Food, flattery, and friendship

This week's cover has already caused some consternation in the BMJ's offices. One or two people had heard that it depicted pigs and reptiles. Yet the verbal description “pigs and reptiles” sounds much harsher than the rather loveable creatures drawn by Malcolm Willett. And that illustrates one of the underlying messages of this week's theme issue on the relationship between doctors and the drug industry. This relationship isn't a Manichean battle between good and evil but the entwinement of individuals from different backgrounds and value sets who get to know, and often to like, each other and therefore want, as humans do, to reciprocate friendships and favours. “Food, flattery, and friendship are all powerful tools of persuasion,” quotes Ray Moynihan in his two part article on entanglement.

Moynihan's articles (pp 1189, 1193) set the scene for this theme issue. His first explores the sorts of relationships that exist between doctors and the pharmaceutical industry—ranging from pens and free lunches through education, sponsored supplements in journals, funded research, to support for professional societies and consultancy. He describes the fierce debates going in the University of California in San Francisco about the relationship: some academics want to relax the tight rules of disclosure of competing interests, while the dean of medicine wants to regulate the access of drug company representatives to young doctors on the campus.

These entanglements are old and well known: what of the new and not so well known? Andrew Herxheimer warns that the relation between drug companies and patient organisations is usually unequal (p 1208). Grants from companies can help patients' organisations “grow and be more influential but can also distort and misrepresent their agendas.” Relationships, he urges, should therefore be open, “without public relations flummery.” The public relations flummery of the moment, according to Bob Burton and Andy Rowell (p 1205), is the third party technique—separating the message from an apparently self interested messenger. Hence the importance of “opinion leaders.” Even reprints of studies that don't support a company message can be useful: “the introduction and discussion sections still provide an excellent platform for message delivery.”

But perhaps most interesting is how the citadels of evidence based medicine can be undermined by clever companies. Silivio Garattini and others provide a guide to ethics committees on trial protocols that do more to market a drug than to advance understanding (p 1199). Such protocols might explain why the published literature on drugs is biased. In their systematic review Joel Lexchin and colleagues (p 1167) show that research sponsored by companies is more likely to produce results favouring the company's product than that funded by other sources. This is not because the studies are methodologically worse but because of inappropriate comparators and publication bias.