Editor’s Note: At the SSP Annual Meeting, Phil Davis will be leading a panel presentation entitled “Ghosts in the Machine: the Industry of Medical Authorship” (June 2, Session 1B), which brings together three experts on the topic: Annette Flanagin from JAMA, Sergio Sismondo from Queens University, and our medical ghostwriter, who has agreed to speak to us on condition of anonymity.
Today, we are rerunning two classic posts from our archive on medical ghostwriting, “Interview with a Ghost (Writer),” which debuted before Halloween, 2010, and “Ghosts in the Machine,” a subsequent story which covers a fascinating paper by Sismondo on the industry of medical authorship.
Interview with a Ghost Writer
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 . . . ).
Ghost in the Machine
Medical ghostwriting is difficult to investigate, for the actors involved in conducting, analyzing, writing, marketing and managing a piece of research are unacknowledged in the final manuscript.
What little is known about ghostwriting is based on anonymous surveys, interviews, and the occasional deposition of a disgruntled whistle-blower. In the event of a lawsuit, when companies are forced to reveal internal documents, we may view the underbelly of this spectral industry, which is thought to be involved behind much of the influential medical literature.
Sergio Sismondo, a philosopher and sociologist at Queens University in Canada, used a different approach to understand medical ghostwriting. Given the propensity for industries to organize, Sismondo simply attended one of their conferences.
In his 2009 article, “Ghosts in the Machine: Publication Planning in the Medical Sciences,” Sismondo documented an annual meeting of the International Society for Medical Publication Professionals (ISMPP) to explore the workings and relationships among different interest groups. The result revealed a complex network of actors including industry sponsors, contract research organizations (CROs), medical communication companies, STM publishers, journal editors, and academics.
And they don’t always work together harmoniously, Sismondo reported. Industry scientists are often antagonistic toward writers and marketers for misreporting their results to create spin. One presenter — an STM publisher — believed that its own journal editors, and the authorship policies they created, were ultimately doing harm to medical publishing:
We spend a lot of time trying to re-educate our journal editors. . . . We’re saying you have to change your instructions for authors. You have to reflect the changing mood of the times. And yet we still get journal editors who say ‘This journal frowns on ghostwriting’ or something similar. ‘This journal will not accept papers that have writing support.’ And actually what we’re trying to say to them is, ‘Fine, you may have that view but what you’re actually doing is driving it underground. It’s far better to be transparent and get this out into the open.
This is not a picture of a finely tuned machine, but an industry composed of various parts with different values, goals, and agendas. Even within specific groups, there may be some ambivalence toward ghostwriting. For instance, journal editors clearly benefit from clear and concise manuscripts crafted by professional writers but also demand adherence to strict authorship criteria, which precluded their listing as authors.
As for academic authors, publication planners view key opinion leaders (KOLs) as little more than indispensable louses:
Although they are recognized as crucial, KOL authors are often portrayed as lazy and greedy. As depicted by planners, they typically make few substantial contributions to the manuscripts they author, are slow to respond, and miss deadlines. They expect prominence in authorship order, and sometimes demand money for their contribution.
To their defense, Sismondo writes, these academic authors are typically provided with only a penultimate version of the article shortly before it is whisked off for journal submission. From the perspective of a publications planner, an academic is viewed more of as a check box on a prepared list of required steps than a true intellectual collaborator.
Sismondo avoids the familiar narrative of painting the issues too simply, as a crisis in scholarly communication, with its heroes and villains and simple solutions. Nor does he see everyone on equal moral grounds, pointing out serious conflicts of interest, such as when a CRO or academic publisher owns and operates a professional medical communications company.
Stepping back and reflecting on the medical publishing industry, Sismondo is philosophical.
Authorship in the medical sciences has lost its romantic notion of the auteur and has returned us to an earlier version of the scientific author, as the one who speaks with authority. This is the age of Robert Boyle and his air pump, where scores of assistants and technicians performed the necessary functions of science and yet remained hidden from the scholarly record.
And yet there is one difference. The academic “author” has been marginalized in the process, sought only for the authority of his name and no longer for his knowledge or expertise. When operated in this way, medical science is reduced to a form of marketing, which draws its authority from traditional academic science.
Given the investments and payoffs from this new model of corporate science, don’t expect change anytime soon. For the applied biomedical sciences, this has become the new normal.