In yet another messy spat, a leading British journal has had to promise to investigate findings that it had originally published along with a blast of press releases and self-important interviews. This is the latest in a long series of mistakes by both the BMJ and The Lancet that generated headlines at first and embarrassment later.
Why do the British journals do it? The simple explanation is that they are trying for “appointment to read” journalism in an era when doctors rely on Google searches. A more worrying thought is that the behaviour of the BMJ and the Lancet may be part of a culture of indolence and arrogance that arises out of the UK’s distinctive healthcare system.
The controversy this time focuses on statins. Seven months ago, the BMJ published a controversial paper by Abramson and colleagues (BMJ 2013;347:f6123, doi:10.1136/bmj.f6123) that made a series of basic errors. The Abramson paper said that an earlier study by Zhang et al had found that 18% of patients had side -effects from statins and that the same number had withdrawn, at least temporarily, from treatment, because of side effects. In fact, the Zhang study was not placebo controlled; its authors had highlighted the limitations and; the study had not said that 18% had discontinued therapy but said that it might be “up to 9%”. As if all this weren’t enough, Abramson et al made dismissive references the vast number of randomised, placebo-controlled studies that show no difference between the side effects from statins and those from placebos
None of this amused Professor Sir Rory Collins of Oxford University, a world authority on preventing heart disease. He told the Guardian that the reporting was creating a situation which had echoes of the MMR vaccine controversy. (In that episode, the Lancet published a series of papers which alleged links between MMR vaccines and autism — the papers were later shown to have been thoroughly fraudulent and probably motivated by a corrupt link between the researchers and those seeking to bring lawsuits over false damages claims). On the BMJ statin story, Collins told the BBC , “it is a serious disservice to British and international medicine.” Millions might stop taking statins and thousands might suffer from strokes or heart attacks, he said.
Back in March, the BMJ’s editor, Dr Fiona Godlee, defended the articles, saying conventional research understated the risks of side-effects. “The randomised control trial data is notoriously poor at reporting adverse events. So I think it’s extremely important that the public understand when we’re talking about extending statins to people at low risk, that the balance between benefits and harms becomes much more important,” she said. With that grand, sweeping statement, several of the principles of modern medical research appear to have been dismissed by Dr Godlee.
Now the BMJ has taken back the inaccurate statements and convened an independent panel to consider whether to withdraw the articles altogether. Professor Collins worries that it will not be really independent.
The BMJ has form, of course. It has frequently published the paranoid ramblings of Dr Jacob Pulliyel, one of India’s most notorious vaccine deniers who claims (among other things) that pentavalent vaccines used around the world are uniquely dangerous in South Asian children and that the Government of India is engaged in a vast cover-up on the true number of polio cases in the country (although, to be fair to the BMJ, even it has not published that latest outburst — the link is to a Facebook page)
Why do the BMJ and the Lancet do it? The obvious explanation is that they are increasingly irrelevant. Students used to do their research by poring through back copies of medical journals. Doctors had bound volumes in book cases lining their offices. Now, everyone just looks at Google on their iPads. Unless the journals do sexy, newsworthy stuff, they will be forgotten about and — more important — their advertisers will disappear. That is, no doubt, part of the story.
The British journals also, though, reflect British medical culture. The UK’s GPs are mostly self-employed and almost all paid by the state on a capitation basis. In other words, they get a set sum of money for every patient on their books whether they ever see the patient or not. To try to address the UK’s place at the bottom of most cardiovascular disease league tables, there are now various government targets with rewards and penalties in place for diagnosing and treating older at-risk patients (just as there are for immunisation and for stopping smoking) but the GPs resent these. They should, they think be allowed to carry on as Europe’s best-paid GPs without any special obligations to improve public health. It may just be that the BMJ is doing its job as the trade magazine of the British Medical Association, doctors’ trade union: it is arguing that members should continue to be paid whether they do their jobs or not. Calling in patients to prescribe statins or give injections is just another unreasonable employer demand to be resisted.