Bad Medicine: How hidden incentives and opaque conflicts dictate what you read in medical journals

If you believe that scientific journals and publications are unbiased town squares of academic thought, I have a bridge to sell you. And I’ll throw in an ice cream farting unicorn for free.

While authors of published articles are compelled to disclose their conflicts, the most import conflict of interest scientific journals don’t clearly disclose is their own. Journals remain unusually taciturn about disclosing where they get their revenue from and how advertising and subscriptions influence their publication decisions.

It is no secret that pharmaceutical company sponsorship drives a leviathan portion of medical publishing revenue. Open any journal and you’re gobsmacked with full page color advertisements extolling the virtues of unpronounceable drugs placed strategically close to scientific articles about that very drug. How convenient.

Regardless of how you feel about these advertisements, it is at least obvious and abundantly clear to the reader who paid for it and what its purpose is. Some argue that journal advertising offers readers the benefit of information to which they would otherwise not have had access to, or in a timely manner were it not for industry sponsorship defraying some of the publishing costs. Plus nobody is obliged to read the ads, and they have recourse to complaint about intentionally misleading or offensive material.

However, there exist less recognizable and incredibly opaque ways by which journals are incentivized to prioritize the publication of drug studies that show pharmaceutical drug benefit over those that show none or a even a net negative benefit from their use. The two main mechanisms by which the invisible finger of Big Pharma tips the scales in favor of drug publishing are reprints and citations.

Reprints

When a journal article shows favorable outcomes for a particular drug, the pharmaceutical company that makes the drug will often buy a reproduction of the paper—called a reprint—in bulk from the journal. This reprint is then distributed to to prescribers, health agencies and the media to promote sales and public perception.

For many pharmaceutical companies, hard copy article reprints represent the primary way of disseminating information. Reprint purchases can add up to more than $2 million each. That is a significant chunk of a journal’s revenue. For example, the Lancet’s revenue total annual is estimated to be about $40 million a year, while NEJM generates around $100 million—of which about a third is profit.

Here is the best part: reprints are more profitable than advertising because the production costs are much lower compared to the cost of publishing a new article. No copyediting, formatting or waiting for clearance from legal. Just hit print. Pure profit.

Consider the following scenario: a pharmaceutical company sponsors a clinical trial—completely or in part. The authors of the clinical trial—many paid by the pharmaceutical company—submit the article to a journal. The pharmaceutical company then buys ads in the same journal. The journal knows that publishing the article brings additional revenue from reprints of the article if accepted. What are the odds that the journal will decline it and risk losing a hefty piece of their revenue?

In 2011, an astounding 41% of the Lancet’s income came from the sale of reprints. Annals of Internal Medicine and New England Journal of
Medicine (NEJM) did not reveal their data. Contemplate that number carefully. Nearly a half of a major medical journal’s revenue came from reprints. How unbiased can you be when half of your revenue stream is predicated on publishing stuff that will get reprints?

The 2011 analysis of the Lancet’s income is one of the few that was able to obtain any data on reprint revenue, and it is likely many journals earned even more from reprints but didn’t disclose their data. But although the conflict of interest associated with sales of reprints has been well known for a long time, there has been no improvement in journals’ transparency.

Citations

The greatest status symbol in scientific publishing is called the “impact factor.” Impact factor is a measure of the frequency with which the average article in a journal has been cited in a particular year. The higher the impact factor, the more important and prestigious the journal.

Industry-supported trials are more likely to be published. Almost one third of all medical publications are in some way shape or form industry funded. Because they are often positive, they are cited more often, and are often cited by authors paid by the same pharmaceutical company publishing more data about the same drug. This almost guarantees that every pharmaceutical sponsored trial will enhance a journal’s impact factor and makes industry-sponsored studies all the more appealing to journals.

This creates an uneasy and murky conflict of interest. John Abramson, a Harvard Medical School professor and the author of Sickening, a book on the role of big pharma’s pursuit of profit in American healthcare explains “It creates a conflict of interest in the medical journal industry, because they then have a financial incentive not to demand all the data, not to review as critically as they might if they had no opportunity for financial gain”

Why does this matter?

Incentivizing the publication of positive studies in effect censors the publication of negative or equivocal data. This not only impacts patient care—the greatest and most important consideration—but also scientific and academic freedom. When a study claiming spectacular therapeutic success is published in a big name journal, people are more likely to believe its claims of efficacy. However, not infrequently, data that conflicts the set narrative only makes it into second-tier, lesser known journals and barely gets noticed. And of course, there are no big pharma reprints of those articles being mailed out to people to help them take notice that the drug is not all that was promised. Is it any wonder then that we are increasingly a society filled with bad medicine, bad data, bad health, bad trust and high costs of healthcare?