The Corruption of Evidence Based Medicine – Killing for Profit

The idea of Evidence Based Medicine (EBM) is great. The reality, though, not so much. Human perception is often flawed, so the premise of EBM is to formally study medical treatments and there have certainly been some successes.

Consider the procedure of angioplasty.  Doctors insert a catheter into the blood vessels of the heart and use a balloon like device to open up the artery and restore blood flow. In acute heart attacks studies confirm that this is an effective procedure. In chronic heart disease the COURAGE study and more recently the ORBITA study showed that angioplasty is largely useless. EBM helped distinguish the best use of an invasive procedure.

So, why do prominent physicians call EBM mostly useless? The 2 most prestigious journals of medicine in the world are The Lancet and The New England Journal of Medicine. Richard Horton, editor in chief of The Lancet said this in 2015

“The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue”

Dr. Marcia Angell, former editor in chief of NEJM wrote in 2009 that,

“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”

This has huge implications. Evidence based medicine is completely worthless if the evidence base is false or corrupted. It’s like building a wooden house knowing the wood is termite infested. What caused this sorry state of affairs? Well, Dr. Relman another former editor in chief of the NEJM said this in 2002

The medical profession is being bought by the pharmaceutical industry, not only in terms of the practice of medicine, but also in terms of teaching and research. The academic institutions of this country are allowing themselves to be the paid agents of the pharmaceutical industry. I think it’s disgraceful”

The people in charge of the system – the editors of  the most important medical journals in the world, gradually learn over a few decades that their life’s work is being slowly and steadily corrupted. Physicians and universities have allowed themselves to be bribed.

The examples in medicine are everywhere. Research is almost always paid for by pharmaceutical companies. But studies done by industry are well known to have positive results far more frequently. Trials run by industry are 70% more likely than government funded trials to show a positive result. Think about that for a second. If EBM says that 2+2 = 5 is correct 70% of the time, would you trust this sort of ‘science’?

Selective Publication – Negative trials (those that show no benefit for the drugs) are likely to be suppressed. For example, in the case of antidepressants, 36/37 studies that were favourable to drugs were published. But of the studies not favorable to drugs, a paltry 3/36 were published. Selective publication of positive (for the drug company) results means that a review of the literature would suggest that 94% of studies favor drugs where in truth, only 51% were actually positive. Suppose you know that your stockbroker publishes all his winning trades, but suppresses all his losing trades. Would you trust him with your money? But yet, we trust EBM with our lives, even though the same thing is happening.

Let’s look at the following graph of the number of trials completed versus those that were published. In 2008, the company Sanofi completed 92 studies but only a piddly 14 were published. Who gets to decide which gets published and which does not? Right. Sanofi. Which ones do you think will be published? The ones that favor its drugs, or the ones that prove their drugs do not work? Right. Keep in mind that this is the only rational course of action for Sanofi, or any other company to pursue. It’s idiotic to publish data that harms yourself. It’s financial suicide. So this sort of rational behavior will happen now, and it will not stop in the future. But knowing this, why do we still believe the evidence based medicine, when the evidence base is completely biased? An outside observer, only looking at all published data, will conclude that the drugs are far, far more effective than they are in reality. Yet, if you point this out in academic circles, people label you a quack, who does not ‘believe the evidence’.

Rigging of Outcomes – Or consider the example of registration of primary outcomes. Prior to year 2000, companies doing trials did not need to declare what end points they measured. So they measure many different endpoints and simply figured out which one looked best and then declared the trial a success. Kind of like tossing a coin, looking at which one come up more, and saying that they were backing the winning side. If you measured enough outcomes, something was bound to come up positive.

In 2000, the government moved to stop these shenanigans. They required companies to register what they were measuring ahead of time. Prior to 2000, 57% of trials showed a positive result. After 2000, a paltry 8% showed good results. More evidence of the evidence base being completely corrupted by commercial interest, and the academic physicians who were getting rich on it tacitly allowing corruption because they know that you don’t bite the hand that feeds you

‘Advertorials’ – Or this example of a review paper in the NEJM that fracture rates caused by the lucrative bisphosphonate drugs were “very rare”. Not only did the drug companies pay lots of consulting fees to the doctors, three of the authors of this review were full time employees! To allow an advertorial to be published as the best scientific fact is scandalous. Doctors, trusting the NEJM to publish quality, unbiased advice have no idea that this review article is pure advertising. Yet, we still consider the NEJM to be the very pinnacle of evidence based medicine. Instead, as all the editors of the journals sadly recognize, it has become lucre-based publishing. Mo money = better results.

Money from Reprints – The reasons for this problem is obvious to all – it’s insanely profitable for journals to take money from Big Pharma. Journals want to be read. So they all try to get a high Impact Factor (IF). To do this, you need to get cited by other authors. And nothing boosts ratings like a blockbuster produced by Big Pharma. They have the contacts and the sales force to make any study a landmark. A less obvious benefit is the fees that are generated by Big Pharma purchasing articles for reprint. If a company publishes an article in the NEJM, they may order several hundred thousand copies of the article to be distributed to unsuspecting doctors everywhere. These fees are not trivial. The NEJM publisher Massachusetts Medical Society gets 23% of its income from reprints. The Lancet – 41%. The American Medical Association – a gut busting 53%. No wonder these journals are ready to sell their readers (ordinary physicians) down the river. It pays. Who needs journalistic ethics when there’s a Mercedes in the driveway? Mo money, baby. Mo money.

Bribery of Journal Editors – A recent study by Liu et al in the BMJ shed more light on the problem of crooked journals. Crooked journal editors. Editors play a crucial role in determining the scientific dialogue by deciding which manuscripts are published. They determine who the peer reviewers are. Using the Open Payments database, they looked at how much money the editors of the most influential journals in the world were taking from industry sources. This includes ‘research’ payments, which are largely unregulated. As mention previously, much ‘research’ consists of going to meetings in exotic locale. It funny how many conferences are held in beautiful European cities like Barcelona, and how few are done in brutally cold Quebec City.

Of all journal editors that could be assessed, 50.6% were on the take. The average payment in 2014 was $27,564. Each. This does not include an average $37, 330 given for ‘research’ payments. Other particularly corrupt journals include:

This is slightly horrifying. Each editor of the Journal of the American College of Cardiology received, on average $475 072 personally and another $119 407 for ‘research’. With 35 editors, that’s about $15 million in bribes to doctors. No wonder the JACC loves drugs and devices. It pays the private school bills. Mo money = we’ll publish your crooked studies for you. Mo money, baby, mo money.

Publication Bias – The evidence base that EBM depends upon  is completely biased. Some people think I’m really anti-Pharma, but this is not really true. Big Pharma companies have a duty to their shareholders to make money. They have no duty to patients. On the other hand, doctors have a duty to patients. Universities have a duty to remain unbiased.

It is the failure of doctors and universities to keep their greedy paws out of the corrupting influence of Big Pharma money that is the problem. If Big Pharma is allowed to spend lots of $$$ paying off doctors and universities and professors, then it should do so to maximize profits. That is their mission statement. Doctors love to blame Big Pharma companies because it takes peoples gaze off the real problem – lots of doctors taking $$$ from anybody who will pay. The pharma industry is not the problem. Bribery of university doctors is the problem – one that is easily fixed if the political will exists.

Consider this study.  Looking at studies in the field of neurodegenerative disease, researchers looked at all the studies that were started but never finished or never published. Approximately 28% of studies never made it to the finish line. That’s a problem. If all the studies that don’t look promising for drug candidates are not published, then it appears that the drugs are way way more effective than they really are. But the published ‘evidence base’ would falsely support the drug. Indeed, Pharma sponsored trials were 5 times more likely to be unpublished.

Imagine you have a coin flipping contest. Suppose a player call ‘Big Pharma” chooses heads, and also pays the coin flipper. Every time the coin flipper pulls up tails, the results don’t count. Every time it comes up heads, it counts. This happens 28% of the time. Now, instead of a 50/50 split of heads and tails, it’s more like a 66/34 split of heads/tails. So the ‘evidence based medicine’ lover claims that heads is far more likely to come up than tails, and castigates people who don’t believe the results as ‘anti-science’.

Evidence based medicine depends entirely upon having a reliable base of evidence (studies). If the evidence base is tampered with, and paid for, then EBM as a science is completely useless. Indeed, the very editors whose entire careers have been EBM have now discovered it to be worthless. Does the CEO of Phillip Morris (maker of Marlboro cigarettes) smoke? That tells you all you need to know about the health risks. Do the editors of the NEJM and the Lancet believe EBM anymore? Not at all. So neither should we. We can’t believe evidence based medicine until the evidence has been cleaned up from the corrupting influence of commercial interests.

Financial conflicts of interest (COI), also known as gifts to doctors, is a well accepted practice. A national survey in the New England Journal of Medicine in 2007 shows that 94% of physicians had ties to the pharmaceutical industry. This gravy train only rides in one direction. From Big Pharma to the wallets of doctors. Sure Big Pharma can simply pay doctors directly, and it does plenty of that. It’s no surprise that medical students with more exposure to pharmaceutical reps develop a more positive attitude towards them. Many medical schools have limited exposure of medical students in response, but declined to get off the gravy train themselves. There is a simple relationship between how prominent a physician is (more articles published – almost always academic doctors and professors) and how much money they take from Big Pharma. Mo prominent = mo money. Further, there is a ‘clear and strong link’ between taking industry money and minimizing the risk of side effects of medications. What, you thought people teach at prestigious institutions like universities for the good of mankind? Maybe that’s why they went there, but that’s not why they stay. They came for the science. They stayed for the money.

So here’s a damning list of all the problems of EBM

  1. Selective Publication
  2. Rigged outcomes
  3. Advertorials
  4. Reprint Revenues
  5. Bribery of Journal Editors
  6. Publication Bias
  7. Financial Conflicts of Interests

When the evidence base of medicine is bought and paid for, people die. Unfortunately, doctors and universities have been willing participants in this game of killing for profit. We need to end it now. End the corruption of the universities. Stop the bribery of doctors. Stay tuned, the non-profit Public Health Collaboration, currently based in the UK, but soon encompassing Canada, Ireland, USA, and Australia is gearing up to tackle this issue of corruption in medical science.

For more – check this video trailer –

This Talk Will Change Your Life!

Next Thursday I am inviting top names in European Medicine to expose how Big Food and Big Pharma are killing millions of people 😱

Posted by Nathan Gill MEP on Friday, April 6, 2018

2018-04-09T08:56:56+00:00 22 Comments

About the Author:

Dr. Fung is a Toronto based kidney specialist, having graduated from the University of Toronto and finishing his medical specialty at the University of California, Los Angeles in 2001. He is the author of the bestsellers ‘The Obesity Code’ and ‘The Complete Guide to Fasting’. He has pioneered the use of therapeutic fasting for weight loss and type 2 diabetes reversal in his IDM clinic.

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Diana
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Diana

I’m pretty much convinced that all of our systems are corrupt.

Richard
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Richard

I think that particular point of view is a mistake. It amounts to little more than just giving up altogether, and thereby avoiding any kind of critical thinking. Although such a point of view may feel somewhat satisfying in the short run. Part of the problem is that some of the information we (meaning all of us) have available and receive is wrong. Part is that is that any human system or process or program contains some level of honest error. This is the “to err is human…” issue. It’s kind of how we or anyone could define being human.… Read more »

Patrik
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Patrik

The masses have been caught in mind traps by the elite throughout history. In medieval times people did what the church told them and paid their taxes to avoid an eternity in hell. Yes, people was illiterate then but do you think they had lower IQ? Why do you think they accepted such things as real? Because it was enforced upon them and became their reality. We have the same situation today, and the age of de-enlightenment has been going on for centuries. Science has been turned into a religion, and is backed up by the miracles shown in media.… Read more »

Jim
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Jim

Because of a service connected disability, I have a Veterans Administration doctor who examines me once a year including complete labs. She is very good, and I have been going to her since starting VA. Really good care and so compassionate. When she found out I was caring for my mother who is 95 with cognitive impairment she wrote a prescription to send me to Yin yoga to help with stress. She knew I was going to other more strenuous yoga, but told me to try Yin. She was right, Yin is excellent. I keep fit with weight training, cardio,… Read more »

Stephen
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Stephen

I haven’t had much faith in any nutrition based research since reading Gary Taubes “Good Calorie, Bad Calorie” and understanding how poorly conceived and executed most nutrition research is. Admittedly, some of that is simply because, morally, you can’t put humans in the kind of conditions you need to in order to really isolate causation, for example.

Setting aside the problem of the limits mortality places on the types of research available, the problem then becomes how to isolate the good research from the bad research, avoiding the issues of study suppression and selection bias in the process.

Stephen T
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Stephen T

The BMJ is the only medical journal I have any faith in thanks to its editor, Dr Fiona Godlee.

I’m a member of the Public Health Collaboration in the UK. One of the few remaining organisations in medicine untainted by pharma money and putting patients first. Doctors with diabetic patients who actually get better!

BernardP
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BernardP

I read the ORBITA study abstract. It essentially says that PCI (angioplasty) is a placebo.

One of my friends is feeling much better after a recent angioplasty. As it’s already done, I won’t tell him he has been placeboed.

glib
Guest

One of your best articles. The whole truth and nothing but the truth.

Patrik
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Patrik

Thank you Dr. Fung for writing like you do. Medicine has betrayed the Scientific method but so has most fields of science. I’ve started to call this particular era that we live in the age of de-enlightenment. Science and media has through corruption been turned upside down. Scientists can no longer ask interesting questions and apply the scientific method when trying to answer them. That would be blasphemy since science today is a dogmatic religion. You probably agree up to this point, but have no idea of how bad it really is. For example everyone in the West has been… Read more »

Carlos
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Carlos

I’m not going to absolve the universities and researchers from their guilt, and as the doctor says, Big Pharma is just doing their job, but let’s not avoid the fact that the State, the doctors in general and even us, the citizenry, are also responsible of willfull blindness and gullibility. OF COURSE I’m not going to publish data that makes me look bad OF COURSE I’m not going to publish data that makes my sponsor look bad OF COURSE I’m going to favor people that offer me stuff to favor them That’s just plain, logical human nature. We are, in… Read more »

Ronnie Horesh
Guest

Thanks for this, Dr Fung, and all the other good work you do. I think we need to re-orientate the incentives away from activities, publications, and other surrogate indicators, and focus entirely on outcomes that are meaningful to ordinary people: longevity, infant mortality, Disability Adjusted Life Years etc. In the abstract, this sounds difficult, but my suggestion of a new financial instrument could help: http://socialgoals.com/health.html.

Benthamite
Guest

^^^^^^^^^^^^^^^^^^^^^^^^^^^ A wonderful article expose what doctors know, but don’t share with patients. However, though beyond the scope of the article, it is a level worse than you write. Not only is select population tested, one that is better than the real-world population, but other tools of deception including running a washout period, in which the volunteers are given the drug or a placebo, then tested, and some of the volunteers are dropped, such as one that don’t have a response to the drug, or have side effects. If we ask how can they get away with scientific fraud? Simple,… Read more »

Richard
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Richard

I think these are great points to make about apparently “scientific” and published evidence, so thank you Dr. Fung for that. However, if these studies and reports, etc. are not to be believed, what is left? What are we to consider when looking for the best information and trying to make decisions? This includes both medical doctors and all other individuals as well. The issue and concern would seem to be the taint that is on any study with doctors and big pharma involved, but we also know that governments have their own agendas too, particularly when it comes to… Read more »

Vishal
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Vishal

Just bought your new book, The diabetes code. All the free info on your blog helped save my life and my job.
I’ve recommended your website to many of my friends who are or have relatives in similar situations.

Thank you Dr Fung.

Benthamite
Guest

Yes Diana Medicine is a corrupt system, because it is as Adam Smith said: “All for ourselves, nothing for anybody else, that is the cruel maxim of the rulers of mankind.” He wrote at length on the political influence of the sugar grower from Jamaica. Every industry and every large corporation within it seeks to maximize its profits, that is the nature of corporations. Or as my father would say, the devil invented capitalism. ANd Ralph Nader said in a talk at the University of Colorado, Capitalism makes all things worse. He then went on to talk about their infiltration… Read more »

Richard
Guest
Richard

I’m not sure your quote is entirely accurate, and I wonder if you are taking it quite the way Adam Smith intended. He was, and remains, a quite liberal voice in economics and life in general. He had no fondness for (excess) profits, and he described profits as pernicious in their effect. He was quite aware of the goal of fair wages. And Dr. Fung makes the point well enough when he says that corporations are run for the benefit of the shareholders, not entirely or even mainly for the customers. And we could well ask who the customers are…maybe… Read more »

Benthamite
Guest

I am glad that you have more than the common understanding of Adam Smith. He was against Keynesian economics, because as my Jamaican example implies, govern intervention in most cases does more harm than good, and he said that burden such as higher tariff was carried mostly by the poor. We are back to the insight of plato, in his Republic on how to make government work for the masses. As Teddy Roosevelt siad, “We shall never have proper management as long as their political voice remains. Thanks for the comment..

Les
Guest
Les

A fuller discussion of this matter is contained in “Big Pharma” by Ben Goldacre, a trained doctor turned journalist. Although centred on the UK’s NHS (if I remember correctly) it may be especially informative to North Americans as it illustrates the depth of control big. pharma exerts, and not just influence over individual doctors.
The second good read on the subject is “Doctoring Data” by Malcom Kendrick, which details the data massaging tricks that can be used to obtain the required answer. The author is a practicing GP, perhaps better known for ‘The Great Cholesterol Con”.
Read and weep.

Hap
Guest
Hap

I happen to know the executive editor JACC, not chief editor, and jacc website has a detailed disclosure page for each editor.

Please look for yourself. Not a single editor discloses any potential COI…… updated today.

Perhaps dr fung might explain.

internist
Guest
internist

Thank you for pointing out the truth at this blog, something that many of us are coming around to. I’m a frustrated internist myself. There is, in the United States, a tight relationship between big finance, pharmaceutical companies, insurance companies, and hospitals. Hospitals may be the least offensive, but are still corrupted. All that matters in medicine is the business of more. More volume, more profits, endless expansion. Which of course means more drugs, more procedures, most costs, and eventually sicker patients and a bankrupt system. Ordinary physicians have next to no power in this system but to play the… Read more »

Richard
Guest
Richard

In simple terms, the idea of the government being the enemy is of course nonsense. The government (at least in the USA) is now somewhat perverted, in the sense of being mis-led, with excessive control given to powerful elites who are able to manipulate ignorant and unthinking voters. Yet still the power to control all this rests with the voters in “properly set up” governments. This would the USA and all “Western” governments and possibly Japan and Korea. To some extent we are already living in the rule by the ignorant, people who are improperly informed and determined to remain… Read more »

frank
Guest
frank

Good to read the opinions on this topic. Mine is simple, get Governments to fund the research since the end result is the health of the nation- simple. But alas even that is difficult to control when the lobbyists are already inside the office of politicians. Medicine is now big business and everyone in the associated fields of health care know that and so everyone wants a “piece of the action” except the patients! In reality we are all guinea pigs of the “extend trials” that first began in the lab and continues in the Health Professionals rooms. Any wonder… Read more »