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“Fake news" in medicine: How much trust can we have in the medical information we receive?

“Fake news

Medical journals are in a crisis of credibility

The term “fake news,” suddenly a widely used and discussed acronym, is by no means only restricted to political discourses. With the ascent of social media and the opportunity they offer to spread highly subjective information quickly and unhindered to large numbers of people, discerning what is factual and what is “fake,” has become increasingly difficult. Unfortunately, this conclusion also applies to dissemination of medical information, - and not only to lay people. “Fake news” also increasingly affect the medical profession and that, of course, can have significant adverse consequences on many.

Lay public and the medical profession largely rely on different sources for information: The lay public received information mostly via media, including newspaper, magazines and television but, now, increasingly relies on social media and the Internet. In parallel with declining numbers of newspaper and magazine readers and viewers of major TV networks, serious medical journalism has in recent years been declining in quantity and quality. Like in general news coverage, reporting has become shorter and much more superficial, while covered subjects are often not chosen based on importance but potential shock value. With rapidly shortening attentions spans, this is what, after all, attracts.

Physicians, in contrast, are expected to rely on more “serious” data, mostly evidence-based studies, usually carefully extracted from scientific journals, which, free of commercial interests, only publish carefully vetted submissions after objective peer review. The reality of where physicians these days receive their information from, and the quality of this information, however, differs quite significantly from the above-outlined idealistic scenario.

Though, interestingly, only very few studies exist on this subject, like for all printed materials, readership of peer reviewed journals has been rapidly declining, as the Internet has also become a major source of information for physicians. Indeed, websites like WebMD may be frequented by physicians as often as by lay people. Medical journals, in addition, increasingly either switch from print to electronic publishing or add sister journals that are only publishing electronically. By the end of the decade, one can expect printed medical specialty journals to be an oddity.

The trend toward electronic publishing of peer reviewed articles is based on a completely revamped economic model, under which readers are no longer required to buy journal subscriptions but are given free access to all published articles. The model is instead financed by publication fees authors pay the journal/publisher, often out of the grant money that finances their research. Scientists, thus, not only provide content for free to commercial scientific publishers, as they have done for centuries, but they now also have to pay for the honor.

Because electronic publishing is significantly cheaper than print publishing, commercial interests saw this new publication model as a promising opportunity. In recent years, literally thousands of new journals have launched. In order to have material to publish and, of course, in order to generate revenue, these journals accept almost any and all submitted manuscripts without proper peer review and, sometimes, without any. Every accepted publication is, of course, a serious revenue source for thousands of dollars, while publishing costs are minimal. These journals are called “predatory open-access journals” or “junk scientific journals." They are often given names that play off prominent journals in the specialty, have usually no professional editor at all or editors without academic gravitas, and their editorial boards, if at all existent, are usually composed of academically and scientifically unknown individuals. Most of their overhead costs come from almost daily electronic solicitation efforts to established scientists with publication records, literally begging for submissions to their journals.

Credible scientists, of course, would not go anywhere near any of these journals; marginal academics, who are not lacking in numbers, and must pad their publication lists to support their academic careers, have, however, unfortunately been feeding many of these journals. The public and poorly informed media, therefore, now often fail to distinguish between what appears in more credible peer-reviewed journals and those appearing in predatory journals, resulting in increasing amounts of junk science being presented as facts. This trend is, of course, further strengthened by the Internet, where what is factual is even less important. Because of all of these developments, total published medical information is growing exponentially, overall quality of information is, however, in parallel unfortunately declining. Where information is retrieved from has, therefore, become of increasing importance.

Recognizing the special dangers of “junk” in medical information distribution, Google has developed algorithms that the company claims reward websites in their ranking, which provide credible and original content, while trying to punish “junk science.” Various other web-based companies, including Facebook and YouTube, have made similar claims, though how successful the Internet ultimately can be in filtering out “junk science” remains to be seen because algorithms favoring certain site features may be discriminatory and are, of course, always subjective.

Various watchdog organizations have, therefore, arisen, which in different areas are trying to objectively select the websites with most credible content. This is one reason, why CHR was so honored when its website received the 2018 eHealthcare Leadership Award, together with such giants of healthcare as the Cleveland ClinicMayo Clinic and others, all, of course, having incomparably larger budgets to foster their respective websites than CHR. Among fertility centers, this reward, therefore, represents an unprecedented honor, which CHR greatly appreciates.

Returning to medical journals, even established medical journals are often no longer what they once used to be. Increasingly, “newsworthiness” for the media outweighs the quality of a manuscript, when it comes to deciding which paper is accepted or rejected. It often appears like editors care more about the public visibility of their journals in news media than even the so-called “impact factor,” which, on its own, has become an obsession of editorial boards and publishers.

The “impact factor” is one of several metrics that are being used to compare journals. It (and other similar metrics) is calculated based on how frequently articles in a given journal were quoted by other published articles. The more that happens, and the better the journal rankings where those quotes appeared, the better the impact factor of the journal. With improving “impact factor,” journals become more desirable for authors and receive more submission, they can become more discriminatory in which manuscripts they accept for publication, and readership as well as advertisement rates go up. The “impact factor” of journals, therefore, greatly matters in academics, and in better academic institutions, promotions, therefore, not only depend on quantity of production but also on quality, often deduced from the “impact factors” of the journals where faculty's papers appeared.

The “impact factor,” however matters for editors and their bosses, the publishers even more, because the "impact factor," of course, also affects profitability. Publishers, therefore, are highly motivated to steadily improve their journals’ “impact factors,” and there are quite a number of tricks to achieve that. For example, rather than publishing original scientific research papers, many journals have radically increased acceptance of invited review articles and so-called expert opinions (which, among all evidence levels, are considered the lowest) because those are much more frequently cited in other publications than original scientific papers.

Fertility & Sterility, the official organ of the American Society for Reproductive Medicine (ASRM), is a good example. Rapidly losing “impact factor” under its prior editor and editorial board, the ASRM decided a number of years ago that it was time to reverse the slide. A new team of editors was recruited and a distinct policy, to reduce original scientific articles while increasing reviews and opinion pieces, was implemented. As a consequence, roughly one-third of the page volume in each journal issue now represents what some in medical publishing call “fluff.” By doing so, Fertility & Sterility, indeed, has succeeded in reversing its “impact factor” slide; whether that made it a better journal is highly questionable, and many--CHR included--would argue the opposite.

With the traditional motivation of publishing the best possible scientific studies being replaced by a host of other considerations, many specialty journals with often decades of distinguished history have been increasingly losing scientific credibility. “Leading” scientific journals, like NATURE and SCIENCE, and the leaders among more clinical journals, like The New England Journal of MedicineJAMA and The Lancet, demonstrate that what ultimately still matters is who publishes the best science.

Even medical publishing in very respectable peer-reviewed journals, however, is increasingly questioned on ethical and sometimes also scientific grounds. As the number of retractions of papers in even some of the best journals has skyrocketed in recent years, serious questions are not only raised about ethics in the research community and integrity of published research but, also, about the credibility of the peer review process. More and more voices are speaking out against aspects of “political correctness” in editorial offices that have become overly prevalent. The “Holy Grail” around the concept of the so-called evidence-based medicine (EBM), basically representing the concept that the highest levels of evidence are obtained via prospectively randomized controlled trials (RCTs) (standing on its own, this is a correct statement), which then can be further significantly amplified if meta-analyses are performed and analyzed in aggregated format, is increasingly criticized as naïve and, indeed, harmful in many circumstances.

As Jop de Vrieze, a science journalist, recently pointed out in an article in SCIENCE [2018;361(6408): 1185-1188], this concept has in editorial offices been practically elevated to a religion. As he convincingly explains, contrary to widely held believes, meta-analyses are not valid enough to end debates and they, indeed, often cause only more controversy on a subject. For a detailed explanation, we strongly recommend his article and an earlier 2014 piece in the British Medical Journal (BMJ) by Des Spence, MD, titled, “Evidence based medicine is broken” (2014;348:g22).

Though RCTs do, indeed, offer the highest level of evidence among all possible study formats, they do so only if those RTCs are well designed, and this is very difficult to do and very costly. Many, if not most RCTs, therefore, cut corners and, thereby, fail. Peer reviewers are, however, often so smitten by the fact that a submitted study claims to be a (correctly executed) RCT, that they fail in critically reviewing the materials and methods section to verify in appropriate detail that the study really represents what it claims to be. Extremely poorly executed RCTs, therefore, very frequently “sail through” peer review, as do meta-analyses, where reviewers only rarely bother reviewing the authors’ selection of studies that were included in the meta-analysis. Meta-analyses have, indeed, become a serial manuscript production line for especially Chinese academicians and, often, are not even worth the paper they are written on.

Following the old IBM-dictum “garbage in, garbage out,” which studies authors choose to aggregate or leave out, of course, will determine the outcome of any meta-analysis. Yet, rarely do peer reviewers bother to look into this selection process since just the notion that somebody submits an RCT and/or a meta-analysis in the eyes of most reviewers and editors already elevates the manuscript.

Examples abound: In the field of infertility, an excellent example are a few RCTs that claimed IVF outcome benefits for what now is called preimplantation genetic testing for aneuploidy (PGT-A) and, then, was called preimplantation genetic screening (PGS) of embryos.

Three such RCTs, indeed, became essential tools in the commercial marketing efforts of PGT-A/PGS. Proponents of the procedure, in fact, still cite these three RCTs, even though publications from CHR investigators and others have in detail pointed out the biases in study designs of these RCTs. A recently published combined ASRM/SART Clinical Opinion also described these RCTs, in contrast to their authors, as “inconclusive.” Though these RCTs quite obviously reached wrong conclusions, the alleged peer review process they underwent failed to notice those biases. With thousands of perfectly normal embryos disposed as a consequence of inaccuracies in PGT-A/PGS, adverse consequences have, of course, been substantial. Moreover, proponents of the procedure now, unabashedly, aggregate those data in meta-analyses when arguing in favor of PGT-A/PGS, thereby further magnifying the mis-directions of their conclusions.

Why such obviously misleading studies make it through peer review is widely discussed but probably comes down to the rather simple conclusion that the peer review process, in itself, has in recent years been seriously damaged. When, for example, a prominent editor in the field publishes his own and his wife’s papers in the journal he edits, and when he publishes articles from employees of an organization he co-owns, and when he does so not only occasionally but practically in every issues of the journal and, when in addition, some of these articles promote commercial products in which he has personal and/or indirect financial interests (without so disclosing), then we are, indeed, witnessing quite a significant deterioration in the integrity of the peer review process. The same can be said when commercial interests (i.e., for example drug companies) are permitted to publish articles, obviously written by shadow authors and when peer review is handed over to reviewers with obvious conflicts of interest.

The New York Times dedicated on December 9, 2018 a front page article by Charles Ornstein and Katie Thomas to the subject, where the title says it all: “Broken system lets doctors omit industry ties in journals.” Involving leading names in many different medical fields, this article demonstrated deftly the depth of corruption the medical publication industry has, especially over the last decade, permitted to permeate the whole enterprise.

Just a few weeks earlier, the New York Times reported on a prominent dermatology journal, where the editor-in-chief removed from print publication an, after peer review already accepted and electronically published research article, when “prominent” economic interests protested publication of the article. As de Vrieze absolutely correctly points out in his above cited article, financial interests (he calls them simply “money”) can always be a source of reporting biases. Even if actual results are not affected, “the spin when authors draw their conclusions” is often enough to misrepresent the meaning of a study to the readers.

In practical terms, all of this, unfortunately, means that, even what is published in often highly regarded medical journals, must be viewed cautiously and with a healthy degree of skepticism. Special interests, whether drug or device manufacturers, commercial laboratories or other interested parties, have discovered that components of the supposedly independent peer review process can be influenced with relative ease. Even reputable medical journals, therefore, at times are not beyond publishing “fake news.”

This is a part of the December 2018 CHR VOICE.

Norbert Gleicher, MD

Norbert Gleicher, MD, FACOG, FACS

Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.

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