{"id":41709,"date":"2018-03-23T12:55:50","date_gmt":"2018-03-23T11:55:50","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=41709"},"modified":"2018-04-03T10:50:00","modified_gmt":"2018-04-03T09:50:00","slug":"richard-smith-the-dangers-of-textbooks","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2018\/03\/23\/richard-smith-the-dangers-of-textbooks\/","title":{"rendered":"Richard Smith: The dangers of textbooks"},"content":{"rendered":"<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/12\/richard_smith_2014.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-33037\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/12\/richard_smith_2014-150x150.jpg\" alt=\"richard_smith_2014\" width=\"128\" height=\"128\" \/><\/a><span style=\"font-weight: 400\"><a href=\"https:\/\/www.tandfonline.com\/doi\/full\/10.1080\/23294515.2018.1436095\">Recently published research<\/a> has found that about half of the authors of <\/span><i><span style=\"font-weight: 400\">Harrison\u2019s Principles of Internal Medicine<\/span><\/i><span style=\"font-weight: 400\">, which is nothing short of a <\/span><i><span style=\"font-weight: 400\">Bible<\/span><\/i><span style=\"font-weight: 400\"> in medicine, have received payments from 17 pharmaceutical and device companies and about a quarter hold patents.\u00a0<\/span><span style=\"font-weight: 400\">Some of these payments were considerable: authors in total had received more than $11m over four years, and one author had been paid $560\u2009021 over a 17 month period, 90% of it for consulting. But none of these conflicts of interest were declared in the textbook. The research found that other textbooks had authors with financial conflicts of interest that were not declared, confirming earlier research. There is simply no tradition of publishing conflicts of interest in textbooks, as there is now, at long last, for articles in journals. Guidelines are beginning to follow with publishing conflicts of interest, and surely textbooks will follow eventually. But how much does it matter that textbooks don&#8217;t publish the conflicts of interest of authors?<\/span><\/p>\n<p><span style=\"font-weight: 400\">It&#8217;s not surprising that authors of textbooks have financial conflicts of interest. Most authors of articles in journals have financial conflicts of interest, and the authors of textbooks are the same authors. What&#8217;s more, authors of a textbook like <\/span><i><span style=\"font-weight: 400\">Harrison&#8217;s<\/span><\/i><span style=\"font-weight: 400\"> are by definition KOLs (pronounced to rhyme with trolls), key opinion leaders, who are valued by the pharmaceutical industry as big game hunters value tigers. <\/span><span style=\"font-weight: 400\">A supportive word from a KOL can be worth millions, and even if they aren\u2019t supportive they might hold back from negative comments if paid enough.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Do the financial conflicts of interest lead to biased information in textbooks? We don&#8217;t have direct evidence that they do, but we should expect that they will&#8211;because we have evidence that they do in journal articles and guidelines. Why would textbooks be different?<\/span><\/p>\n<p><span style=\"font-weight: 400\">But I marvel that textbooks matter at all. It takes years to assemble a textbook, and much of the information they contain will be out of date by the time they are published. There is also something terribly old fashioned about the whole nature of textbooks, wisdom brought down from on high as Moses brought down from the mountain the 10 commandments. Doctors now have access online to information sources like <\/span><i><span style=\"font-weight: 400\">BMJ Best Practice<\/span><\/i><span style=\"font-weight: 400\">, <\/span><i><span style=\"font-weight: 400\">UpToDate<\/span><\/i><span style=\"font-weight: 400\">, and the <\/span><i><span style=\"font-weight: 400\">Cochrane Library<\/span><\/i><span style=\"font-weight: 400\"> and increasingly decision support aids that are regularly updated. Going to look up something in a textbook is a bit like accessing the Dead Sea Scrolls for guidance.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Plus, although we don&#8217;t know how exactly conflicts of evidence corrupt textbooks, <a href=\"http:\/\/www.jameslindlibrary.org\/articles\/exposing-the-dangers-to-patients-of-medical-reviews-and-textbooks-that-ignore-scientific-principles\/\">we do know that textbooks are far from evidence-based<\/a>. <\/span><span style=\"font-weight: 400\">Iain Chalmers, founder of the Cochrane Collaboration, told a House of Lords Committee that the <\/span><i><span style=\"font-weight: 400\">Oxford Textbook of Medicine<\/span><\/i><span style=\"font-weight: 400\"> had continued to publish wrong advice years after it had been proven incorrect by a research study. <a href=\"http:\/\/www.jameslindlibrary.org\/articles\/exposing-the-dangers-to-patients-of-medical-reviews-and-textbooks-that-ignore-scientific-principles\/\">This led to <\/a><\/span><i><span style=\"font-weight: 400\">The Sunday Times<\/span><\/i><span style=\"font-weight: 400\"> running the headline \u201c<\/span><span style=\"font-weight: 400\">Hundreds killed by doctors relying on outdated manuals.\u201d\u00a0<\/span><span style=\"font-weight: 400\">A famous study by Tom Chalmers and others showed that textbooks continued to publish conflicting, often wrong, <a href=\"https:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/398415?guestAccessKey=43e632ed-ef90-4143-8157-468a4b3c20f5\">advice years after it could have been known that thrombolytic agents<\/a> could reduce deaths from heart attacks.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Although often out of date and inaccurate, a successful textbook is a gold mine. <\/span><i><span style=\"font-weight: 400\">Harrison\u2019s<\/span><\/i><span style=\"font-weight: 400\">, now in its 19<\/span><span style=\"font-weight: 400\">th<\/span><span style=\"font-weight: 400\"> edition, costs \u00a3142, and you can also buy an accompanying book for self-assessment costing \u00a360. It was first published in 1950 and has been translated into 14 languages. I couldn\u2019t find data on how many copies have been sold, but it must be well over a million and might be closer to 10 million. The printing costs will be relatively small, and the authors, both conflicted and unconflicted, will not be paid much (their real payment will be the glory of being a prophet in such a sacred text), so the profits must be huge. The 20<\/span><span style=\"font-weight: 400\">th<\/span><span style=\"font-weight: 400\"> edition will be published in August 2018. There is huge vested interest in the continuation of such gold mines, but my advice is stay away from textbooks whether or not written by conflicted authors: <\/span><span style=\"font-weight: 400\">you could be misled, and your patients could suffer.<\/span><\/p>\n<p><em style=\"font-size: 1rem\"><strong>Richard Smith<\/strong>\u00a0was the editor of The BMJ until 2004.<\/em><\/p>\n<p><span style=\"font-weight: 400\"><strong>Competing interest<\/strong>: RS receives a pension from the BMA, which owns BMJ, which publishes <\/span><i><span style=\"font-weight: 400\">BMJ Best Practice<\/span><\/i><span style=\"font-weight: 400\">, and when editor of the <\/span><i><span style=\"font-weight: 400\">BMJ<\/span><\/i><span style=\"font-weight: 400\"> and chief executive of the BMJ Publishing Group he was involved in the creation of <\/span><i><span style=\"font-weight: 400\">Clinical Evidence<\/span><\/i><span style=\"font-weight: 400\">, a forerunner of <\/span><i><span style=\"font-weight: 400\">BMJ Best Practice<\/span><\/i><span style=\"font-weight: 400\">. He was also until 2016 a chair of the Cochrane Library Oversight Committee.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Recently published research has found that about half of the authors of Harrison\u2019s Principles of Internal Medicine, which is nothing short of a Bible in medicine, have received payments from [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2018\/03\/23\/richard-smith-the-dangers-of-textbooks\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":41713,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[955],"tags":[],"class_list":["post-41709","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-richard-smith"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Richard Smith: The dangers of textbooks - 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