A Loss of Decency - and a Call for Voluntary Academic Integrity.

Not too long ago our Global Spine Journal Editorial Board received an email raising concern by a well-known member of our Spine community regarding an undeclared significant commercial conflict of interest by a member of an author group of an article that was extolling the virtues of a newer and expensive technology. A brief investigation revealed this concern to be correct, the author admitted the error and apologized, an erratum to the article was created and the missed information corrected. Unfortunately, but not entirely surprisingly, this conflict of interest had gone undetected by our Reviewers (who are blinded to the authors), Deputy Editors, Editorial staff and the Publisher until the volunteer reporter contacted us after reading the article.

For good reasons industry influences in academic publishing are one of the major concerns worthy of public reporting. Fostering functional ties of health care providers to industry for the greater good has clearly shown itself to be a major driver for positive advances in health care. Due to the dimension of financial incentives attainable and the potential for major adverse effects on patient health and well-being of health care systems some regulatory oversight is obviously desirable. Aside from blatant fraudulent intent, perhaps one of the most underrecognized aspects of commercially funded studies is a confirmation bias as shown in the significantly higher propensity for reporting positive outcomes with industry sponsored studies compared to nonfunded studies (78.9% vs 63.3% in one study and 98 vs 88% in another).[2,3] Of course, author bias from direct commercial interests remains one of the most prevalent concerns in a lucrative field like Spine surgery as shown repeatedly over the last 30 years. In general, we sadly have to assume that there is a continued strong and persistent underreporting of financial relationships with industrial entities despite near ubiquitous requests for declaration of conflicts of interest. In a recent study of 5070 articles in Orthopaedic and General surgery Trauma literature only 16.6% of authors disclosed their financial conflicts correctly, with 26.3% of Orthopaedic Surgeons and only 4.8% of General surgeons disclosing their conflicts as requested. Reasons for nonreporting are multifold and may range from relatively benign causes like ‘forgetfulness’ and ‘being unaware’ to ‘disclosure overload’ and the ‘cumbersome software’ programs used by some entities. Hopefully ‘intentional nonreporting’ is rare, but exact numbers on this most concerning form of commercially motivated academic misconduct are hard to come by. An improvement in transparency has been brought on in the greater advancement of legislative efforts in some countries to force companies to make public payments to health care practitioners. In example, the ‘Open payments’ databank that started in the USA following the ‘Sunshine act’ in the Fall of 2013 provides such a resource for the benefit of the public. In the 2020 summary a total of US$ 9.03 Billion transactions were reported ($2.03 Billion paid in General payments, $1.12 Billion in Ownership and investment interest and $5.88 Billion research payments) and 6.36 Million records were publicized by this resource of the US Center for Medicare & Medicaid Services, which is updated biannually. It was this resource that lead the reporting surgeon colleague to bring the significant unreported conflict of interest of the author mentioned in the introduction to the attention of GSJ. Sadly, this kind of financial transparency tool remains a user-friendly public entity available only in select democratic societies and is predictably not available or not trustworthy in totalitarian government systems. To the present date, there are, however, to our knowledge no software search programs to detect payment flows of commercial entities to private individuals or their holding companies, so individual efforts remain an important aid in identifying underreporting.

Next to the failure to adequately disclose conflicts of interest another serious form of academic misconduct has seemingly been reduced somewhat due to significant improvements in software programs. Flagrant plagiarism, once a bane of the academic publication world, has become much easier to reveal as every responsible scientific publishing entity now runs any submission through at least one if not more publicly available or commercial software programs that look for word, formatting and text similarities throughout the ‘world wide web’ with increasing sophistication by applying pattern recognition and machine learning algorithms. While it is hard to reveal theft of ideas and original thought formulations with such linear systems, the increasing analytical capacity of these search engine programs allows for far more expansive comparisons of text submissions to anything ever published in a digital format.

This welcome news is, however, dampened by newer reports of significant academic misconduct in form of authorships and whole studies being for sale online. The principles of authorship in medical journals are especially fundamental concerns for all of us humans as each medical journal author is bound by virtue of their name appearing in a publication to be responsible for the content presented. It needs to be remembered that ultimately any medical publication may indeed impact diagnosis and treatment rendered on behalf of our patients in direct or indirect form. While we all make mistakes and scientific insights and procedures can change over time, being true to the physician credo of helping others and avoiding harm where possible remains a fundamental value since the advent of civilization. To account for the individual responsibility of medical authorship the International Committee of Medical Journal Editors (ICMJE) has formulated its well-known four authorship criteriae, most recently updated in 2013

1. Contributions to conception, design, analysis and data acquisition / interpretation

2. Drafting or revising the article for important intellectual content

3. Final approval of manuscript

4. Agreement to be held accountable for all parts of the research

These well accepted 4 core principles unfortunately have not anticipated rapid technological changes and loss of ethically based societal consent decrees in favor of more reckless forms of pursuing individual advancements.

The use of so called ‘editing services’ has been a more recent introduction into the digital publishing market sphere and initially seemed like a welcome resource for potential authors pushed for academic publications but without English language proficiency sufficient to avoid early rejection from scientific journals published in English language. The scope of work of such ‘editing services’, which are commonly online businesses with off-shore locations usually in countries without a culture of public accountability, however, appears to be wide ranging and now in some cases extends beyond language editing into selling authorships based on their listing in the authorship order and even actual content creation of at least dubious foundation. This emerging illegal market has been highlighted repeatedly as far back as the 2013 landmark publication by Hvistendahl in ‘Science’ but due to the lack of internal accountability of the governmental agencies involved has not led to any appreciable changes in this market place. Based on more recent publications it seems that such forms of frank academic fraud are actually evolving into ‘paper mills’ that seem to be officially tolerated forms of ‘business’ in their host countries.

While there are many unanswered issues surrounding the important topic of authorship inclusion and ranking, the issue of authorship for sale and actual confabulation of academic material is an unthinkable transgression of basic medical ethics and will require a clear response from our medical community. Adjustments to the published ICJME principles, sharing of data files by researchers and consideration of transparency of source sites by reviewers may become a near term reality. Regardless of refinements in search tools it is ultimately we the physician community standing together by demanding honesty, transparency and accountability in our reporting as a basic nonnegotiable core value that we will be able to parry off these evolving attacks on research integrity. And yes, sometimes that means reporting on one another in case of questions to help us all in making a meaningful positive difference in the lives of our patients.