Corporate capture is a massive problem in our capitalist society. It is undermining our most vital institutions. I don’t know what the solution is other than the end of capitalism (and how do we make that happen? Universal basic income, maybe?)
Ever since my fledgling days at UCSF I have refused to take gifts and reprints from pharmaceutical reps. I did that to remain evidence based, and unbiased. But the window to unbiased quality studies is closing fast as someone mentioned, because of agency capture, journal capture and medical practice capture.
When I work with young public health physicians I tell them to review papers carefully for who requested the study, who did the study, who funded the study. Then read the paper with a critical eye.
John wrote another short article about a response to this one, you can see it here (https://sensiblemed.substack.com/p/a-listener-criticizes-our-conversation?utm_source=profile&utm_medium=reader2). In it John writes about the person who provided feedback as follows "The commenter is an established academic who will remain nameless because his success depends on journals publishing his work." The fact that this can be written with a straight face and no comment on the chilling effect this implies is yet another example of the cognitive dissonance going on in the medical/science/political fields. If you can't speak plainly and publicly about your thoughts on all sides of an issue even if you are wrong we are all doomed. It may be time to just admit that there is way more truth in the utter rot of the system, medical, academic, political, etc that people like RFK Jr, Trump, and others describe even if they not ideal messengers. We can't just work around the edges on this mess if it is true that people can't speak freely without fear of losing everything. How is it that any system is supposed to work if that is the situation we are in.
Took vaccinated rates of myocarditis (no covid infection) and compared it to unknown vaccinated status, with a covid infection.
Divided one by the other and came to the number claiming that infection was 7 times more likely to cause it than vaccination. Truly trash methodology, considering that probably more than 2/3 of the infection arm were vaccinated. They most likely had the data to compare these properly but chose not to.
I entirely agree, John. I am a lifetime subscriber to the NEJM and have been revolted by their partisan editorial bias which has persevered for decades. I remember the Nov 22 masking article and the criticism that I read on Substack at that time. Your analysis is spot on. If the conclusions are important enough AND support the policy preferences of the editorial board, they have published rarely deeply flawed articles. Yes, it is notoriously difficult to do randomized controlled trials of masking but that is no excuse for both publishing deeply flawed studies and then supporting them with a biased editorial. Too many physicians are busy lemmings who have eschewed their responsibilities to hold their leaders and journal editors to the historically high standards of science. The current situation is appalling.
I don’t know that I can help you feel better about the situation, and I’m betting you won’t like my suggestion of a better way, but here are my few cents (however poorly written).
I believe today’s situation rests on a few historical antecedents.
According to a thesis written by a UC Berkeley grad student (I wish I could find it again!) the AMA was created with the intention of elevating “doctors” above all other health care providers (osteopaths, eclectics, herbalists, etc.) and achieving for them greater power, prestige, and money.
Now stir in some philosophical influences: First, Descartes’ division of mind and body is, for one, inaccurate, but also angst-inducing. Second, the primary motivation of Western medicine is to prevent death (versus, for example, promoting health). We are thus left swimming in internal conflict while avoiding the certain future we all face. Creating a medicine devoid of or separate from spiritual significance, whether technically correct or not, invites an existential gap in the mind of creatures who need meaning.
Sprinkle in the dehumanizing effects of technology*, the primal drive for wealth, and other modern-day cultural phenomena, and it is very easy for us to want to believe in something so badly we can’t think clearly any more. Or to simply stop caring about the impacts of what we do. Money, power, fame, or even just the band-aid of hope or delusion… anything is better than the emptiness we experience on a daily basis. Especially since we really are not reckoning with our ultimate fate.
Death gives life meaning. How about taking some inspiration from Atul Gawande and reshaping medicine (and everything else) around what is ahead for all of us? (“The stronger civilization becomes, the more deeply the love of death is buried in the subconscious.” — Antal Szerb)
And… One way of achieving greater awareness of our shared destiny as well as our interconnectedness it to use our hands. *I am convinced that buying all of our daily supplies – rather than making them – creates a void, a sense of inadequacy and insufficiency. Knowing that we can make something useful (clothing, shoes, housing, furniture, tools, food, etc.) and seeing just how productive our hands can be create a fundamental sense of confidence and strength. Understanding how much work goes into what we eat, wear, live in, sleep on, etc. helps us recognize the contributions that others make to our lives. That is how we begin seeing how much we truly depend on each other, valuing each other, and recognizing the impact we have on each other. That, I think, is how we start to see how we harm each other, as well as ourselves, when we cut corners…. say, for example, publishing false information in medical journals.
(One concrete suggestion, for example, is to redesign education from K-8, and perhaps high school, around agriculture, animal husbandry, furniture, building construction, textile production & sewing, etc.)
It's the same in politics. Who sneaks in a policy from a senator's lobbyists under the all-inclusive bill for the President to sign? Who is really running the country, the Democrats, the Republicans, or the NAR, Pharma, NRA? Corruption, short cuts, manipulation run rampant across every platform.
Dr. Mandrola, Thank you for speaking out. You, and other truth speakers, give me hope. I am trying to tell everyone I know to research their choice of physician to try to find someone who is like minded. This is going to be more and more important as future PLandemics are launched on us. Please know how appreciated you are.
My conclusion: Those "top" journals are GARBAGE, not worthy to waste your time even looking at them. The system is indeed broken. It's not health care, it's a get rich scheme, how to make tons of money off of human illness and suffering.
Yes, there are deep flaws in American medicine. However, as a longtime consumer of the NEJM and a retired professor of pediatrics, I can assure that there is great research that is ongoing, uncorrupted by bias or dollars, and progress continues to happen. The smear of the entire pharmaceutical industry and the entire medical profession is ignorant and detrimental. I did NOT get rich working in academic pediatrics for over 40 years. Many surgeons acquire wealth but the majority of physicians do well without getting rich. My greatest objection is that too many physicians do not read and confront the issues of public health malfeasance and transgender care.
It’s a pox on all their houses. The trialists obviously know the methodologies were weak, and/or blatantly biased. Yet they undersold the limitations and oversold their results in the manuscripts. Some of the editorialists had conflicts so huge as to obscure the sun. These journals allowed all of that to occur, without demanding corrections to more clearly and plainly emphasize the limitations while removing the spin.
P.S. Just one more suggestion....Sorry if some of this is repetition from comments on prior articles. Two of the major ethical principles by which doctors are supposed to abide are informed consent, and respecting patient autonomy, which are related, since you can't really respect autonomy if you fail to provide accurate and unbiased information via the consent process. IMO, this is not done well at all. I imagine part of that is due to time constraints, and partly due to lack of knowledge of ARR's and rate of SAE's among physicians. A simple way to communicate that is "The Drug Facts Box." (link below). Perhaps something similar could be created for other types of medical interventions, such as surgeries, although the latter is not always known, given the dearth of studies with sham surgeries. If like-minded physicians lobbied AMA hard to lobby Congress hard to implement this, maybe it would FINALLY be implemented. I've been waiting for 10 years! Ask the FDA what they're waiting for! Maybe ask a known truth teller on an FDA advisory panel like Paul Offit what he knows about it.
I'm a psychologist. Would you like me to do a study of motivations? :) Most people here seem to think money is the main/sole motivation. Probably true, but I don't believe it's conscious most of the time, as our motivations are not always conscious. The other major driver as I see it is ego, which makes it difficult for most people, especially those who are high achievers, to admit they were ever wrong about something, especially within their careers. People are very good at deceiving themselves, and these people are not evil, and not even necessarily narcissists, as some here accuse. They are normal humans operating within a broken system. It will probably get worse before it gets better, but don't give up. Keep speaking up loudly, in as many places as you have access to. I would say to start with the guidelines, because that appears to be about the only thing my PCP ever reads!
ego or money, or both, doesn't much matter. They have lost their direction, lost their purpose, lost their souls, they are no longer seeking to help people heal. Instead, they are feeding off of human suffering. That makes them no better than war mongers or street thugs.
I am a retired pediatric professor and did not acquire wealth during my career nor so most pediatricians. Yes, it matters greatly if the problem is money or values. Pediatricians do seek children for whom to provide care and to heal. They unfortunately have allowed the demands of work to blind them from the larger issues of journal editor political correctness, autocratic public health policies, and the crime of subjecting pubertal children to transgender medical and surgical interventions. We need to confront the education, the worldview, and the ongoing demands of being responsible citizens which have led to so much passivity and silence among responsible physicians.
I very much agree - money is always going to be a motivator BUT in my experience (and that is all I have to go on as I'm unaware of great evidence on this topic) intellectual conflicts of interest are by far the biggest problem. Intellectual COIs are when a researcher/clinician/person has a specific point of view about a topic and that often drives much of what they do and say. All you have to do is look at chronic disease state guidelines (blood pressure, lipids, glucose) to see intellectual COIs in full force. Again in my experience, the recommendations are very much determined not by the best available evidence or patient values and judgements but who is on the committee. That is why our group of primary care clinicians peerevidence.ca decided to abandon being on national guidelines and created our own primary care driven guidelines. Does that mean we have no biases - of course not - but our biases at least aren't driven by lipid beliefs/glucose beliefs/mechanisms but rather by what does the best evidence show for important outcomes and making things simplified and focussing on shared decision-making.
Astounding. Thank you for bringing this to light here.
Corporate capture is a massive problem in our capitalist society. It is undermining our most vital institutions. I don’t know what the solution is other than the end of capitalism (and how do we make that happen? Universal basic income, maybe?)
Ever since my fledgling days at UCSF I have refused to take gifts and reprints from pharmaceutical reps. I did that to remain evidence based, and unbiased. But the window to unbiased quality studies is closing fast as someone mentioned, because of agency capture, journal capture and medical practice capture.
When I work with young public health physicians I tell them to review papers carefully for who requested the study, who did the study, who funded the study. Then read the paper with a critical eye.
Thank you for the discussion
John wrote another short article about a response to this one, you can see it here (https://sensiblemed.substack.com/p/a-listener-criticizes-our-conversation?utm_source=profile&utm_medium=reader2). In it John writes about the person who provided feedback as follows "The commenter is an established academic who will remain nameless because his success depends on journals publishing his work." The fact that this can be written with a straight face and no comment on the chilling effect this implies is yet another example of the cognitive dissonance going on in the medical/science/political fields. If you can't speak plainly and publicly about your thoughts on all sides of an issue even if you are wrong we are all doomed. It may be time to just admit that there is way more truth in the utter rot of the system, medical, academic, political, etc that people like RFK Jr, Trump, and others describe even if they not ideal messengers. We can't just work around the edges on this mess if it is true that people can't speak freely without fear of losing everything. How is it that any system is supposed to work if that is the situation we are in.
This one is truly awful.
Took vaccinated rates of myocarditis (no covid infection) and compared it to unknown vaccinated status, with a covid infection.
Divided one by the other and came to the number claiming that infection was 7 times more likely to cause it than vaccination. Truly trash methodology, considering that probably more than 2/3 of the infection arm were vaccinated. They most likely had the data to compare these properly but chose not to.
https://www.sciencedaily.com/releases/2022/10/221013104601.htm
I entirely agree, John. I am a lifetime subscriber to the NEJM and have been revolted by their partisan editorial bias which has persevered for decades. I remember the Nov 22 masking article and the criticism that I read on Substack at that time. Your analysis is spot on. If the conclusions are important enough AND support the policy preferences of the editorial board, they have published rarely deeply flawed articles. Yes, it is notoriously difficult to do randomized controlled trials of masking but that is no excuse for both publishing deeply flawed studies and then supporting them with a biased editorial. Too many physicians are busy lemmings who have eschewed their responsibilities to hold their leaders and journal editors to the historically high standards of science. The current situation is appalling.
I don’t know that I can help you feel better about the situation, and I’m betting you won’t like my suggestion of a better way, but here are my few cents (however poorly written).
I believe today’s situation rests on a few historical antecedents.
According to a thesis written by a UC Berkeley grad student (I wish I could find it again!) the AMA was created with the intention of elevating “doctors” above all other health care providers (osteopaths, eclectics, herbalists, etc.) and achieving for them greater power, prestige, and money.
Now stir in some philosophical influences: First, Descartes’ division of mind and body is, for one, inaccurate, but also angst-inducing. Second, the primary motivation of Western medicine is to prevent death (versus, for example, promoting health). We are thus left swimming in internal conflict while avoiding the certain future we all face. Creating a medicine devoid of or separate from spiritual significance, whether technically correct or not, invites an existential gap in the mind of creatures who need meaning.
Sprinkle in the dehumanizing effects of technology*, the primal drive for wealth, and other modern-day cultural phenomena, and it is very easy for us to want to believe in something so badly we can’t think clearly any more. Or to simply stop caring about the impacts of what we do. Money, power, fame, or even just the band-aid of hope or delusion… anything is better than the emptiness we experience on a daily basis. Especially since we really are not reckoning with our ultimate fate.
Death gives life meaning. How about taking some inspiration from Atul Gawande and reshaping medicine (and everything else) around what is ahead for all of us? (“The stronger civilization becomes, the more deeply the love of death is buried in the subconscious.” — Antal Szerb)
And… One way of achieving greater awareness of our shared destiny as well as our interconnectedness it to use our hands. *I am convinced that buying all of our daily supplies – rather than making them – creates a void, a sense of inadequacy and insufficiency. Knowing that we can make something useful (clothing, shoes, housing, furniture, tools, food, etc.) and seeing just how productive our hands can be create a fundamental sense of confidence and strength. Understanding how much work goes into what we eat, wear, live in, sleep on, etc. helps us recognize the contributions that others make to our lives. That is how we begin seeing how much we truly depend on each other, valuing each other, and recognizing the impact we have on each other. That, I think, is how we start to see how we harm each other, as well as ourselves, when we cut corners…. say, for example, publishing false information in medical journals.
(One concrete suggestion, for example, is to redesign education from K-8, and perhaps high school, around agriculture, animal husbandry, furniture, building construction, textile production & sewing, etc.)
It's the same in politics. Who sneaks in a policy from a senator's lobbyists under the all-inclusive bill for the President to sign? Who is really running the country, the Democrats, the Republicans, or the NAR, Pharma, NRA? Corruption, short cuts, manipulation run rampant across every platform.
More evidence that the medical establishment cannot be trusted.
Dr. Mandrola, Thank you for speaking out. You, and other truth speakers, give me hope. I am trying to tell everyone I know to research their choice of physician to try to find someone who is like minded. This is going to be more and more important as future PLandemics are launched on us. Please know how appreciated you are.
My conclusion: Those "top" journals are GARBAGE, not worthy to waste your time even looking at them. The system is indeed broken. It's not health care, it's a get rich scheme, how to make tons of money off of human illness and suffering.
Yes, there are deep flaws in American medicine. However, as a longtime consumer of the NEJM and a retired professor of pediatrics, I can assure that there is great research that is ongoing, uncorrupted by bias or dollars, and progress continues to happen. The smear of the entire pharmaceutical industry and the entire medical profession is ignorant and detrimental. I did NOT get rich working in academic pediatrics for over 40 years. Many surgeons acquire wealth but the majority of physicians do well without getting rich. My greatest objection is that too many physicians do not read and confront the issues of public health malfeasance and transgender care.
“Whoa….I don’t want to go there”.
I’m afraid ur gonna hafta.
It’s a pox on all their houses. The trialists obviously know the methodologies were weak, and/or blatantly biased. Yet they undersold the limitations and oversold their results in the manuscripts. Some of the editorialists had conflicts so huge as to obscure the sun. These journals allowed all of that to occur, without demanding corrections to more clearly and plainly emphasize the limitations while removing the spin.
It is a truly sad state of affairs.
.
Most People Are Stupid.
Very Stupid.
You Are Not.
- Start There.
.
Awesome! Where do I sign up?! :)
P.S. Just one more suggestion....Sorry if some of this is repetition from comments on prior articles. Two of the major ethical principles by which doctors are supposed to abide are informed consent, and respecting patient autonomy, which are related, since you can't really respect autonomy if you fail to provide accurate and unbiased information via the consent process. IMO, this is not done well at all. I imagine part of that is due to time constraints, and partly due to lack of knowledge of ARR's and rate of SAE's among physicians. A simple way to communicate that is "The Drug Facts Box." (link below). Perhaps something similar could be created for other types of medical interventions, such as surgeries, although the latter is not always known, given the dearth of studies with sham surgeries. If like-minded physicians lobbied AMA hard to lobby Congress hard to implement this, maybe it would FINALLY be implemented. I've been waiting for 10 years! Ask the FDA what they're waiting for! Maybe ask a known truth teller on an FDA advisory panel like Paul Offit what he knows about it.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3752172/
I'm a psychologist. Would you like me to do a study of motivations? :) Most people here seem to think money is the main/sole motivation. Probably true, but I don't believe it's conscious most of the time, as our motivations are not always conscious. The other major driver as I see it is ego, which makes it difficult for most people, especially those who are high achievers, to admit they were ever wrong about something, especially within their careers. People are very good at deceiving themselves, and these people are not evil, and not even necessarily narcissists, as some here accuse. They are normal humans operating within a broken system. It will probably get worse before it gets better, but don't give up. Keep speaking up loudly, in as many places as you have access to. I would say to start with the guidelines, because that appears to be about the only thing my PCP ever reads!
ego or money, or both, doesn't much matter. They have lost their direction, lost their purpose, lost their souls, they are no longer seeking to help people heal. Instead, they are feeding off of human suffering. That makes them no better than war mongers or street thugs.
I am a retired pediatric professor and did not acquire wealth during my career nor so most pediatricians. Yes, it matters greatly if the problem is money or values. Pediatricians do seek children for whom to provide care and to heal. They unfortunately have allowed the demands of work to blind them from the larger issues of journal editor political correctness, autocratic public health policies, and the crime of subjecting pubertal children to transgender medical and surgical interventions. We need to confront the education, the worldview, and the ongoing demands of being responsible citizens which have led to so much passivity and silence among responsible physicians.
I very much agree - money is always going to be a motivator BUT in my experience (and that is all I have to go on as I'm unaware of great evidence on this topic) intellectual conflicts of interest are by far the biggest problem. Intellectual COIs are when a researcher/clinician/person has a specific point of view about a topic and that often drives much of what they do and say. All you have to do is look at chronic disease state guidelines (blood pressure, lipids, glucose) to see intellectual COIs in full force. Again in my experience, the recommendations are very much determined not by the best available evidence or patient values and judgements but who is on the committee. That is why our group of primary care clinicians peerevidence.ca decided to abandon being on national guidelines and created our own primary care driven guidelines. Does that mean we have no biases - of course not - but our biases at least aren't driven by lipid beliefs/glucose beliefs/mechanisms but rather by what does the best evidence show for important outcomes and making things simplified and focussing on shared decision-making.