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The Corruption of Evidence Based Medicine — Killing for Profit
The idea of Evidence Based Medicine (EBM) is great.
The reality, though, not so much. Human perception is often flawed, so the
premise of EBM is to formally study medical treatments and there have certainly
been some successes.
Consider the procedure of angioplasty. Doctors insert a
catheter into the blood vessels of the heart and use a balloon like device to
open up the artery and restore blood flow. In acute heart attacks studies
confirm that this is an effective procedure. In chronic heart disease the COURAGE study and more recently the ORBITA study showed that angioplasty is largely useless. EBM
helped distinguish the best use of an invasive procedure.
So,
why do prominent physicians call EBM mostly useless? The 2 most prestigious
journals of medicine in the world are The Lancet and The New England Journal of
Medicine. Richard Horton, editor in chief of The Lancet said this in 2015
“The case against science is
straightforward: much of the scientific literature, perhaps half, may simply be
untrue”
Dr.
Marcia Angell, former editor in chief of NEJM wrote in 2009 that,
“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”
This
has huge implications. Evidence
based medicine is completely worthless if the evidence base is false or
corrupted. It’s like building a wooden house knowing the
wood is termite infested. What caused this sorry state of affairs? Well, Dr.
Relman another former editor in chief of the NEJM said this in 2002
“The
medical profession is being bought by the pharmaceutical industry, not only in
terms of the practice of medicine, but also in terms of teaching and research.
The academic institutions of this country are allowing themselves to be the
paid agents of the pharmaceutical industry. I think it’s disgraceful”
The
people in charge of the system — the editors of the most important medical
journals in the world, gradually learn over a few decades that their life’s
work is being slowly and steadily corrupted. Physicians and universities have
allowed themselves to be bribed.
The
examples in medicine are everywhere. Research is almost always paid for by
pharmaceutical companies. But studies done by industry are well known to have positive results far more frequently. Trials run
by industry are 70% more likely than government funded trials to show a
positive result. Think about that for a second. If EBM says that 2+2 = 5 is
correct 70% of the time, would you trust this sort of ‘science’?
Selective
Publication — Negative trials (those that show no benefit for the
drugs) are likely to be suppressed. For example, in the case of antidepressants, 36/37 studies that were
favourable to drugs were published. But of the studies not favorable to drugs,
a paltry 3/36 were published. Selective publication of positive (for the drug
company) results means that a review of the literature would suggest that 94%
of studies favor drugs where in truth, only 51% were actually positive. Suppose
you know that your stockbroker publishes all his winning trades, but suppresses
all his losing trades. Would you trust him with your money? But yet, we trust
EBM with our lives, even though the same thing is happening.
Let’s look at the following graph of
the number of trials completed versus those that were published. In 2008, the
company Sanofi completed 92 studies but only a piddly 14 were published. Who
gets to decide which gets published and which does not? Right. Sanofi. Which
ones do you think will be published? The ones that favor its drugs, or the ones
that prove their drugs do not work? Right. Keep in mind that this is the only rational
course of action for Sanofi, or any other company to pursue. It’s idiotic to
publish data that harms yourself. It’s financial suicide. So this sort of
rational behavior will happen now, and it will not stop in the future. But
knowing this, why do we still believe the evidence based medicine, when the
evidence base is completely biased? An outside observer, only looking at all
published data, will conclude that the drugs are far, far more effective than
they are in reality. Yet, if you point this out in academic circles, people
label you a quack, who does not ‘believe the evidence’.
Rigging of Outcomes — Or
consider the example of registration of primary outcomes. Prior to year 2000,
companies doing trials did not need to declare what end points they measured.
So they measure many different endpoints and simply figured out which one
looked best and then declared the trial a success. Kind of like tossing a coin,
looking at which one come up more, and saying that they were backing the
winning side. If you measured enough outcomes, something was bound to come up
positive.
In
2000, the government moved to stop these shenanigans. They required companies
to register what they were measuring ahead of time. Prior to 2000, 57% of
trials showed a positive result. After 2000, a paltry 8% showed good results.
More evidence of the evidence base being completely corrupted by commercial
interest, and the academic physicians who were getting rich on it tacitly
allowing corruption because they know that you don’t bite the hand that feeds
you
‘Advertorials’ — Or
this example of a review paper in the NEJM that fracture rates caused by the
lucrative bisphosphonate drugs were “very rare”. Not only did the drug
companies pay lots of consulting fees to the doctors, three of the authors of
this review were full time employees! To allow an advertorial to be published
as the best scientific fact is scandalous. Doctors, trusting the NEJM to
publish quality, unbiased advice have no idea that this review article is pure
advertising. Yet, we still consider the NEJM to be the very pinnacle of
evidence based medicine. Instead, as all the editors of the journals sadly
recognize, it has become lucre-based publishing. Mo money = better results.
Money
from Reprints — The reasons for this problem is obvious to all — it’s insanely
profitable for journals to take money from Big Pharma. Journals want to be
read. So they all try to get a high Impact Factor (IF). To do this, you need to
get cited by other authors. And nothing boosts ratings like a blockbuster
produced by Big Pharma. They have the contacts and the sales force to make any
study a landmark. A less obvious benefit is the fees that are generated by Big
Pharma purchasing articles for reprint. If a company publishes an article in
the NEJM, they may order several hundred thousand copies of the article to be
distributed to unsuspecting doctors everywhere. These fees are not trivial. The
NEJM publisher Massachusetts Medical Society gets 23% of its income from
reprints. The Lancet — 41%. The American Medical Association — a gut busting
53%. No wonder these journals are ready to sell their readers (ordinary
physicians) down the river. It pays. Who needs journalistic ethics when there’s
a Mercedes in the driveway? Mo money, baby. Mo money.
Bribery
of Journal Editors — A recent study by Liu et al in the BMJ shed more light on the
problem of crooked journals. Crooked journal editors. Editors play a crucial
role in determining the scientific dialogue by deciding which manuscripts are
published. They determine who the peer reviewers are. Using the Open Payments
database, they looked at how much money the editors of the most influential
journals in the world were taking from industry sources. This includes
‘research’ payments, which are largely unregulated. As mention previously, much
‘research’ consists of going to meetings in exotic locale. It funny how many
conferences are held in beautiful European cities like Barcelona, and how few
are done in brutally cold Quebec City.
Of
all journal editors that could be assessed, 50.6% were on the take. The average
payment in 2014 was $27,564. Each. This does not include an average $37, 330
given for ‘research’ payments. Other particularly corrupt journals include:
This is slightly horrifying. Each editor of the Journal
of the American College of Cardiology received, on average $475 072 personally
and another $119 407 for ‘research’. With 35 editors, that’s about $15 million
in bribes to doctors. No wonder the JACC loves drugs and devices. It pays the
private school bills. Mo money = we’ll publish your crooked studies for you. Mo
money, baby, mo money.
Publication
Bias — The evidence base that EBM depends upon is completely
biased. Some people think I’m really anti-Pharma, but this is not really true.
Big Pharma companies have a duty to their shareholders to make money. They have
no duty to patients. On the other hand, doctors have a duty to patients.
Universities have a duty to remain unbiased.
It
is the failure of doctors and universities to keep their greedy paws out of the
corrupting influence of Big Pharma money that is the problem. If Big Pharma is
allowed to spend lots of $$$ paying off doctors and universities and
professors, then it should do so to maximize profits. That is their mission
statement. Doctors love to blame Big Pharma companies because it takes peoples
gaze off the real problem — lots of doctors taking $$$ from anybody who will
pay. The pharma industry is not the problem. Bribery of university doctors is
the problem — one that is easily fixed if the political will exists.
Consider this study. Looking at studies in the field of neurodegenerative
disease, researchers looked at all the studies that were started but never
finished or never published. Approximately 28% of studies never made it to the
finish line. That’s a problem. If all the studies that don’t look promising for
drug candidates are not published, then it appears that the drugs are way way
more effective than they really are. But the published ‘evidence base’ would
falsely support the drug. Indeed, Pharma sponsored trials were 5
times more likely to be unpublished.
Imagine
you have a coin flipping contest. Suppose a player call ‘Big Pharma” chooses
heads, and also pays the coin flipper. Every time the coin flipper pulls up
tails, the results don’t count. Every time it comes up heads, it counts. This
happens 28% of the time. Now, instead of a 50/50 split of heads and tails, it’s
more like a 66/34 split of heads/tails. So the ‘evidence based medicine’ lover
claims that heads is far more likely to come up than tails, and castigates people
who don’t believe the results as ‘anti-science’.
Evidence
based medicine depends entirely upon having a reliable base of evidence
(studies). If the evidence base is tampered with, and paid for, then EBM as a
science is completely useless. Indeed, the very editors whose entire careers
have been EBM have now discovered it to be worthless. Does the CEO of Phillip
Morris (maker of Marlboro cigarettes) smoke? That tells you all you need to
know about the health risks. Do the editors of the NEJM and the Lancet believe
EBM anymore? Not at all. So neither should we. We can’t believe evidence based
medicine until the evidence has been cleaned up from the corrupting influence
of commercial interests.
Financial
conflicts of interest (COI), also known as gifts
to doctors, is a well accepted practice. A national survey in the New England Journal of Medicine in 2007 shows that 94% of
physicians had ties to the pharmaceutical industry. This gravy train only rides
in one direction. From Big Pharma to the wallets of doctors. Sure Big Pharma
can simply pay doctors directly, and it does plenty of that. It’s no surprise
that medical students with more exposure to pharmaceutical reps develop a
more positive attitude towards them. Many medical schools have limited exposure
of medical students in response, but declined to get off the gravy train
themselves. There is a simple relationship between how prominent a physician is
(more articles published — almost always academic doctors and professors) and
how much money they take from Big Pharma. Mo prominent = mo money. Further, there
is a ‘clear and strong link’ between taking industry money and minimizing
the risk of side effects of medications. What, you thought people teach at
prestigious institutions like universities for the good of mankind? Maybe
that’s why they went there, but that’s not why they stay. They came for the
science. They stayed for the money.
So here’s a damning list of all the problems of EBM
1.
Selective Publication
2.
Rigged outcomes
3.
Advertorials
4.
Reprint Revenues
5.
Bribery of Journal Editors
6.
Publication Bias
7.
Financial Conflicts of Interests
When
the evidence base of medicine is bought and paid for, people die. That is how
doctors have created this opioid crisis that kills thousands of people.
Pharmaceutical companies want to pay off
doctors, just as drug lord want to pay off judges and police officers. Doctors,
being human, should put safeguards against this temptation. Unfortunately,
doctors and universities have been willing participants in this game of killing for profit. We need to end it now. End the
corruption of the universities. Stop the bribery of doctors.
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