1. Is medicine corrupt? Richard Smith Editor, BMJ www.bmj.com/talks

2. What I want to talk about? What is corruption? Evidence from medical students Richard Horton story The Banerjee case Doctors and drug companies Examples from medical publishing Other possible areas of corruption Why is this happening? What might be done?

4. What is corruption? Corrupt (verb transitive): to taint, destroy the purity of, to pervert, to debase, to spoil, to bribe Corrupt (verb intransitive): to rot, go bad, to lose purity, spoil

5. What is corruption? Corrupt (adjective): defiled, depraved, dishonest, venal, of the nature of--or involving-- bribery, bribed, not genuine or pure, rotten, putrid, debased or made very faulty in transcription

6. Is medicine corrupt?

7. Of course, everything is corrupt to some degree

8. So the question is “How corrupt is medicine?”

9. Evidence from studies on medical students

10. Are "tomorrow's doctors" honest? Questionnaire study exploring medical students' attitudes and reported behaviour on academic misconduct S C Rennie and J R Crosby BMJ 2001; 322: 274-275. 676 students surveyed in Dundee 471 responded (62% response rate)

11. Survey of 461 medical students Do you consider it misconduct to write “Nervous system-- examination normal” when it hasn’t been done? Yes 75% Have you done it? Yes 32%

12. Survey of 461 medical students Do you consider it misconduct to forge a doctor’s signature on a piece of work? Yes 93% Have you done it? Yes 9%

13. Survey of 461 medical students Do you consider it misconduct to copy text directly without acknowledging the source? Yes 82% Have you done it? Yes 14%

14. Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study Lisa K Hicks, Yulia Lin, David W Robertson, Deborah L Robinson, and Sarah I Woodrow BMJ 2001; 322: 709-710. 108 students in Toronto 90% response rate 47% had been asked to act unethically

15. Survey of 103 medical students in Toronto Conflict between medical education and patient care (17) Patients asked to return to clinic for follow up visits and not informed that the visits were entirely for teaching purposes Students asked to perform pelvic examinations on patients under general anaesthesia without patients' prior consent House officer instructed a student to perform a femoral puncture, for purely educational reasons, on a comatose patient who did not need the procedure

16. Survey of 103 medical students in Toronto Responsibility exceeding student's capabilities (15) Student completed antenatal visits with patients who were never seen by a doctor House officer refused to respond to student's request for help in assessing an unstable patient Student and house officer left by teacher to close wound, without knowing how to close it properly Student expected to give weekly psychotherapy sessions without supervision

17. Survey of 103 medical students in Toronto Involvement in care perceived to be substandard (9) Patient requested a narcotic-free vaginal delivery but given intravenous narcotics without her knowledge Student witnessed house officer responding inappropriately to patient's refusal to have joint aspiration; consent form completed, but consent not meaningfully given Student instructed by house officer to repair a child's scalp laceration with inappropriate supplies

18. The ethics of intimate examinations: teaching tomorrow's doctors Yvette Coldicott, Catherine Pope, Clive Roberts BMJ 2003; 326: 97-101. 452 students in Bristol 386 responded (85% response rate)

19. Intimate examinations without consent being recollected

20. Medical students see that academic misconduct is common Survey among 229 German medical students 97% response rate Results are from 201 who had completed their MD dissertation Eysenbach G. BMJ 2001; 322: 1307

21. Medical students see that academic misconduct is common Eysenbach G. BMJ 2001; 322: 1307 Survey among 229 German medical students 97% response rate Results are from 201 who had completed their MD dissertation

22. Survey of 201 German medical students 12 “completely agreed” that “students have to deliver the results expected by the supervisor” 16 had been omitted from a publication despite contributing work 9 had been plagiarised

23. Survey of 201 German medical students 5 had taken words or ideas from others without credit 5 had presented results selectively 7 had trimmed or falsified results

24. Survey of 201 German medical students: observations on others Selective reporting 43% Trimming or falsifying results 36% Wrong authorship attribution 25% Multiple publication 18% Wilfully misleading 14% Plagiarism 14%

26. Institutional corruption in medicine Peter Wilmshurst BMJ 2002; 325: 1232-5.

27. Anjan Kumar Banerjee

28. Banerjee’s story Awarded honours and distinction in his final medical exams Won 24 undergraduate prizes Junior jobs at the Hammersmith and Northwick Park Within a few years of graduating had 49 publications and the first part of his FRCS

29. Banerjee’s story Started research with Professor Tim Peters 1988--doubts raised about his research: included authors on his papers who said that they had not been involved; doubts that he could have done the work Moved with Tim Peters to Kings

30. Banerjee’s story Received grants from charities and pharmaceutical companies for research into the effect of NSAIDs on the gut Colleagues said the work was fraudulent Banerjee confessed that it was--but it had already been printed as an abstract in Gut in 1990 Gut was not notified until 2000 that the work was fraudulent: the retracted it

31. Banerjee’s story 1990--full paper submitted to Gut with Banerjee and Peters as sole authors Retracted as fraudulent 10 years later 1990--widespead doubts about Banerjee; Kings starts an inquiry

32. Banerjee’s story July 1991: Inquiry completed. Chairman writes to Peters and school secretary: "Having carefully examined the documentary evidence which you sent me, I am totally satisfied that much of the research data reported by Dr Banerjee since 1988 is at best unreliable, and in many cases spurious.”

33. Banerjee’s story The report disappeared Kings didn’t notify the MRC or Gut University of London awarded him an MD degree based on the fraudulent research; never retracted Royal College of Surgeons made him a Hunterian professor based on his (fraudulent) research

34. Banerjee’s story Early 90s Banerjee became a consultant surgeon in Halifax 2000 resigned November 2000--found gulity of serious professional misconduct for falsifying research February 2001--Peters found guilty of serious professional misconduct for failing to act on Banerjee

35. Banerjee’s story September 2002: found guilty of serious professional misconduct for financial dishonesty: misled patients about the length of NHS waiting lists to induce patients to opt for private treatment and sought payments for treatments not performed. Concerns were also expressed about clinical skills.

36. Banerjee’s story More than 10 years elapsed between there being clear evidence of fraud and proper action being taken He flourished professionally despite strong evidence of misconduct Many were harmed by his behaviour Many knew about his misconduct Documents were lost Whistleblowers were threatened

37. “ For the triumph of evil it is only necessary for good men to do nothing.” Edmund Burke

38. Institutional corruption No individual within an institution wants misconduct to flourish, but nobody is directly responsible--so it does flourish.

39. Bristol: another example?

40. Doctors and drug companies. Too close for comfort?

42. 16 forms of entanglement between doctors and drug companies Face to face visits from drug company representatives Acceptance of direct gifts of equipment, travel, or accommodation (“Will you advertise my drug on your person for a year if I pay you 20p?”) Acceptance of indirect gifts, through sponsorship of software or travel

43. 16 forms of entanglement between doctors and drug companies Attendance at sponsored dinners and social or recreational events (“If they have to pay the full whack they won’t come?”) Attendance at sponsored educational events, continuing medical education, workshops, or seminars (“Could you hurry up so we can get to the vol au vents?”) Attendance at sponsored scientific conferences (“Bugger Bognor, but the Gritti Palace in Venice sounds good.”)

44. 16 forms of entanglement between doctors and drug companies Ownership of stock or equity holdings Conducting sponsored research (“It’s so hard to get money from the MRC and £800 for registering a patient is not bad.”) Company funding for medical schools, academic chairs, or lecture halls Membership of sponsored professional societies and associations Advising a sponsored disease foundation or patients' group

45. 16 forms of entanglement between doctors and drug companies Involvement with or use of sponsored clinical guidelines Undertaking paid consultancy work for companies (“A return flight on Concorde, five nights at the Ritz Carlton, and 20 grand is not bad for two hours of blah.”) Membership of company advisory boards of "thought leaders" or "speakers' bureaux” (“Flattery and money: I can resist everything except temptation.”)

46. 16 forms of entanglement between doctors and drug companies Authoring "ghostwritten" scientific articles (A critic on Naomi Campbell’s autobiography: “If she can’t be bothered to write it I can’t be bothered to read it.”) Medical journals' reliance on drug company advertising, company purchased reprints, and sponsored supplements (“It’s a million quid and £800 000 profit for reprints of a major trial. Without it I might have to lay off staff. But we’re not influenced in our decision making.”)

47. Does all this matter? Virtually all new drugs, which have been so important for medicine, have come from drug companies Drug companies must have the right to market their products Prescribing is influenced--often to be unnecessarily expensive

48. Does all this matter? Information is biased Doctors are too dependent on drug companies for both education and information Companies spend more on marketing than on research Costs are inflated

49. Corruption in medicine? Evidence from medical publishing

50. Corruption in medical publishing Redundant publication occurs in around a fifth of published papers About a fifth of authors of studies in medical journals have done little or nothing Most authors of studies in medical journals have conflicts of interest, yet they are declared in less than 5% of cases

51. Conflict of interest: a case study in poor performance within biomedicine

52. How common are competing interests? 75 articles on calcium channel anatagonists 89 authors 69 (80%) responded 45 (63%) had financial conflicts of interest Only 2 of 70 articles disclosed the conflicts of interest Stelfox HT, Chua G, O'Rourke K, Detsky AS. Conflict of interest in the debate over calcium channel antagonists. N Engl J Med 1998; 338: 101- 105

53. Why don’t authors declare conflicts of interest? Some journals don’t require disclosure The culture is one of not disclosing Authors think that it’s somehow “naughty” Authors are confident that they are not affected by conflicts of interest

54. Does conflict of interest matter? Financial benefit makes doctors more likely to refer patients for tests, operations, or hospital admission, or to ask that drugs be stocked by a hospital pharmacy. Original papers published in journal supplements sponsored by pharmaceutical companies are inferior to those published in the parent journal. Reviews that acknowledge sponsorship by the pharmaceutical or tobacco industry are more likely to draw conclusions that are favourable to the industry.

55. Does conflict of interest matter? Is there a relationship between whether authors are supportive of the use of calcium channel antagonists and whether they have a financial relationship with the manufacturers of the drugs? Stelfox HT, Chua G, O'Rourke K, Detsky AS. Conflict of interest in the debate over calcium channel antagonists. N Engl J Med 1998; 338: 101- 105

57. Does conflict of interest matter? 106 reviews, with 37% concluding that passive smoking was not harmful and the rest that it was. Multiple regression analysis controlling for article quality, peer review status, article topic, and year of publication found that the only factor associated with the review's conclusion was whether the author was affiliated with the tobacco industry. Only 23% of reviews disclosed the sources of funding for research. Barnes DE, Bero LA. Why review articles on the health effects of passive smoking reach different conclusions. JAMA 1998; 279: 1566-1570

58. Does conflict of interest matter?: third generation contraceptive pills At the end of 1998 three major studies without sponsoring from the industry found a higher risk of venous thrombosis for third generation contraceptives; three sponsored studies did not. To date, of nine studies without sponsoring, one study found no difference and the other eight found relative risks from 1.5 to 4.0 (summary relative risk 2.4); four sponsored studies found relative risks between 0.8 and 1.5 (summary relative risk 1.1) The sponsored study with a relative risk of 1.5 has been reanalysed several times, yielding lower relative risks; after this failed to convince, a new reanalysis was sponsored by another company. One sponsored study finding an increased risk has not been published. Vandenbroucke JP, Helmerhorst FM, Frits R Rosendaal FR. Competing interests and controversy about third generation oral contraceptives. BMJ 2000; 320: 381.

59. Other topics I might have covered Private practice “X has had a heart attack. Who’ll do his on call?” “Whover does it normally, when he’s doing his private practice.” Merit awards Fundholding: keeping prescribing deliberately high in order to maximise next year’s budget Racism “Lucragrams”

60. Why do we have corruption? Why wouldn’t we? Much of medicine operates on trust Inadequate accountability Inadequate training Poor role models “Pressure to publish”

61. Why do we have corruption? The main target of one of the world’s richest industries Tribal loyalty “Under no circumstances would I shop another doctor” “Not even if he was murdering his patients, like Harold Shipman.” “Not even then. I know how hard it is to be a doctor.”

62. Why do we have corruption? “There but for the grace of God go I.” “The bogus contract” Patient: “Modern medicine is wonderful. You can see inside me, fix my problems” Doctor: “I’m more impressed with what medicine can’t do than it can do. I can’t fix this. I’d better keep quiet. My salary and my status comes from my ‘magical’ powers.”

63. What can be done about corruption in medicine? Set high standards Increase transparency in appointments, merit awards, private practice Increase accountability: appraisal, revalidation, CHAI, etc Interact more professionally with the drug industry

64. Survey on bmj.com: 1479 responding Would you like doctors to stop seeing drug company representatives, replacing them with more independent sources of health information? Yes 79% Would you like doctors to stop receiving all forms of direct and indirect gifts from drug companies? Yes 84%

65. Survey on bmj.com: 1479 responding Would you like industry-funded education of doctors replaced by education funded by more independent sources? Yes 84% Would you like all financial relationships between doctors and drug companies conducted with transparent contracts that are disclosed to patients and the public? Yes 96%

66. What can be done about corruption in medicine? Teaching/discussions on best practice in relating to patients, research, etc Leadership (“Tone at the top”)

67. Finally, recognise something that I didn’t recognise until I was fifty and three quarters

68. “Integrity is not something you have and hope not to lose but something you must work at every day.”