Monday, January 05, 2009

Is medical literature not to be trusted at all?

Are medical publications so corrupted and biased by special interests ( i.e. drug and medical device companies to name just two) that physicians no longer can rely on the medical literature to learn how to manage patients and prescribe medications? That seems to be the conclusion reached by Dr. Marci Angell in her commentary in JAMA. ( subscription required for all but the extract) Here is a no-punches- pulled summary in her words:

Looking at this picture altogether, it would be naive to conclude that bias is only a matter of a few isolated instances. It permeates the entire system. Physicians can no longer rely on the medical literature for valid and reliable information. This is the conclusion I reluctantly reached toward the end of my 2 decades as an editor of the New England Journal of Medicine, and it has been reinforced in subsequent years. Clinicians just do not know anymore how safe and effective prescription drugs really are, but these products are probably nowhere near as good as the published literature indicates.

This are not the words of an- over- the hill, bitter, retired doctor who has been accused of being biased against academics, and of longing for the good old days when docs did whatever the hell they wanted and has protested against the misuse of evidence based medicine to further the aims of big pharma and fellow travelers.Rather they are those of someone who has spend twenty years of editing one of the (if not the-most prestigious) medical journal in the country.

All journal articles do not have to be biased or misleading or down right fraudulent to taint the entire endeavor so that the end result may be a marked diminution is the reliability of medical journal articles in general.

As bleak as Dr. Angell's analysis was, Dr. Roy Poses, of Health Care Renewal, wonders if she might not have been too optimistic. I am afraid what was too optimistic in her paper was her suggestion that there be an independent body (perhaps an institute in the NIH) to administer all clinical trials with drugs.

Why would not the same influences and pressures that, according to her analysis, have corrupted some (much?) of academic medicine not have the same effect in a governmental body ? I cannot believe that medical ( or at least drug ) research overseen by the government would be immune to the biases and incentives that government agencies generally are subject to.

For example, the FDA has been subject to increasing criticism regarding actions seemingly orchestrated-or at least influenced to a large degree-by both the drug companies they are alleged to regulate and well as bending to political pressure to make decisions that mix well with certain philosophical stances taken by the executive branch. There is a rather large and I think convincing body of evidence that demonstrates the degree to which governmental regulatory agencies often act more as facilitators for those they purport to regulate than as policemen .

Dr. Poses would prefer a non-governmental, independent body to a governmental one. I would also have problem with that notion including:

Considering the big bucks involved in medical care-how could independence be maintained?

How could an independent body have the necessary power to function and control research without being in effect " government".

And, perhaps most importantly would not this panel ( governmental or non-governmental) have to deal with the same suspect body of medical literature whose reputation is impugned by Dr. Angell's analysis.

Such a body, a Med-Fed sort of thing, is gaining traction as it is apparently part of Senator Baucus's medical reform plan.My cynicism is that regard may be misplaced and as suggested by DB in his blog this type of explicit rationing may well be better than the current state of covert rationing as described by DrRich in his blog and in his book.

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