EDITORIAL
Less Than the Truth
Timothy Rowe, MB BS, FRCSC
Editor-in-Chief
A sk yourself this: do you think that your clinical
decisions are ever swayed by financial influences? Or
by other influences that lead to personal gain? Most of us
would likely answer “no,” and feel annoyed by the question.
Members of society like to believe that their physicians act
entirely in their patients’ best interests, using the most up-
to-date information and weighing the risks and benefits of
interventions without prejudice. We like to think that we
live up to these expectations, and that financial influences
have no effect on what we recommend to a patient.
But—realistically—physicians (and other care givers) are all
human too. When all is said and done, we are just as likely
to act in our own interests as anybody else. The problem is
that we tend to deny this and say (and even think) that we
are not motivated by self-interest. We tend to deny that we
have any conflict of interest if a pharmaceutical company
buys us a nice dinner. We tend to insist that it won’t affect
our judgement in any way. Yet a substantial body of data
has shown that it does.1
So should I have a guilty conscience? Am I fully aware
of all the things that affect my judgement? At the recent
International Congress on Peer Review and Biomedical
Publication in Chicago, a presentation by a representative
of the Nordic Cochrane Centre in Copenhagen garnered
considerable attention and sparked much debate. It
described the findings of a study conducted to determine the
number of undisclosed conflicts of interest in publications
from clinical trials involving Danish physicians, who must
apply for permission to have paid collaboration with
industry.2 This requirement has led to concern on the part
of Danish physicians that it will threaten the viability of
future clinical trials in Denmark. Is this legal requirement
always followed? According to Kristine Rasmussen of the
Nordic Cochrane Centre, who presented the results of
the study, it is not. Of the first 100 clinical trials she and
her colleagues identified (the trials reports had to have at
least one Danish author), 49% were industry-sponsored.
Among the Danish authors, 27% had a conflict of interest
related to the trial in which they participated, and 48% of
these conflicts were not disclosed by the authors. Overall,
89% of the authors had some form of undisclosed
relationship with industry (Kristine Rasmussen, Nordic
Cochrane Centre, oral communication).
This degree of non-disclosure (and the preponderance of
conflicts) led to—well, not shock and awe, exactly, but a
good deal of concern, because it reinforces the perception
that physicians simply don’t take conflict of interest
seriously. The figures in Denmark could reasonably be
expected to apply to most developed countries. The
consequences of having undisclosed conflicts of interest
in clinical trials have been discussed in many forums,
perhaps most boldly by Marcia Angell, former Editor-in-
Chief of the New England Journal of Medicine, in a 2009
article titled “Drug Companies and Doctors: A Story of
Corruption.”3 In this article, she describes the astonishing
financial involvement between pharmaceutical companies
and supposedly independent physicians in the United States,
the pervasive influence of pharmaceutical companies on
drug trials, and her observation that industry-sponsored
trials published in medical journals consistently favour
the sponsors’ drugs; this appears to be largely because
studies with negative results are not published, those
with positive results are published repeatedly in slightly
different forms, and negative results are given a positive
spin (of which more in a moment). A 2008 review of 74
US Food and Drug Administration registered trials of
antidepressants found that 37 of 38 studies with positive
results were published, but that of 36 studies with negative
or questionable results, 22 were not published and 11 were
published in a way that conveyed a positive outcome.4 This
meant that from publications it appeared that 94% of the
trials were positive, but according to US Food and Drug
Administration reviews only 51% were positive. It’s hard
to say whose fault this publication bias is, and I’m prepared
to acknowledge that it is partly the fault of journal editors.
J Obstet Gynaecol Can 2013;35(11):971–972
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Editorial
But in defence of editors, I would point out that we rarely
if ever have access to raw data, and in many cases we lack
the expertise to conduct a valid assessment. We rely heavily
on the good intentions of authors and the shrewdness of
reviewers. That combination usually works.
But not always. Another presentation at the Peer Review
Congress described a study of “spin” and its effect on
how readers interpreted reports of RCTs in the field of
cancer. Spin was defined as a specific way of reporting
with the aim of convincing readers that the beneficial
effect of an experimental treatment is greater than shown
by the results. We think this shouldn’t happen, but it does;
it may be a result of ignorance of the science under study,
unconscious bias, or a wilful desire to deceive.5 In a study
published in 2010 of RCTs with a clearly identified primary
outcome showing statistically non-significant results, 50%
of 72 eligible studies showed spin in the Conclusion, and
29% even had spin in the Results.6 So it does happen.
In the presentation at the Peer Review Congress, 300
established authors of clinical trials in the field of cancer
were randomized to assess an abstract with spin or the
same abstract rewritten to remove spin. The findings were
not surprising: reviewers of the abstract with spin were
more likely to feel that the treatment it described would
be beneficial for patients than were reviewers of the no-
spin abstract (Isabelle Boutron, INSERM, Paris, oral
communication). This is an alarming finding, because the
abstract is the only portion of an article indexed in many
electronic databases, and is for many readers the only part
of an article they actually read. Conceivably a small amount
of spin can have far-reaching consequences.
Whether or not spin is allowed to appear in medical
journals is ultimately the responsibility of editors. We
972 l NOVEMBER JOGC NOVEMBRE 2013
recognize this, and do our best to stamp it out. The
spin experts (we won’t call them “spin doctors”: that
has another connotation) have promised to disseminate
guidelines to help in recognizing and eliminating this
potentially dangerous hoodwinking. We can best deal
with conflicts of interest by recognizing that we all have
them; we at JOGC, like the British Medical Journal,1 label
them “competing interests” rather than “conflicts,” in
order to reduce the stigma associated with the latter term.
The prevailing culture should be to declare all potential
conflicts whenever there is any hint that they might have
a bearing on behaviour. Regrettably, at least as far as
Canadian medical schools go, ensuring that conflicts are
declared is still a work in progress.7
REFERENCES
1. Smith R. Conflicts of interest: how money clouds objectivity. J R Soc Med
2006;99(6):292–7.
2. The Danish Association of the Pharmaceutical Industry. Collaboration
agreement between the Danish Medical Association and the Danish
Association of the Pharmaceutical Industry on clinical trials. Available at:
http://www.laeger.dk/portal/pls/portal/!PORTAL.wwpob_page.show?_
docname=5642847.pdf. Accessed September 14, 2013.
3. Angell M. Drug companies & doctors: a story of corruption. New York
Review of Books, 15 January 2009. Available at: http: //www.nybooks.com/
articles/22237. Accessed on September 15, 2013.
4. Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective
publication of antidepressant trials and its influence on apparent efficacy.
N Engl J Med 2008;358:252–60.
5. Fletcher RH, Black B. ‘‘Spin’’ in scientific writing: scientific mischief and
legal jeopardy. Med Law 2007;26:511–25.
6. Boutron I, Dutton S, Ravaud P, Altman DG. Reporting and interpretation
of randomized controlled trials with statistically nonsignificant results for
primary outcomes. JAMA 2010;303:2058–64.
7. Shnier A, Lexchin J, Mintzes B, Jutel A, Holloway K. Too few, too weak:
conflict of interest policies at Canadian medical schools. PLoS ONE
2013;8(7):e68633.