We are all more interested in the conflicts of interests of others than we are in our own, and editors are no exception. Having preached to authors and reviewers on conflict of interest, editors have largely neglected their own, but an important and fascinating paper in PloS Medicine shows how editors can be exposed to dramatic conflicts of interest.
The paper is suitably po faced, as is the accompanying editorial, but, as a blogger and ex-editor, I can spell out one of the conflicts of editors in stark terms. It arises when considering a large clinical trial funded by a drug company, and, for example, a third of the trials in the New England Journal of Medicine are funded by industry with almost another half having mixed funding that includes a drug company. Editors know well that they may be able to sell a million dollars worth of reprints of such an article, with a profit margin of perhaps 70%. In other words publishing that one paper will lead to $700 000 on the bottom line. Very few actions in business provide such a substantial profit from so little.
Deciding whether to publish such a paper provides a stark conflict of interest because editors have to think a lot about money. As income from advertising falls, as it is for many journals just as with newspapers, some journals slip into the red. The minute that a journal loses rather than makes money the owners begin to wonder if they need it. Then even if the journal makes a great deal of money, as do several of the bigger journals, the owners would always like it to make more—or at least maintain the profits because they may well be dependent on them.
So how else might editors put $700 000 onto the bottom line? They have to sell about 10 000 extra subscriptions—because subscriptions have a much lower profit margin. To sell so many subscriptions is virtually impossible—and remember that this is to replace the profit from publishing one drug company sponsored trial. As the paper in PloS Medicine shows, the New England Journal of Medicine in 2005-6 published 66 trials supported solely by industry and another 95 with some industry funding.
Another option would be to cut costs, which probably means staff. The editor would have to fire at least five staff (and probably many more) to add $700 000 to the journal’s profits, and clearly such a strategy could not be followed more than a couple of times.
It’s thus very tempting to publish that drug company sponsored trial, and the temptation is increased further by such trials boosting impact factors, as the PloS Medicine paper shows. Such trials are well cited partly because they are important and partly because drug companies have considerable resources to promote the papers, not least by distributing hundreds of thousands of reprints. The PloS Medicine authors calculate that the impact factor of the New England Journal of Medicine would be reduced by about 15% if it declined to publish drug company sponsored trials.
And editors care very much about impact factors. A high score means not only prestige but also more important papers, more subscriptions, and so more money. Publishing a drug company sponsored trial rather than, say, a study of changing the built environment to increase physical activity will bring both profit and an increased impact factor. How tempting.
The PloS Medicine authors show, as have others, that the proportion of trials funded solely by industry ranges from 7% in the BMJ through 26% for JAMA to 32% for the New England Journal of Medicine. The authors asked the owners of the six journals they studied to give them data on sources of income, but only the BMJ and the Lancet agreed. In 2005-6 the BMJ made 16% of its income from display advertising and 3% from the sale of reprints, while the Lancet made 1% from display advertising and 41% from reprints. The Lancet sold 11,5 million reprints, and the BMJ 968 000.
The authors tried to work out the income of the American journals from their tax returns, but it wasn’t easy because their owners publish more than one journal. They asked the owners to confirm their calculations but were unable to elicit any response from the editors of JAMA and the New England Journal of Medicine.
The conclusion of the authors is that journals should disclose financial conflicts of interest in the way that they require authors and reviewers to do. They will, I suspect, have a long wait.
I must confess that nothing surprised me in the paper, but I do think that it’s am important step to begin to provide some data, albeit tentative and incomplete, on the financial conflicts of interest of editors and journals.
But what did surprise me was the quote from Marcia Angell with which Harvey Marcovitch ended his editorial in PloS Medicine. Angell was an editor on the New England Journal of Medicine for some 20 years, and I knew her a little. She is brilliant and feisty, has been voted one of the most influential women in the US, and fought battles with the Massachusetts Medical Society, the owners of the New England Journal of Medicine. She wrote a very readable and influential book on medicine and the drug industry, and she writes excellent pieces in the New York Review of Books.
I’ve read several of her articles, but I hadn’t read the one that Marcovitch quoted in which she wrote: “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 the New England Journal of Medicine.”
Sadly I followed the same path and spelt out my disillusionment in my “j’accuse” book The Trouble with Medical Journals. I wrote it in 2004, and since then my pessimism has deepened.
Competing interest: RS was editor of the BMJ and chief executive of the BMJ Publishing Group from 1991 to 2004. He is also a member of the board of the Public Library of Science.