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MARCH 29, 2009 8:24PM

Academics Sling Mud

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Reports have arisent that the editors of the prestigious Journal of the Medical Association(JAMA) are under investigation for attempting to intimidate a doctor. 

 Seriously. 

The reason?  Whistle-blowing.

If this sounds like an episode of Gossip Girl to you, you're not alone.  But here's the story--Dr. Johnathan Leo, a professor of neuroanatomy at the Lincoln Memorial University in Tennessee, read a recent article in JAMA about the antidepressant drug Lexapro in stroke patients.  He decided to do a Google search to learn more. 

He discovered by Googling that the author of the study had a financial relationship with the Lexapro's maker--Forest Labs.  However, that hadn't been disclosed in the article, a big no no in academic medicine and research.  When he realized this, he wrote to another journal, the British Medical Journal, which published his letter online

This got JAMA's editor pretty angry per the reports.  So much so that its editor-in-chief, Catherine DeAngelis, and the deputy editor, Phil Fontanarosa, called the dean of Dr. Leo's school and demanded a retraction.

But here's where the story get really juicy in a geeky sort of way--according the dean of Dr. Leo's school, both editors tried to intimidate Leo and the school into behaving with threats.  Fontanarosa allegedly said that Leo "will be banned from JAMA for life.  You will be sorry. Your school will be sorry.  Your students will be sorry." DeAngelis said she would "ruin the reputation" of the Tennesee University's medical school. 

Ouch. 

The Wall Street Journal contacted DeAngelis about the issue.  Her reponse:

“This guy is a nobody and a nothing” she said of Leo. “He is trying to make a name for himself. Please call me about something important.” She added that Leo “should be spending time with his students instead of doing this.”

Double ouch. 

It looks like that kind of language may come back to bite both big wigs.  After harsh criticism from academic quarters over how they handled the situation, the AMA, JAMA's parent group, has started an internal investigation.

At this point, it's not exactly clear as to why Dr. Leo just didn't got to JAMA with his concerns.   However, DeAngelis and Fontanarosa published an editorial in JAMA to defend themselves (must have been hard to get that by the editorial board...oh, wait! They ARE the editorial board!). 

 Maybe they're right in saying they deserve the right to investigate the matter internally before ruining reputations.  However, intimidating a whistleblower seems like anything but a good idea. 

www.rahulkparikh.com

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_________________________________________________

3/31/09:  Addendum:  Thanks for some crack letters by the OS community, I realized I overlooked the fact that Dr. Leo did attempt to bring this issue to JAMAs attention well before he went public. 

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So JAMA publishes a study that says that Lexapro is better than therapy, without mentioning that the difference wasn't statstically significant. They also don't tell us that the PI was on the payroll of the company that makes Lexapro -- something they could have found out with a Google search.

Wow.

It seems that JAMA did make a good faith effort to investigate the allegations. But they could have avoided a lot of unecessary headches for themselves if they had kept Dr. Leo in the loop. But they didn't, so he fired off his missive to BMJ. Then, it seems like every step after that, DeAngelis and Fontanarosa just kept digging themselves in deeper and deeper.

Calling an investigative reporter from the Wall Street Journal a liar was a big mistake. That's going to come back and haunt them. Deservedly so.
Reading this makes me wonder how common "conflict of interest" is in medicine . . .Perhaps I shouldn't think too hard about it, I'll scare myself, lol.

Great piece!

Rated!
You wonder "how much" conflict of interest is in medicine? Much more than you think. Particularly if you consider how readily medical providers are bombarded with lavishly dishonest PR campaigns and how readily consumers are influenced by direct-to-consumer ads about prescription medications. I'm talking about just what we're exposed to and how it affects us, like all advertising. But when professionals cross the line and make money off of products that they are "advertising" in peer referenced journals, that seems like criminal behavior to me.
I wonder if the whistle blower didn't automatically go to JAMA because of the attitude of the editorial board. Why start a battle that can't be won?

Conflicts of interest are becoming detrimental to research and degrading the field when they escalate to these levels. The net generation of doctors and researchers thought are learning by example what NOT to do.
The more I think about this, the more amused I am at the thundering outrage the AMA exhibits toward anyone who thinks they might be deficient at policing their ranks. After all, theirs is the profession that gave the world tonsillectomies, appendectomies, hysterectomies for retroverted uteri, and clitoridectomy as a cure for female masturbation. Not to mention a little thing called lobotomy.

Read "The Lobotomist" by Jack El-Hai. Even the physicians who were screaming abuse at Freeman at professional meetings wouldn't go to the press with their misgivings. Lobotomy went out of favor only after the first generation of tranquilizing drugs was introduced.

Scary stuff.
Conflicts of interest are the rule, not the exception. So much research is directly or indirectly funded and determined by for-profit manufacturers that sometimes those closest to the microscopes do not even realize how much they are being influenced.

Medical journals and peer review are supposed to be the internal oversight mechanisms for research, but they have become corrupted as well. This story is just one that happened to make the news.
"It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of TheNew England Journal of Medicine." - Marcia Angell, Senior Lecturer in Social Medicine at Harvard Medical School.

The hubris of JAMA editors is what's so disturbing. They are angered that Leo would dare to discuss their publication with the press, as if their actions were not open to scrutiny. They undermine their own credibility by arguing that everyone should hold off until their internal investigation is published. Huh? If they were a publication with merit they would instead have the balls to dare people to investigate them continuously, instead of threatening those who do.
Thanks for this article. JAMA's editors must have noticed that Karl Rove and the Bush/Cheney White House could get away with silencing whistleblowers like Joseph Wilson (one of many, though the most well-known), so why not they? : )
This touches on a serious issue. Medical research is increasingly commissioned and paid for by drug companies who control if it is published and how it is conducted. Researchers have conflicts of interest.

As a result, people have lost faith in science and the medical establishment which pops up in all sorts of ways, like the vaccine-autism theory.
Heck - check out the New York Times - students at Harvard Medical School are up in arms because they are receiving a sub-standard education by faculty pushing their backers' drugs instead of other treatments. Sad and unethical no matter how you look at it.
Harvard and its tentacles is appearing more and more to be the nexus of malfeasance in healthcare. Personally, I also whistle blew at a Harvard affiliated medical center, and the thugs have ruined my life. I think it stems from the over-representation of Harvard in positions of power and influence, its bias towards viewing itself as perfect expert,and its blinders to its own assumptions and limitations. Hubris, it's got in over abundance. Honest intellectual curiosity and beneficence - not so much at all.

I wish you as a medical writer and practitioner would write about what happens to whistle blowers, because I would no more recommend doing that than committing murder, which it really is - at the hands of "civil society". No one has the right to demand whistle blowing unless they are housing, feeding, employing and protecting one who has spoken truth to power and is reaping the wrath of corporate, legal and societal resources alone.
Hmmm. Veddy veddy interesting.

Did I happen to mention in the blog about my worst job ever that I escaped that nut-house by parachuting (gratefully) into the AMA?

I still have a couplea friends who work there.

Must email for gossip.
Here's another fun dimension to the story: The company at the core of the disclosure flap, Forest Labs, is, according to this article being sued by the Department of Justice for placing positive news stories in the media about Lexapro (whatever "placement" is about; apparently that's also a no-no).

Back to JAMA: I'd think that, all else being equal, Robinson and Forest Labs would have been more to blame for damaging the journal's reputation than Leo. Did the editors call Robinson's dean to talk about possible improprieties? Did they threaten to ban him? Hmm...
The reaction of DeAngelis and Fontanarosa is not the condescension the arrogant display toward the misinformed. It's more like the white-hot anger of a criminal caught red-handed.
Patrick,
thanks for reading. as usual, you have thoughtful comments.

I'm still not sure why Dr. Leo made the decision to go public in another medical journal, but like you suggested, attacking him digs JAMAs editors deeper and deeper.
LadyMiko and Risa,
There are increasing pressures on pharma and doctors to be very transparent about conflicts of interest. That's a good thing, which is why I think Dr. Leo going public may have not been such a bad thing. But besides policing ourselves, Congress is putting a lot of pressure on us--they've been very aggressive about outing mental health providers over the past half year--see reports by Gardiner Harris in the NYT
Malusinka,
good points--trust in doctors has eroded, which is part of the problem with why we haven't been able to reassure parents about vaccines and autism, although we're right on that one.
tribulation-
thanks for the suggestion--I've written several pieces on conflicts of interest between pharma and doctors--all on my os blog--take a look back in the archives and you'll find a few
Rob-thanks for sharing the interesting news about DOJ and Forest Labs. I agree that JAMA ought to be angrier with them than they are with Dr. Leo
Actually, if you read the editorial by DeAngelis and Fontanarosa in JAMA, you will see that Leo did first contact the editors--only after being disregarded for months on end did he decide to go with BMJ.
Well, beyond the questions of conflict of interest, this really shows what academic politics are all about: EGO.
It is filled, like I suppose, the rest of life with EGOMANIACS.
I can't tell though if it is really any worse than the corporate and governmental worlds; maybe it is just human nature for truth and power to have a...distant relationship.
One thing to clarify: folks unfamiliar with the academic press may not be aware that the BMJ online "Rapid Response" section is not, in fact, peer reviewed or edited. BMJ allows anyone (yes, even you) to add virtually any comment you like to any article, and then tell everyone that you've been "published by the BMJ", and have a bmj.com URL to go with it. BMJ's editors believe that speed and transparency outweigh the obvious risks of propagating nonsense under the BMJ name. There are downsides: eg RR was a hotbed of HIV denial awhile back. As long as everyone understands that RR is about as reliable as a typical blog comment, it'll all be okay.
MedVed,
thanks for clarifying this--I overlooked it as I was writing this post (was seeing patients all day yesterday!). I suppose one question worth asking this is did Dr. Leo tell them he was planning to go more public with his concerns?
T Fox,
thanks for reading--a lot of journals have gone this route in the age of the Internet--the AAPs journal, Pediatrics calls it P3R (no idea what it means). When I published a commentary about a year ago about autism and vaccines in it, anti-vaccine bloggers had their say there.
I just read through the JAMA editors' missive. I thought I was reading someting written by the Bush administration. It's hard to imagine this is America's permier medical journal. My faith in the AMA has just diminished by half.
A friend of mine who is a doctor writes a blog about public health policy, and he has posted about this particular incident, fleshing in some detail:

http://www.docorion.org/node/25

Some of the questions in these comments are explained there.
Just a note about names. I have no idea where Medved53 comes from. I don't know him, but Medved means Bear in Russian, so there's a high probability that Medicine/medical/medication (as in your spelling of MedVed) is not part of his name.
Screen Name,
thanks for the link to your friend's post--it was helpful
Thanks for writing about this. My opinion of JAMA has gone down a few notches after reading about their unprofessional reaction to the whistle-blower. The editors should have apologized for their lack of oversight in listing the sponsors of the research. rated.