I’ve met a ghost. Not the kind who haunt old Victorian mansions, moaning, pacing hallways, slamming doors, but a family man with an ordinary day job.
He works as medical writer, and in the last seven years, he has authored an impressive set of articles found in top scientific journals. You won’t recognize his name, because he is unacknowledged for his contributions.
Because they leave few traces, little is known about ghostwriters. Luckily, I had the privilege of interviewing one who agreed to speak freely about ghostwriting on condition of anonymity. For All Hallows’ Eve, we present you with an Interview with a Ghost.
Q: Can you briefly describe what you do as a medical ghostwriter?
A: I work as part of a publishing team consisting of: 1) the supporting pharmaceutical company, 2) the true authors of the study, 3) reference support staff, and 4) graphic support staff, if I’m lucky. In a perfect world, this team would work together to produce a readable, accurate account of the study in question, its results, and a critical review of how those results may (or may not) change the standard of care. In reality, authors are required to publish their findings, and the pharmaceutical company is paying for the study, so they are looking to me to produce a manuscript that will help make the company’s drug the new top dog.
Q: What led you to medical writing?
A: When I was a graduate student, I had no idea there was anything else for a PhD in biochemistry and molecular biology to do other than an industry lab, a government lab, or staying in academia. My first position, a publications manager for a medical communications company, just sort of fell in my lap.
Q: What do medical writers charge for their work?
A: Experienced medical writers will typically charge between $100 and $150/hr or about $3,000 to $4,000 per assignment.
Q: In cases where you are not listed as an author, are you listed as a contributor in the acknowledgments section of a journal?
A: Some clients feel it is in their best interest to present me as an author, but the pharmaceutical company will often shut them down, since I am not a thought-leader in that field. Sometimes I am added to the acknowledgments; most often I am not mentioned at all, which technically makes me a ghost.
Q: In what journals have articles that you’ve ghostwritten appeared?
A: My work appears in almost every medical field, from the New England Journal of Medicine, to the Journal of Clinical Oncology, Oncology, PLoS Medicine, American Journal of Psychiatry, Cardiology, and supplements to most of these journals as well. I have also authored a number of online continuing medical education (CME) sessions, various symposia presented at medical conferences, as well as posters, abstracts, and those pamphlets you see at your doctor’s office discussing treatment for a disease or how to self-medicate.
Q: Are there any tell-tale signs of a ghostwritten article? Can you detect it in other papers?
A: Ghostwriting is easy to detect if you know the primary author, or witnessed that individual present at a conference. When someone isn’t clear, or jumps around a lot, or can’t speak the language, yet has a publication in the NEJM, you can bet there was a ghost involved. Very prolific clinical researchers – especially those actively seeing patients and running their own clinics – are also likely to be working with ghosts.
Q: Studies of the prevalence of ghost and honorary authorship in medical journals , and Cochrane reviews  report that about one in 10 articles include ghost authors. Both of these studies were based on author self-reports. How accurate do you think these estimates are?
A: I think that figure is a little low. You have to remember that authorship is key to success and survival for most researchers.
Q: Litigation against Merck regarding Vioxx revealed that academics were routinely recruited and paid to put their names on articles they had little (if any) involvement in producing, for the explicit purpose of creating credibility for the study . Is this a common practice?
In my experience, the pharmaceutical company would pay a communications/marketing company to write the manuscript, who would then go out and find academics who would be willing to become the “authors” of the manuscript and paid an honorarium. I’ve worked with some authors who do absolutely nothing on the manuscript, requiring an additional ghostwriter to be hired, and still demand an honorarium for their time. These academics are willing to enter into this relationship because of the importance of authorship to their careers. You can’t entirely blame the pharma company. Universities encourage academics to play this game.
Q: Do you believe that you add value to medical publishing, or are you merely a hired hand for work that others refuse to do or do badly?
A: Short answer is “yes.” I believe I provide a service to those who need assistance presenting their findings to the scientific community. If you have a great study but present it badly you won’t be seeing it anytime soon in NEJM. Until we do away with authorship requirements for promotion and tenure all together, we will continue to need the skills of individuals, like myself, if these studies are to be published at all.
Q: Have you attempted to influence an editor to accept a manuscript?
A: I personally have not. Besides being morally wrong in my view, it is extremely difficult to get in touch with journal editors, which makes the submission process such a joy. Yes, that was sarcasm.
Q: Have there been cases where your sponsor wanted you to make conclusions that were not supported by the data? How did you deal with these instances?
A: Yes, I have. Every manuscript includes some marketing spin and controlling how much spin is the trick. Sometimes the abstract — often written by someone else — comes to a different conclusion than the main manuscript or relies on different data. The easiest way to deal with the issue [of unsupported conclusions] is to use the data.
Q: Are you a member of a professional society for science writers? Does that society have any guidelines for ghostwriting?
A: I have been a member of the American Medical Writers Association from time to time. They do have a series of guidelines and a code of ethics and they do suggest that medical communicators be recognized for their contributions.
Q: How do you claim credit for articles that you have ghostwritten for which you are not acknowledged? What does your CV or resume look like?
A: My CV consists of the various positions I’ve held through the years, and I do have a portfolio of projects that I have worked on. Most of my new business comes from former clients. If you stop hearing from a company that you have a long working relationship with, it may be due to some issue they had with your last project.
Q: Do you trust the medical literature? Or, now that you have a view on how the system really works, does it give you pause when you read the literature?
A: Every manuscript uses some marketing gimmick or spin in order to enhance the weight of the data. I remember when I was a graduate student, we were taught to look at our data with a critical eye. When a figure from a scientific lab has extra bands or markings that are not even mentioned in the text, it throws the whole manuscript in question for me. I can’t stop questioning the literature, especially in the higher tier journals, where there is a lot of “I’ll wash your back if you wash mine,” mentality. Don’t get me wrong, I love science, I just know how the game is played, and it leaves a bad taste in my mouth.
Q: Some have proposed that we need to rid the medical literature of ghostwriters; others argue that we merely need to make their identity and contributions known . What is your opinion?
A: Either journals should establish agreed-upon rules for what defines an “author” or do away with authorship altogether. I believe that everyone who worked on the paper should be mentioned in the Contributors section.
Q: Can you see your reflection in a mirror?
A: Well, since I’m nocturnal, there is never enough light for me to see anything in a mirror. I can walk through walls, though.
Q: What do you think of garlic?
A: I love it. Remember, I’m not a vampire.
Q: What are you dressing up for Halloween?
A: A medical researcher. Or the fifth dentist (4 out of 5 dentists agree . . . ).