Should Medical Textbook Authors Have To Disclose Industry Payments?

If you pose the question "Should authors of premier medical textbooks be required to disclose industry payments or patents?," then an affirmative answer is to be found in a recent study published by the AJOB Empirical Bioethics. Unlike primary literature (like journals) along with clinical guidelines, it is not commonplace to include potential financial conflicts of interest (pCoIs) in biomedical textbooks.

The old adage "if it ain’t broke, then don't fix it” comes to mind.

This is more a reflection of current concerns about conflicts of interest than insight or fruitful discovery. By searching databases for patent listings and compensation for authors of the most recent editions of six medical textbooks, they determined

“an appreciable subset of biomedical authors have patents and have received remuneration from medical product companies and this information is not disclosed to readers.”

It should come as no surprise, after all the editors and authors of textbooks are the acknowledged experts. The researchers lump together training sources for physicians, dentists and pharmacists and recognize

“our findings do not necessarily suggest that payments by pharmaceutical manufacturers or patents adversely impacted the textbook content (e.g. presentation of material that is inconsistent with evidence-based medicine).”

In fact, they go on to state

“although evaluating textbook content versus pCoI is outside the scope of this article” but conclude that “transparency of financial pCoIs should become a standard practice among the authors of biomedical education materials.”

But, should it?

Let's focus on the staple text for medical students and physicians-in-training of Harrison’s Principles of Internal Medicine, such a work is in its 20^th edition updated by leading experts in the field to optimize its timeliness and remaining current. These same professionals are among the routinely cited journal and conference set. Therefore, their disclosures are frequent and in the public domain.

A textbook like the one just mentioned details how to evaluate patients for a specific diagnosis, but also the pathophysiology and treatment of disease. It doesn’t provide one treatment recommendation suited to the author patent at the expense of other alternatives. Rather, it is a compendium, listing all forms of therapies and delineating risks and benefits for patients. This material is presented with innumerable adjunctive reference sources and accompanied by instruction, albeit in the classroom with professors and the hospital wards with attendings.

This type of manual is incrementally changed over long expanses of time. It is our dogma. There are many permutations of this type of opus in the medical sphere, covering all specialties from vascular surgery to pediatrics.

At what point does imposing a bias cause bias?

Being a chapter author of these reference books is considered an honor and is usually bestowed upon those ideally suited for the task – those advancing and improving their respective fields; authors who understand both the overview and the nuance. (1) Even the authors of this study suggest

“the presence of financial potential conflicts of interest should not be interpreted to stigmatize or tarnish the reputation of a health care provider. Innovation thrives in an environment of close relationships between industry and providers.”

Yet, in another breath they attach words like “undisclosed” or “the authors do not typically disclose” which implies subterfuge, an unwarranted assumption at best.  

Journal articles based on studies of medical devices and treatments, conferences or clinical guidelines can all be sponsored by industry or fall prey to conflicts of financial and intellectual interests. Again, this doesn’t necessarily delegitimize the work. Disclosure is sensible in these settings as it allows the audience to be aware and deduce as they so desire the impact or lack of impact of such information on new work, work yet to be embraced by the majority of the medical community. 

Knowing the heart is still located anatomically where it was centuries ago in an anatomy textbook seems to be a place where such extraneous input is just that - excessive and solving problems that aren’t even there.