Kent Sepkowitz's "Under the Influence" is an insult to medical journals and the physicians they serve. While entitled to his view on what might constitute a conflict of interest, he intentionally conflates COI issues and scientific fraud, two very different issues. Is it a fraud, for example, that Slate doesn't disclose its sources of income or that Dr. Sepkowitz doesn't disclose his institutional affiliation or sources of income? Obviously it is not, although some might argue these facts are relevant to judge objectivity. Additionally, many readers will infer based on the way Sepkowitz has written his article that The New England Journal of Medicine publishes supplements that are not peer reviewed and are sponsored by drug companies. The New England Journal of Medicine does not publish any supplements, sponsored or otherwise.

It is true that top-tier medical journals go to great lengths to ensure that authors disclose financial ties that may represent a conflict of interest that readers would have no way of discerning without disclosure, and that these journals include advertisements in their pages and make reprints available after publication. It is also true that physicians can readily tell the difference between advertising and editorial content. Rigorously managed industry guidelines ensure this. Additionally, at NEJM, advertising and editorial content appear in different sections to further ensure this distinction.

Can editors be influenced by business matters when deciding which papers to publish? This is theoretically possible, especially if a journal mixes the management of business and editorial matters. But at NEJM, editorial and business matters are managed separately, as they are at many other leading publications. This wall between editorial and business exists expressly to protect editorial integrity and to ensure that matters of business can't influence editorial judgment. Perhaps Richard Smith, who is quoted by Sepkowitz, is speaking from personal experience at BMJ, where he was simultaneously Editor and CEO, but at NEJM editors make decisions about which papers to publish exclusively based on the scientific merit of the paper itself and not based on potential commercial value.

Thomas J. Easley

Managing Director, Publishing

The New England Journal of Medicine

I appreciate Mr Easley's response to my article "Under the Influence." I obviously disagree with most of his comments but do want to say that I feel for NEJM and JAMA, two remarkable and high-minded medical journals that, because they are the national brand names, get mentioned in the wrong circles more frequently than they deserve. That said, I also would like to say to him and to others in his position -- welcome to the annoying world of financial disclosure. His response, to my read, is very similar to the response I had for the first few times I was required to reveal my affiliations with industry in anticipation of publishing a medical article. One cannot help but feel distinctly and inescapably accused at being asked to provide a full frontal glimpse of one's financial situation. I resented it (still do though I have gotten used to it) and felt belittled and tainted by the process. I thought then and think now that the conflict of interest / medical fraud police would do better to snoop into someone else's bank account -- just as Mr Easley suggests that nothing untoward is occurring in the offices of the New England Journal of Medicine. But finally I have come to accept that, though it might be an inefficient and annoying measure, it is a necessary one: these broad, insensitive, non-specific sweeps through the innocent (most) and the guilty (few) are, alas, all we have to monitor the product and assure some semblance of integrity. The public, I fear, assumes doctors and medical journals and Big Pharma are all in cahoots and, as individuals entrusted with moving medicine forward, we should greet all requests for greater disclosure with a polite if strained "I am happy to oblige." We then can wince and mutter on our own time. Kent A. Sepkowitz, MD

As a practicing physician, I do not agree that Dr Sepkowitz' article is an insult to the profession, and I wonder at the vehemence of Mr Easley's charge that it is. While I can understand that the use of the NEJM logo in the article calls for a strong protestation of innocence from the Journal, Dr Sepkowitz' article fairly illuminates a heretofore little discussed aspect of medical publishing.

Richard Deyo of the University of Washington recently commented on this subject as well. In "Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises," Dr Deyo reports on another aspect of this problem, the pressure major medical journals face to attract notice in the lay press, which attracts pharmaceutical advertising. He quotes a Dartmouth report faulting medical journal press releases for failing to include information on limitations of studies, magnitude of drug effects, and conflicts of interest on the part of editorialists.

The Journal's reviewer of its former editor's book "On the Take" found no error in Dr Kassirer's outline of sub-rosa corporate influence on medical thought and practice. The reviewer expressed concern that ordinary people would trust their physician less if they knew of those admittedly shameful practices.

Few of my patients have read Dr Kassirer's book or Dr Sepkowitz’ article in Slate; nonetheless, most express a general distrust of the profession. Drs Sepkowitz, Deyo, and Kassirer are not manufacturing this distrust. Such distrust will not dissipate until medicine as a profession takes action to correct its current shortcomings.

No physician would wish to target the New England Journal especially, but since Mr Easley has stepped to the fore, I will voice another concern. The Journal now prints editorials when authors receive up to $10,000 annually from corporate interests, provided such conflicts are identified at publication. The Journal explained that it was increasingly difficult to find qualified writers with no such conflicts. As a subscriber, I'd prefer for the best editorialist available with no conflict of interest. An editorialist referees; we need someone with no money in the game. When I need to help people decide whether this or that very expensive medical intervention is worthwhile, I would be much happier not having to factor in how much that $10,000 ( or less) had colored the editorialist's view.

Every issue of the Journal elicits my respect for the physicians whose intelligence and concern for patients informs the pages of the Journal.

Yet, as all of us do, I sometimes find views expressed with which I do not entirely agree. This I can accept when there is no commercial bias. Suspicion of such bias poisons communication. If there is no such bias, then there is no reason not to welcome calls for transparency such as made by Dr Sepkowitz.