Health Letter, May 2015
By Sammy Almashat, M.D., M.P.H.
In recent years, there has been an increasing focus on corporate financial ties of authors of articles published in medical journals. This, fortunately, has resulted in the near-universal practice of disclosing such conflicts of interest at the end of a journal article.
However, there has been little discussion of the conflicts of interest of the editors of those same journals, and most journals apparently still do not disclose those ties to the medical community and general public. Consequently, little is known about the prevalence of such conflicts among this select group of entrusted gatekeepers to medical knowledge. Medical journal editors play a pivotal role in deciding what data health care providers and the public have access to when making life-and-death medical decisions. They are responsible for ensuring that the medical knowledge disseminated through the published literature is both accurate and unbiased. For this reason, it is critical to minimize the possibility of editors’ decisions being compromised by financial ties to the industries that fund much of the research making up the published literature.
International recommendations on managing conflicts of interest
The International Committee of Medical Journal Editors (ICMJE) has, since 1979, been responsible for setting the “best practice and ethical standards” of publication for peer-reviewed medical journals. Since the 1988 edition of its guidelines, the ICMJE has recommended that authors of journal articles disclose any financial conflicts of interest related to the articles’ content.
The 1994 ICMJE guidelines, for the first time, addressed the conflicts of interest of other participants in the peer-review process, namely article reviewers and journal editors.  With respect to these groups, the guidelines made two major recommendations, both of which have been retained, with only slight modifications, in the most recent ICMJE guidelines, issued in December 2014:
- Peer reviewers “should disqualify themselves from reviewing specific manuscripts if they believe it appropriate.”
- “Editors who make final decisions about manuscripts should have no personal financial involvement in any of the issues they might judge. Other members of the editorial staff, if they participate in editorial decisions, should … disqualify themselves from any decisions in which they have a conflict of interest.”
While there has been no recommendation that editors inform readers of instances where one or more editors had to recuse themselves from decisions to accept or reject a published article, the 2004 guidelines recommended that “[e]ditors should publish [for the public] regular disclosure statements about potential conflicts of interests related to the commitments of journal staff.”
Compliance with ICMJE recommendations
It is difficult, if not impossible, to shed light on or compare the adequacy of self-policing among the hundreds of medical journals in existence today, because journals generally do not disclose how often their editors have had to recuse themselves from manuscript acceptance decisions.
It is easier to verify compliance with the 2004 ICMJE recommendation that editors regularly disclose their conflicts of interest. Unfortunately, more than 10 years since this guideline was first published, most medical journals do not even have policies regarding the disclosure of editors’ conflicts of interest.
A 2009 study of all 42 English-language ophthalmology journals found that all had a conflict-of-interest disclosure policy for authors, but only a third of those for which data were available had a similar policy for editors. A more comprehensive 2013 study of the 399 highest-impact biomedical journals in 27 different biological and medical fields (“impact ratings” measure how frequently journals’ articles are cited by others) found that less than 40 percent required editors to disclose their conflicts of interest, compared with 90 percent requiring such disclosure from authors.
Prevalence and disclosure of editors’ corporate financial ties
ProPublica, an independent investigative journalism organization, has made it possible to glean the prevalence of conflicts of interest among journal editors with its Dollars for Docs database. Launched in 2010, the regularly updated Dollars for Docs database lists payments from 17 pharmaceutical companies to U.S.-based physicians.
Public Citizen’s Health Research Group searched the Dollars for Docs database for all drug industry payments over $250 made to U.S.-based senior editors of the 10 medical journals with the highest impact ratings (though we were unable to determine whether the payments were made before or after the individuals assumed their current positions as journal editors).
Two of the 10 journals with the highest impact ratings, Annals of Internal Medicine and BMC Medicine, have at least one editor with financial ties to the drug industry., Annals of Internal Medicine has one such editor. Of the 42 U.S.-based physicians on the editorial board of BMC Medicine, 12 have financial ties to the drug industry and another is an employee of a pharmaceutical company. The 13 editors received a total of $1.27 million from 13 different drug companies between 2009 and 2013, an average of $97,600 per editor.
Two of these 12 BMC Medicine editors received their money from four different drug companies, one received money from five, and another from 10. Given so many potential conflicts, implementing the ICMJE recommendation that editors with conflicts of interest simply recuse themselves from publication decisions may not be feasible.
Consistent with the findings on disclosure policies cited above, no disclosures of editors’ financial ties, as recommended by the ICMJE, were found on the websites of either Annals of Internal Medicine or BMC Medicine.
And while the other journals with top-10 impact ratings had no U.S.-based editors with ties to the 17 drug companies in the ProPublica database, only one, PLOS Medicine, posts conflict-of-interest statements for all of its journal editors on its website. The statements contain extensive details on the editors’ and their family members’ financial and professional interests that could potentially affect their work. According to both the PLOS Medicine website and the ProPublica database, none of the editors have financial ties with pharmaceutical or any other corporations.
Publicize, then eliminate editors’ conflicts of interest
It is troubling that, more than 20 years after the ICMJE’s initial recommendations, many journals have failed to heed the organization’s call to publicly disclose conflicts of interest in the editorial process.
More medical journals should follow the example set by PLOS Medicine and disclose their editors’ financial ties to the public. But as has been the case with authors’ conflict-of-interest disclosures, transparency on its own will do little to remove the potentially corrupting influence of corporate money within medical journals’ editorial boards.
Medical journals should go further and exclude those with financial ties to the pharmaceutical, medical device, and other profit-driven health care industries from serving as editors in the first place. For critics arguing that such a policy would be too extreme, it is worth noting that most of the top-10 medical journals in the world already are staffed by editors not beholden to the industries whose bottom lines often hinge on their decisions.
Even More Information on Editors’ Industry Ties Now Made Public
ProPublica’s Dollars for Docs database provided groundbreaking initial insights into the extensive financial ties between physicians and a limited number of pharmaceutical companies whose products they prescribe and use. Last year, the federal government released an even more comprehensive database known as Open Payments. Originally mandated in the 2010 Physician Payments Sunshine Act and administered by the federal Centers for Medicare and Medicaid Services, the free, publicly accessible database contains payments from virtually all U.S.-based pharmaceutical and medical device companies to both physicians and teaching hospitals. As most medical journal editors tend to be physicians, this new resource, along with Dollars for Docs, grants the public unprecedented access to information about the ties that bind for-profit health care industries to the top echelons of the medical journal establishment.
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 International Committee of Medical Journal Editors. Purpose of the recommendations. http://www.icmje.org/recommendations/browse/about-the-recommendations/purpose-of-the-recommendations.html. Accessed March 27, 2015.
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 National Institute of Environmental Health Sciences. High impact journals. https://tools.niehs.nih.gov/srp/publications/highimpactjournals.cfm. Accessed March 27, 2015.
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 ProPublica. Dollars for Docs. https://projects.propublica.org/docdollars/. Searched March 24, 2015.
 These are, in descending order based on impact rating: New England Journal of Medicine, Lancet, Journal of the American Medical Association, British Medical Journal, PLOS-Medicine, Journal of the American Medical Association-Internal Medicine, Journal of Cachexia Sarcopenia and Muscle, and Cochrane Database of Systematic Reviews.
 PLOS-Medicine. Competing interests of the PLOS medicine editors. http://www.plosmedicine.org/static/editorsInterests. Accessed March 27, 2015.
 Lee J. Open Payments website launches. Modern Healthcare. September 30, 2014. http://www.modernhealthcare.com/article/20140930/NEWS/309309920. Accessed March 27, 2015.
 Centers for Medicare and Medicaid Services. Open payments. http://www.cms.gov/OpenPayments/index.html. Accessed March 27, 2015.