‘Somewhere, something incredible is waiting to be known.’ —CARL SAGAN
It happened in 2016
Every time I go to Hyderabad for a conference, I learn something new. This time it was the IBD Summit 2016—a comprehensive continuing medical education programme focused on inflammatory bowel disease (IBD). Meeting old friends was a bonus.
We all went for breakfast early, so as not to miss the first talk. I picked up my breakfast and went to sit on a table where AS was sitting. AS and I were friends for the past 30-odd years and I admired him for his several qualities. He was an exceptionally intelligent, hardworking, talented gastroenterologist and had made a niche for himself in national medical academia while working at a government medical college in a tier-2 city. He was known for his razor sharp wit and contagious sense of humour. There he was discussing something animatedly.
Medical Research in India
The topic of discussion was a Times of India report1 on the poor state of medical research in India. It somehow touched a raw nerve in AS and he appeared quite agitated. The report was based on a paper published elsewhere by a retired professor.2 Professor SN was another enigmatic academician, who had left a premier tertiary care hospital to practice in a private hospital. He was a proverbial tall, dark and handsome man who was suave and eloquent. He always called a spade a spade and had raised the bar for medical research in India. In this paper, he said that ‘only 25 (4.3%) of the (medical) institutions produced more than 100 papers a year but their contribution was 40.3% of the country’s total research output. 332 (57.3%) of the medical colleges did not have a single publication during this period.’
Angry Response
‘I respect Professor SN, but does he know about the situation in state medical colleges? He has only seen one college in India and that is AIIMS. He feels every college is like AIIMS,’ AS was saying when I reached the table.
‘And what is the difference?’ I asked.
‘Sir, you have also not worked in a state medical college. Just yesterday, in my college, I realized there was no fan working in our ward when the outside temperature was 48 oC. Patients would have died of heat rather than cholangitis for which they came. I gave money from my own pocket to get one fan repaired.’ AS was still angry.
‘Why not ask hospital authorities? Isn’t it their job?’ I asked.
‘No one listens there. They all have more important things to do, like cozying up to the powers that be. No one is concerned how we are working!’ AS appeared dejected. ‘There have been no grants to our department for decades even for treatment and they expect us to perform all kinds of procedures and even earn money for the government. Most teachers have no publications but are promoted and even become dean and principal. How can they inculcate a desire to work and perform research in the faculty? Everyone is busy in private practice and making money.’
Dismal Situation on Ground
‘SN has said something similar. But what stops people from doing medical research?’ I tried to bring the discussion back to research.
‘Hah,’ AS laughed. ‘Research? If they don’t have `500 to spend on repairing a fan, do you think they can fund your research? For all the thesis work of my students, I have been spending money from my salary! I challenge SN to compare the research grants given to AIIMS and my college and then compare the research output.’
I was aware of the impressive publications AS had had and they appeared still more so when I considered how he might have made it possible. I definitely did not want to bring up what SN had written about lack of research output, ‘The reasons for this state of affairs are alleged to be the overwhelming clinical burden in most medical colleges leaving little time to devote to academic activities; but we believe it is more due to the lack of guidance and absence of role models among seniors, who themselves have published little.’3
AS would have exploded had I read it out then. His work was better than that of many in some premier institutes. To be fair to SN, he had mentioned lack of funding, absence of infrastructure and time-bound promotions for faculty as other causes of poor output.
A Supporter Joins
At that moment, BM, another colleague of ours, walked in with her breakfast to the table and joined the discussion. BM, also a professor of gastroenterology, had spent her lifetime in a government medical college. She said, ‘There is gross shortage of faculty in medical colleges. Over 30 seats were not filled in my college. Just before inspections, the state medical education authority would order emergency transfers to medical colleges from peripheral hospitals to fill in the numbers! Earlier we used to criticize private medical colleges for having ghost faculty, and now state governments are doing the same thing. Similar is the case with essential medical equipment. Medical equipment is taken on loan from suppliers before inspection by the Medical Council of India (MCI), while all non-functional equipment is hidden somewhere.’
A Stranger is on Listening Watch
SB, a young, smart and erudite gastroenterologist with a goatee beard and photochromatic spectacles, was also sitting on the table. He was silently listening to this conversation. He spoke for the first time, ‘I suggest you should outsource research to private professionals! I have been doing it for years.’
‘What do you mean private professionals?’ I enquired.
‘Actually my father taught me this. And very early too. Always get the best professional help available,’ SB seemed to be enjoying our attention.
All three of us were now staring at him. ‘Your father taught you? What does he do?’
SB’s manner was self-assured: ‘He is a simple businessman!’
We kept staring at him as if asking him to explain. He added: ‘In class IX, I was given a project to find out how boys and girls of our school spent their pocket money. My father asked one of his employees to prepare the project for me. I don’t know how that man did it, but my project was declared the best in the school.’
‘But that was just a school project!’ BM said.
Tricks of the Trade
SB continued, ‘In intermediate college while doing class XII, we were asked to prepare a science project for which there were marks for “internal assessment”. This time it was my own research that got me 20 out of 20 marks!’
‘What research?’ I asked.
SB smiled, ‘I found out that our class teacher’s husband sold ready-made science projects. He was actually one of many people who did this work. But if you bought the project from our class teacher’s husband, you got 20 out of 20, otherwise you got 18 out of 20. I told this to my father and got 20 marks!’
‘Where have you done your medicine from?’ I asked. He proudly mentioned the name of his medical college. It was a private medical college in a city I had never heard of. So I asked, ‘How did you write your MD and DM theses?’
‘I told you it was a professional job!’ was his answer.
‘And who are these professionals?’ I asked.
SB flicked his wrist and started clicking on his smartphone. In a few seconds, he pushed a list before my eyes. It seemed to be a list of professional companies writing medical papers as well as MD/PhD theses.4,5,6,7,8
AS looked at the list and said, ‘But these sites may just be offering help in learning how to write a thesis! How do we know they are doing what you say.’
‘The legality of such a business may be questionable. Therefore, they advertise in a legally acceptable manner. I can introduce you to the real professional people I used. They used to do a full dissertation in just three sittings.’
‘Three sittings?’ all three of us said in a chorus.
Secret Divulged
‘Yes,’ he said in a matter of fact tone, ‘In the first sitting you explain to them what you want. The second sitting is to approve or change what they have written. And the third sitting is to negotiate the journal in which you want to get it published!’
‘They get it published too?’ BM asked.
‘Yes, in world-class, high-impact journals! These days, it is preferable to publish in open source publications to get higher citations. Both my theses were accepted for publication during my postgraduate course.’
‘But you said they used to––are they not doing it anymore?’ I asked.
He said, ‘I am sure they are still doing it and may be better than before. But I have not needed them after my thesis work. Now I use a different source.’
‘What source?’ BM asked.
‘During the past 9 years, I have published 27 papers in indexed journals. I am already a professor in the medical college I am attached to. Now I use pharmaceutical firms and device manufacturers for the real work. They have their own competent departments to do such jobs’. he replied.
‘You’re a revelation. I’m finding it difficult to accept all this as real. I wouldn’t even dream of such a thing,’ BM commented.
SB’s respectful reply was: ‘Madam, I have learnt it from the Chinese. A few years back I had gone to attend a conference in China. There, a friend told me about it. The Chinese are ahead of us because in their country, promotions and financial bonuses are linked to the number of publications by an individual. Big companies there provide this service, and almost everyone is using it. The easiest thing is to publish a meta-analysis or a systematic review. It is almost free if you don’t interfere with the slant they want to give in the conclusions.’
A Research Question?
SB’s smile broadened, ‘Is there a dearth of research questions? Someone has defined a “drug” as a substance, which when injected into a rat, produces a research paper.’
‘I can understand that pharmaceutical companies would be interested in drug trials. Tell me, how do pharmaceutical companies help you in writing a research paper?’ I asked. ‘Do they provide a research assistant? Do they collect all your patient data and analyse it for you?’
I was in for another shock. He answered, ‘No they bring the paper, and I submit it in my name. Research is done at their end. I do not know from where they collect the data. I am sure you know about ghost writing.’9
‘Aren’t you scared that you may be caught?’ AS was curious.
Scientific Horror
SB passed a muted smile, ‘Well, there have been instances of people being caught. One example in the literature is of a private practitioner from Moradabad who in 1992 published in the BMJ a randomized controlled trial on the effects of dietary intervention to prevent further heart attacks in susceptible patients.10 One of its key findings was that a year of a low-fat, fibre-rich diet almost halved the risk of death from all causes. This study later became a citation classic (cited more than 225 times). Then, I guess, he became more confident and went on to publish many more and also submitted such articles again to the BMJ. Later, one of the reviewers suspected fabrication of data and asked the editors to investigate not only the script submitted for the publication but also the one published earlier. This man failed to produce the
original patient records because “termites had eaten them”. Then followed a concerted, but informal, international investigation into suspicions of scientific misconduct and data fabrication.’11,12
‘Aren’t you afraid, it might happen to you?’ BM asked.
‘It can!’ He shrugged his shoulders. ‘But I don’t write earthshaking research papers in A-list journals. Mine are mostly “me too” papers written for journals which are eager to accept papers. And there is an epidemic of such journals now. It is also safer.’
Can You Rely on Medical Research?
‘But why have you told us all this?’ I asked. ‘Aren’t you afraid that we might blow the whistle on you?’
‘No sir, I know you won’t. You need evidence for it. Everyone of my generation knows it. I told you, because I respect all three of you and I didn’t want you to fret about a mundane thing such as medical research.’ SB was still respectful.
‘You have given us a jolt. If this is reality, we should not base our medical practice on this kind of research. I for one, will lose all faith in research coming out of tier-2 cities!’ BM lamented.
SB added, ‘Madam, do you think research coming out of big Indian institutes is real, honest and reliable? It will be a rare professor in these institutes who will himself supervise data collection. Residents collect all data, and the main aim of residents is to pass the DM/DNB examination. They have to work in the wards and outpatients 18 hours a day; how honest can you expect them to be in data collection? Have you thought about it?’
AS nodded vigorously, ‘It’s a fact. Unless we computerize everything, data verification will not be possible. Here again everything boils down to infrastructure and funding.’
‘So we are back to relying on western research?’ I said.
Is Western Research Better?
SB laughed, ‘Sir, I know you are not so naïve! You have already written about how pharmaceutical companies in the West decide––what research is done, what results will be shown and what will be published. They also decide what guidelines will say!13 More than half of what is published in peer-reviewed journals is biased. Everything or at least most of what you read has already been doctored, especially the clinical practice guidelines by various societies.’14
What They Never Tell Us
Yes, I have been aware of this malady. We have often discussed this influence of the pharmaceutical industry on medical research.
But SB had more to tell us. He added, ‘And Sir, regarding your comment about relying on the West, let me say that your faith is misplaced. There are numerous instances where falsification of research data or results has been done in the developed world. The list is endless but I can enumerate a few for you:
Gregor Mendel
In 1866, Gregor Mendel published a seminal paper containing the foundations of modern genetics. In 1936, Ronald Fisher published a statistical analysis of Mendel’s data and concluded that “the data of most, if not all, of the experiments have been falsified so as to agree closely with Mendel’s expectations.”16 It has been described with interesting titles such as “Too many small χ2’s or hanky-panky at the monastery? (1968)”, “Great Fakes of Science (1977)” and “Betrayers of the Truth (1983)”.17
Sir Cyril Burt
Sir Cyril Burt, one of the most important psychologists in England, who was awarded the Thorndike Prize by the American Psychological Society, is best known for his study of intelligence with twins separated at birth. He argued that intelligence was highly heritable. In 1972, Burt’s papers came to the attention of Leon Kamin, a Princeton University psychologist, who noticed a number of irregularities in Burt’s published papers and concluded that Burt had “cooked” his data in order to arrive at the conclusion he wanted. “A liar and a fraud,” was Kamin’s verdict.18,32,19
Sir Ronald Darcee
Dr John Ronald Darsee, a physician, was a shining star researcher of Harvard University, and had published over 100 papers. He was later found (and admitted) to have fabricated data and was suspended from Harvard.20
Dr Stephen E. Breuning
Dr Stephen E. Breuning from Pittsburgh is another case where the researcher was indicted for fraud in medical research. A 3-year probe, by the institute’s review panel, concluded that Breuning actually had carried out very little of the work he described. And the impact of his research is still a matter of concern.21
Dr Marc J. Strauss
Dr Marc J. Strauss of Boston University Medical Center was found to have falsified data in the use of a cancer drug and was debarred from federal funding.22
Dr Roger Poisson
Dr Roger Poisson (1994) working on a multicentre clinical trial of lumpectomy versus radical mastectomy in treatment of breast cancer at St Luc’s Hospital, Montreal had enrolled patients who were not eligible for trials and then falsified or fabricated their medical records to cover up their ineligibility.23
Dr Paul H. Kornak
‘Dr Paul H. Kornak was an anaesthetist at Stratton V.A. Medical Center, Albany, New York and was sentenced to almost 6 years in jail after he admitted to doctoring patient test results in his work on “The Iron (Fe) and Atherosclerosis Study (FeAST), VA Cooperative Studies Program”.’24
Others
SB ended his monologue by adding, ‘Then there is another familiar name—Anjan Kumar Banerjee from King’s College Hospital.25 And there are numerous others. Several books have been written on this subject.’26
Corruption in Research
Some time back I had read a paper in the BMJ about corruption in Indian medicine.27 SB had a clear answer to those who felt that corruption was mainly an Indian phenomenon. In a poor country such as India, money could be a motivator to indulge in such fraud and deceit in medical research, but what motivates people in the developed world?28,29
The human mind is complex and always weighs advantages to self before thinking of others. Even if I have everything, I would like to tell everyone that in a world of worms, I am a glow-worm. Creating incentives for research to increase research volumes will always run the risk of being counterproductive in a situation like ours.
BM declared, ‘Increase in research funding together with closer supervision may be the only answer. But one can only dream about it.’
Can We Reform the System?
Ways to prevent such misconduct have been often discussed,30 but nothing concrete has been done. The Government of India has been promoting Ayush, and is looking to cut down funding for scientific research. Lack of funding does drive prospective researchers to approach pharmaceutical companies. Easing availability of research grants can be one way to wean researchers away from such influence. And supervision is essential. Since the majority of work comes from medical colleges, institutional research committees can be tasked with the additional responsibility of supervising research work being done. A special body constituted by the MCI or its state counterparts can check the private players.
These thoughts must have crossed his mind, as they did mine, when AS said, ‘But in a country, where traffic laws cannot be enforced, is there a guarantee that research can be supervised?’
As SB finished his coffee, the smile was back on his face. He winked as he started walking towards the conference hall, and said, ‘Fact remains, despite all this confusion, medical progress is being made. The situation is not very different in our country. Despite the chaos we see every day around us, everyone I know has noted a perceptible improvement in their quality of life.’
Note:
1. The names and places are fictitious, but the issues are real. Any resemblance to a person living or dead is purely coincidental.
2. This paper was originally written in 2017 and published in National Medical Journal of India.31 Only changes I have made in the blog are that subheadings & carttons have been added to make reading easier. The text has been reproduced with permission from the Editor of National Medical Journal of India and the Author is grateful to him for permissions.
References
| ↑1 | Nagarajan R. Study reveals poor state of medical research. TNN, Apr 21, 2016. Available at http://timesofindia.indiatimes.com/india/Study-reveals-poor-state-ofmedical-research/articleshow/51920662.cms (accessed on 28 Apr 2016). |
| ↑2, ↑3 | Ray S, Shah I, Nundy S. The research output from Indian medical institutions between 2005 and 2014. Curr Med Res Pract 2016:6:49–58. Available at www.cmrpjournal. com/article/S2352-0817(16)30037-X/abstract (accessed on 28 Apr 2016). |
| ↑4 | Available at www.papermasters.com/research-paper-prices.html (accessed on 17 Feb 2017). |
| ↑5 | Available at www.turacoz.com (accessed on 17 Feb 2017). |
| ↑6 | Available at www.tutorsindia.com/medical-dissertation-help/ (accessed on 28 Apr 2016). |
| ↑7 | Available at www.prsharma.com.np/articles/thesis_writing.pdf (accessed on 28 Apr 2016). |
| ↑8 | Available at www.medicaldissertations.com/medical-thesis-writing-services.php (accessed on 28 Apr 2016). |
| ↑9 | Sismondo S. Ghosts in machine: Publication planning in the medical sciences. Soc Stud Sci 2009;39:171–98. |
| ↑10 | Singh RB, Rastogi SS, Verma R, Laxmi B, Singh R, Ghosh S, et al. Randomised controlled trial of cardioprotective diet in patients with recent acute myocardial infarction: Results of one year follow up. BMJ 1992;304:1015–19. |
| ↑11 | Saxena D, Kumar P. Data fabrication––Scientific misconduct. Indian J Community Med 2006;31:210. |
| ↑12 | Mudur G. Hint of research fraud. The Telegraph 30 Jul 2005. Available at www.telegraphindia.com/1050730/asp/frontpage/story_5052880.asp (accessed on 28 Apr 2016). |
| ↑13, ↑15 | Anand AC. The pharmaceutical industry: Our ‘silent’ partner in the practice of medicine. Natl Med J India 2000;13:319–21. |
| ↑14 | Anand AC. You are doomed because there is no evidence! Natl Med J India 2011;24:294–9. |
| ↑16 | Pires AM, Branco JA. A statistical model to explain the Mendel–Fisher controversy. Statistical Sci 2010;25:545–65 |
| ↑17 | Rytting B. Mendelian controversies: A botanical and historical review. Am J Bot 2001;88:737–52. |
| ↑18 | Parrington J. The intelligence fraud: Attempts to rehabilitate Cyril Burt, who falsified research to prove that intelligence was hereditary, are investigated. Socialist Review Apr 1996; Issue 196; London, UK. Available at http://pubs.socialistreviewindex. org.uk/sr196/contents.htm (accessed on 28 Apr 2016). |
| ↑19 | Tucker WH. Re-reconsidering Burt: Beyond a reasonable doubt. J Hist Behav Sci 1997;33:145–62. |
| ↑20 | Kochan CA, Budd JM. The persistence of fraud in the literature: The Darsee case. J Am Soc Inf Sci 1992;43:488–93. |
| ↑21 | Garfield E, Welljams-Dorof A. The impact of fraudulent research on the scientific literature: The Stephen E. Breuning Case. JAMA 1990;263:1424–26. |
| ↑22 | UPI Report (No author listed). Doctor admits filing false data and is barred from US support. The New York Times 20 May 1982. Available at www.nytimes.com/1982/05/20/us/doctor-admits-filing-false-data-and-is-barred-from-us-support.html (accessed on 28 Apr 2016). |
| ↑23 | Poisson R. Great science frauds: Science is not known for drama, except when a researcher commits fraud. Time 12 Jan 2012. Available at http://healthland.time.com/2012/01/13/great-science-frauds/slide/dr-roger-poisson/ (accessed on 28 Apr 2016). |
| ↑24 | Harding A. Fraud earns researcher time in jail. The Scientist 13 Dec 2005. Available at www.the-scientist.com/?articles.view/articleNo/23531/title/Fraud-earnsresearcher-time-in-jail (accessed on 28 Apr 2016). |
| ↑25 | Wilmshurst P. Institutional corruption in medicine. BMJ 2002;325:1232–5. Erratum in BMJ 2003;326:333. (The article has not been retracted, but for legal reasons it has been withdrawn from the website. [10 Jun 2004]). |
| ↑26 | Lock S, Wells F, Farthing M (eds). Fraud and misconduct in medical research. 3rd ed. London:BMJ Publishing Group; 2001:1–280. |
| ↑27 | Jain A, Nundy S, Abbasi K. Corruption: Medicine’s dirty open secret. BMJ 2014; 348:g4184 |
| ↑28 | Sarwar U, Nicolaou M. Fraud and deceit in medical research. J Res Med Sci 2012;17:1077–81. |
| ↑29 | Gupta A. Fraud and misconduct in clinical research: A concern. Perspect Clin Res 2013;4:144–7. |
| ↑30 | Padmapriya T. Ethical misconduct and corruption in medical research. J Educ Ethics Dent 2014;4:74–6. |
| ↑31 | Anand A C. Research in India.2017; 30(1): 39-42. |
| ↑32 | Gould SJ. The mismeasure of man. Revised and expanded ed, New York, London: W.W. Norton and Company; 1996. Chapter 6, The real error of Cyril Burt: Factor analysis and reification of intelligence; p. 265–350. Available at http://cb3.unl.edu/ dbrainlab/wp-content/uploads/sites/2/2013/12/5.-Factor-Analysis.pdf (accessed on 28 Apr 2016). |
An eye opener, Sir.
What is the answer? Do we continue in this mud or take some radical measures before it deteriorates further. Research is an individual passion should be inculcated not forced. Holding carrots before a teacher or professor will force him to hoodwink the system. But we all talk , don’t take concrete measures. Nice rumination.
Dear Anand…great narration,as always…I enjoyed it thoroughly…but I would submit that there are ‘islands of excellence’ within our country ,where only science prevails and scrutiny is an everyday event
Agree with you. Thats how progress is being made.
One expects that the percentage of people involved in publishing biased research would be small, especially in reputed journals. But studies indicate that over 75% papers published in reputed journals may have elements of bias or methodological errors. You may find this paper interesting. [Ioannidis JP. Why most published research findings are false. PLoS Med. 2005 Aug;2(8):e124. doi: 10.1371/journal.pmed.0020124. Epub 2005 Aug 30. PMID: 16060722; PMCID: PMC1182327]
An eye opener indeed! And you come to know the extent after your retirement!!
Medical Research publications have great potential of being fraud & it’s probability has been further accentuated because of making it mandatory for everyone’s professional enhancement . This is more evident in India because we have neither been provided with the environment nor with money , the 2 absolutely essential ingredients of any research.
Author & me r classmates from medical college & the post graduation course duration of 3 yrs has remained unchanged since 1965 at least. During the Entire Period , no time is assigned for research , secondly we have become the slaves of statistics, another reason for fraud perpetuation .
I fully endorse the view Of SB, when he says India too has made substantial progress in the Medicine.
Paper of Gregor Mendel was leveller as fraud , it was all because the quest for publishing, has the Mendel’ s law of genetics revised based on the criticism by the next author.
we have to be more pragmatic as well as vigilant regarding medical publications. Money making is the only absolute truth of present times . Lancet & NEJM were involved in fraud publications not too far past, Raising the questions once accused by another Medical professional, promptly revealed the truth about the authenticity of the publication. None of the questions raised were not known to 2 famous medical journals authorities.
I also endorse my friend Pradeep Patnaik’s suggestion of inculcating the environment of research rather than forcing it.
Dear Admiral
A hard hitting insight into the “ethics” of Medical Research.
And yet the Medical world continues to use research output as the yardstick to judge a clinicians standing and capability. Of course the “the islands of excellence” are the saving grace. May their tribe grow.
Warm regards.
This is brilliant, Sir. When doctors are told to either “publish or perish”, they are cornered. A good doctor need not have a researcher’s bent of mind. We need to stop forcing people into roles they neither relish nor benefit from. Empathy, good communication, precise diagnosis, the ability to speak at conferences and the ability to perform good original meaningful research are diverse skills. Let each one chose his niche and stay true to his chosen path.
Always a treat to read your posts, Sir.
Sir, most relevant now when so many fake claims, scientisms and ghosting got exposed during this pandemic. From Surgisphere to papers withdrawn from Lancet & other reputed journals, to the Great Barrington Declaration, this pandemic brought into sharp relief all issues you have taken up in your essay. Ultimately when will medical practitioners return to their True North? To their moral bearing of solidity, ethics and humanism? That is when we will find a way to ensure that governments and societies that benefit from our advancements also foot those bills!