Our Limitless Capacity For Self-Deception

I want to share with my readers a recent post and accompanying comment published on CardioExchange. The original post is by Eric Lindley, a cardiology fellow at the University of Utah:

Journal X: Not so Subtle Marketing Messages

I was the rare resident who thought that conflict of interest issues in medicine were a bit overblown. I did not find (or ignored) the evidence that pharma played a role in prescribing habits very persuasive, at least not when it came to my personal prescribing habits. I was not alone among the house staff, however, in appreciating an occasional “free” lunch, and the much rarer sponsored dinners at places I couldn’t afford as a physician-in-training.

Now I’m a fellow, and my attitudes about the pervasiveness of pharma influence have changed. Am I older and wiser? I’d like to think so. But I owe most of my conversion to the fresh perspective of my three-year-old daughter. She refers to most things by their color, including a majority of my medical journals. For instance, my JACC journals: blue for the mother journal, red for heart failure, green for interventions, etc. But then she started calling the original JACC the “X” journal. When I asked her why, she pointed to the “X” in Xarelto (rivaroxaban). I realized that every issue of JACC is covered front to back with the “X”. The message was subliminal to me, but quite obvious to her.

How do you think all of our pharma marketing looks with naive eyes?

This post prompted the following response from Siqin Ye, a cardiology fellow at Columbia University:

A story that I heard at ACC a few years ago goes something like this:

In a roomful of interventional cardiologists, the speaker asks, “How many of you have ever put in a stent that was unnecessary?”

Two or three hands went up.

The speaker then asks, “How many of you have seen someone in this room put in a stent that was unnecessary?”

About half the room raised their hands.

I think there is something similar with respect to our attitude towards pharma ads and gifts. I know plenty of residents and fellows who firmly believe that ads and dinners do not affect their personal practice patterns. Whether or not this is true for any given individual, the fact that pharma continue to spend so much on these activities suggest that as a whole, we are probably more susceptible than we believe.

 Thanks to Drs. Lindley and Ye for permission to reprint their words.



  1. Lawson English says

    Waiting for your reaction to the recent American Heart Association scientific statement on alternate treatments for hypertension that says that TM is currently the only relaxation/meditation technique that has sufficiently good research available that the AHA can recommend it as an adjunctive treatment for hypertension.

    Surely you must have some comment seeing how they cite the recently published study on TM and cardiovascular disease that you have written so much about…

    • I thought about posting on this and I may still do so. I remain critical of that TM paper but I’m not sure that the AHA statement is completely incorrect. The recommendation is very weak. A IIB endorsement hardly qualifies as a strong endorsement.

      • Lawson English says

        Eh, TM’s only real effects should be in terms of

        1) reversing/healing/normalizing the damage to the body and nervous system due to stressful experience;
        2) strengthening the nervous system to become less susceptible to new stress by establishing the relaxed EEG pattern (and/or whatever is the cause of that pattern) found during TM as a trait found outside of meditation.

        If there is a large stress-related aspect of a specific person’s disease or disfunction, such as hypertension, TM should have a correspondingly large effect. Not all hypertension patients have a large stress-related aspect to their disease, so TM will have correspondingly less of an effect. After averaging everyone together, TM has been found to have a “modest” effect on hypertension, which is what you would expect, given the above.

        I expect that larger studies on TM which can differentiate in terms how stress-related the condition is will find this to be true.

        That recent study which you are still critical of found a rather large reduction in cardiovascular disease. It is entirely possible that there is a very large stress-related component in that population, for various reasons.

        A recent study out of Germany reports that work-related stress can double the incidence of cardiovascular disease, so it isn’t a stretch to think that the TM study might be valid for that specific group of people while for others, the effect might be smaller OR larger.


  2. Robert Weitz says

    I am an patient and am completely frustrated by how brainwashed the cardiology community is. I had a mixoma removed and was thrown into survival mode. That means that I do a lot of reading and trying to understand the rational basis for studies and arguments that relate to my survival. I have other doctors who have heart issues call cardiology “medicine by numbers”. Two things – I ask every Dr. I meet how much training they have in statistics (they rarely have any training) and I am appalled by how they accept poorly done meta studies, with few questions.

    When I confronted an electro-cardiologist about lead failures in ICDs all he could do is stare at the ground and admit the stats I was presenting matched his own experience, but he wasn’t prepared to speak further about it.

    If one is a healthy patient with good habits the results are not recorded and positive outcomes that are not drug or intervention based are ignored.

    • I have no reason to think that cardiologists are any more– or less– susceptible to self-deception than other specialists, or, indeed, other humans. It seems to me that we can only begin to confront this problem once we begin to acknowledge the possibility– indeed, the inevitability– of self-deception in ourselves.

      • All doctors who advise patients are supposed to be professionals. The public puts their trust in professionals believing them to be self-regulated to be above the venality of the ordinary citizen. Professionals, by definition, must avoid any financial or other influence that would even potentially affect the best interest of their clients. Unfortunately, unless the lack of professionalism is grossly obvious and there are many complaints from the public, unprofessional behaviour goes unpunished. Licensing bodies never sanction industrial financial influence on doctors. Self-regulation is a sham. If doctors can’t act professionally what hope is there for the rest of society?

  3. Jean-Pierre Usdin Paris France says

    The most flashing subliminal message of these last months is in my opinion the advertising of this new anti diabetic: Dapagliflozin appearing on the fourth of cover page of NEJM.
    I am not a diabetologist but watching this bottle half full of white powder supposed to be sugar tell me that this new medicine (which does only to increase the content of sugar in the urine with the possibility of harm to the kidney bladder etc.) is the best one on the market!

  4. Dr. Siqin Ye’s story is an example of Muhammad Ali effect in scientists. From my research, it appears that individuals think of the self as considerably more moral (i.e. more fair and less unfair) and only slightly more intelligent than others, a pattern termed the Muhammad Ali effect. Consistent with the Muhammad Ali effect described by Allison and associates, it was found that subjects judged their own behavior as more desirable than the other’s behavior.

    The decrease in admission rates observed over the years in self-reports but not in non-self-reports could be explained by a combination of the Mohammed Ali effect and social expectations. It seems that scientists or cardiologists are no less likely to commit misconduct or to report what they see their colleagues doing, but have become less likely to admit it for themselves.

    Reference: Allison, S. T., Messick, D. M., & Goethals, G. R. (1989). On being better but not smarter than others: The Muhammad Ali effect. Social Cognition, 7, 275–295.

  5. Alan Averson says

    40% of the revenue of your employer, the NEJM, comes from advertisements and reprint sales. Look in the mirror for self deception Mr. Husten.

    • You won’t get an argument from me about this. I agree entirely. To be clear: I’m not against advertising in medical journals. But let’s acknowledge their role.

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