story about the alleged failure of three top research psychiatrists at Harvard, each of them a proponent of drug treatment for psychiatric conditions in children, to report that since 2000 they had collectively received more than $4.2m (£2.1m; 2.6m) from various drug companies.²

After ignoring the growing controversy over conflict of interest for years, journalists now seem only too happy to expose wrongdoing in medicine. Yet when it comes to reporting medical news, those self same reporters often seem to forget that conflicts of interest might also bias the opinions of their expert sources. The media are filled with happy talk about "medical breakthroughs" that is based on information gathered from sources with ties to the industry. Yet simply knowing that conflicts of interest can create bias doesn’t answer the question of which studies we ought to believe. Because journalists fail to seek out sources who can offer an independent perspective, many medical stories in the popular media are either unbalanced or simply wrong.

In an attempt to disentangle commercial messages from science and to contribute to better reporting we took a drastic step that we believe can go to the heart of the problem: we decided to name names. We created a list of nearly 100 international medical experts in a wide variety of disciplines. But contrary to the "gotcha" tradition of journalism, the list’s members are not physicians on the take but rather the reverse: they are leading independent experts, many of them sources we have cultivated over years of reporting. It includes, from journal publishing, two former editors of the New England Journal of Medicine, the former editor of the Western Journal of Medicine, and a senior editor of PLoS Medicine; former advisers to the US Food and Drug Administration; physician educators; researchers; bioethicists; epidemiologists, methodologists, geneticists, and clinicians from various specialties; medical whistleblowers; and several medical journalists.

Those applying to be on the list fill out a form affirming that they have not received "any financial support in any form from pharmaceutical or medical device manufacturers during the past five years" and that they don’t have other affiliations or financial involvements that would present a conflict of interest. A three member board decides whether to accept applicants. We also maintain a "page 2" list of experts who willingly disclose their conflicts of interest or have ended their industry ties but only within the past five years. Despite their recent commercial ties, these experts are included in the list because they have provided key insights into the inner workings of partnerships between physicians and the industry—and thus have bitten the hand that feeds them, in effect.

The reaction to the list, which has been embraced enthusiastically by our fellow reporters and roundly condemned by several allies of the drug industry, suggests that the effect of simply gathering these names together could well go beyond making life a little easier for our fellow journalists.

Seeking Unbiased Sources

The need for such a resource is evident from studies showing that bias and poor reporting on medical topics are widespread in the popular media. Gary Schwitzer, a professor of journalism at the University of Minnesota, publishes HealthNewsReview.org, a website that reviews healthcare news for balance, accuracy, and completeness. Schwitzer and a team of academic researchers analysed 500 stories published in top outlets between April 2006 and April 2008 for two key criteria: did the journalist quote an independent expert, someone not involved in the relevant research; and did they make some attempt to report potential conflicts of interest. The result? Half the stories failed to meet these two very basic requirements.³

In another study Alan Cassels, a pharmaceutical policy researcher at the University of British Columbia, and his colleagues analysed media coverage of five prescription drugs published in 193 Canadian newspapers in 2000.⁴ Cassels, who is on our list, found that the stories were overwhelmingly positive towards the drugs: all 193 articles included at least one drug benefit, while 68% (132/193) failed to mention any potential harm. Two thirds of the stories quoted a source by name, but only a scant 3% (5/164) included information about conflicts of interest for sources who were not government or industry officials.

In the view of one list member, Arnold Relman, former editor in chief of the New England Journal of Medicine and professor emeritus of medicine and of social medicine at Harvard Medical School, such bias fails to serve the public good. "The public has a lot at stake, and the media has a responsibility always to be aware of the source of information and the conflicts those sources might have when they report the results of clinical research," he said. "People who have a financial stake in the results of clinical research can well be biased in the way research is conducted, in the way they report it, and what they say about it when interviewed by the media."

Changing the Status Quo

The question is why reporters seem unable to grasp the connection between the large body of evidence showing that financial conflicts of interest create bias in medical research and the need for the media to seek out independent sources. To be fair, journalists face a daunting task when trying to sift through medical research, and many are as yet unaware of the profound influence the drug industry has over research results and the ways in which the industry shapes medical "truths." Many reporters also fail to realise that the individuals and organisations they turn to for expert commentary, such as professional groups and charities, professional guideline authors, federal advisory panellists, and patients’ groups, often depend financially on the industry. Thus there is a self reinforcing process in which commercially sponsored researchers, whose prominence is enhanced by the industry’s public relations machine, are dubbed "experts," while independent sources are cited less often.

From informal conversations with colleagues we also know that other factors are at work when reporters fail to take conflicts of interest into account. Some confess that they hesitate to ask sources about any potential conflicts for fear that the source will take umbrage and refuse to be interviewed. Others assume that if a study appears in a peer reviewed journal it must be valid.

One of the solutions to the problem of biased news reporting, in the view of Michael Wilkes, professor of medicine and director of global health at the University of California, Davis, is greater transparency.⁵ We think the list is a step in that direction. The chief requirement for membership, besides a recognised area of expertise, is that the expert must not have taken any industry funding for at least the past five years. Beliefs about certain drugs or treatments were not criteria for inclusion or exclusion. Indeed, the list includes experts who sit at opposite poles of the spectrum of beliefs on certain issues.

Backlash and Honor

Within days of our announcing that we would make our list available to reporters the requests began pouring in. Thus far we have sent a copy of the list to 105 reporters, authors, and editors from such media outlets as the New York Times, Newsweek, Forbes, Fortune, Bloomberg News, the Washington Post, US News & World Report, the Canadian Broadcasting Corporation, Medscape, and many other publications across the US and several other nations. Senators and a state attorney general have also requested it.

Surprisingly, we are also receiving requests from recognised experts who wanted to be onthe list. Being a member, it seems, is a badge of honour, say several of the list members we interviewed for the BMJ. Others, like list member Barnett Kramer, want to improve the quality of medical reporting. Kramer, a medical oncologist and associate director for disease prevention at the US National Institutes of Health, said, "Working journalists can be overwhelmed by PR, and they are often looking for experts who can make comments." It’s useful, he said, to have experts "who are not involved directly with the research and have no potential conflicts of interest relevant to the research."

The other surprise came after the publication of a story we wrote in the online magazine Slate that mentioned the list.⁶ Within days bloggers were furiously accusing us of everything from biased, sloppy reporting to being members of the Church of Scientology (which is opposed to psychiatric drugs). Many of our critics—virtually all of them backed by the industry—opined that our list was undoubtedly filled with experts who were on the payrolls of plaintiffs’ attorneys. (A few have testified in court cases, and those who have been paid for their testimony have disclosed it for the list.) This venom was unexpected, as we imagined that the list would be viewed as a positive step towards helping reporters identify doctors and other experts who can address thorny and complex medical issues without having competing financial interests. Now we think we understand the backlash a little better.

One of the problems recognised by Schwitzer is that many journalists rely for story ideas on news releases from the industry’s public relations departments, and some even use releases as the sole source of information on experts to interview. By offering an alternative list of highly credible, independent experts, the industry may fear that its paid key opinion leaders⁷ and the professional societies whose favour they cultivate will no longer be the first source of medical news.

Peter Gøtzsche, director of the Nordic Cochrane Centre and a member of the Danish group Doctors Without Sponsors, described why he joined the list: "Industry knows that buying doctors is an effective marketing tool . . . far more effective than the dollars they spend on drug representatives. This leads to less than optimal health care for patients."

Beyond the list’s usefulness to journalists, we hope that it will also be used by government agencies, medical journal editors, and professional societies as they seek out experts to serve as editorialists and members of clinical guideline and advisory panels. The FDA, for example, has a copy of the list. We would be pleased to send it to other agencies and professional societies.

It is widely claimed that genuine experts in medicine who aren’t funded by the industry are nearly impossible to find. Indeed, one expert who declined our invitation to be listed said, "If you eliminate people to whom industry turns for advice, you’re eliminating people who are more likely to have something worth saying."

Readers can decide for themselves whether our list of independent experts includes any experts with "something worth saying."

References

1. Garber K. Committee questions a top psychiatrist. US News & World Report. www.usnews.com/articles/news/national/2008/06/26/committee-questions-a-top-psychiatrist.html.
2. Lenzer J. Review launched after Harvard psychiatrist failed to disclose industry funding. BMJ 2008;336:1327.[Free Full Text]
3. Schwitzer G. How do US journalists cover treatments, tests, products, and procedures? An evaluation of 500 stories. PLoS Med 2008;5:e95.[CrossRef][Medline]
4. Cassels A, Hughes MA, Cole C, Mintzes B, Lexchin J, McCormack JP. Drugs in the news: an analysis of Canadian newspaper coverage of new prescription drugs. CMAJ 2003;168:1133-7.[Abstract/Free Full Text]
5. Shuchman M, Wilkes MS. Medical scientists and health news reporting: a case of miscommunication. Ann Intern Med 1997;126:976-82.[Abstract/Free Full Text]
6. Brownlee S, Lenzer J. Stealth marketers: are doctors shilling for drug companies on public radio? Slate, www.slate.com/id/2190775/.
7. Moynihan R. Key opinion leaders: independent experts or drug representatives in disguise? BMJ 2008;336:1402-3.[Free Full Text]