Current issues of ACP Journal Club are published in Annals of Internal Medicine


Transurethral microwave thermotherapy for bladder obstruction

ACP J Club. 1993 Nov-Dec;119:93. doi:10.7326/ACPJC-1993-119-3-093

To the Editor

I am concerned about the selection process for reviewers of abstracts included in the ACP Journal Club. According to ACP Journal Club's abbreviated Purpose and Procedure, "abstracts are reviewed by an expert in the content area." No comment is made about possible conflicts of interest the commentator might have and how the journal might deal with such situations.

This concern occurred to me as I read the abstract "Transurethral Microwave Thermotherapy for Bladder Obstruction" and the accompanying commentary by Dr. Glenn J. Gormley (1). Dr. Gormley's comments seemed cautious and weakly positive in tone. His published affiliation is with Merck Research Laboratories in Rahway, New Jersey. Although I am not an expert in corporate ownership, one wonders whether this is the research arm of Merck Sharp and Dohme, which is advertising and marketing its new product Finasteride (Proscar). This oral medication directly competes with surgical procedures, including the subject of this abstract—transurethral microwave thermotherapy. The reader could wonder about the objectivity of the reviewer under these circumstances. I am in no position to dispute the accuracy of his comments but, in situations like this, perhaps the editor could include a brief comment explaining the choice of reviewer. Another option might be to obtain a "second opinion" by a less potentially biased reviewer.

Kenneth D. Grant, MD
Georgetown University School of Medicine
Washington, DC

In response

In a recent position statement (2), the International Committee of Medical Journal Editors indicate that "conflict of interest exists when a participant in the peer review and publication process—author, reviewer, or editor—has ties to activities that could inappropriately influence his or her judgement, whether or not judgement is in fact affected." This statement reflects a growing concern in scientific publication about bias and deception, and an evolving approach (but hardly a consensus) on dealing with these matters. Dr. Grant's letter has caused us to examine our policy on conflict of interest in ACP Journal Club commentaries.

To date, we have relied on four procedures to identify conflict of interest and bias in studies and commentaries. First, we only select articles for inclusion that meet high standards for scientific conduct, protecting against several sources of bias. Second, we print the main organizational affiliations for the corresponding author of articles and for the commentators. Third, in editing commentaries, the staff of ACP Journal Club attempt to detect, challenge, and remove bias and make matters of opinion explicit. Fourth, the commentator and the author are given the opportunity to comment on each other's work before publication, a process that often takes several iterations until they agree on a modified commentary, or they agree to disagree. In the latter case, the author is invited to make a brief rebuttal at the end of the commentary.

But dealing with conflict of interest is often not straightforward. As the Committee's definition indicates, conflict of interest does not mean that a person's judgment is biased; rather, conflict of interest is a risk factor for bias. In some situations, a person who is very highly qualified to comment on a study by virtue of his or her own published work in the field also has a conflict of interest. We chose Dr. Gormley to comment on the study of microwave thermotherapy for prostatism because none of the more than 300 commentators in our database claimed to have expertise in this problem, whereas Gormley had recently published an article on finasteride for prostatism that was abstracted in ACP Journal Club. As Grant notes, however, Gormley has a conflict of interest because he works for a company that makes a product in competition with microwave thermotherapy for prostatism. Gormley did not declare this as a conflict of interest when he agreed to do the editorial for us but we did not ask him either, although it was clear that we were well aware of both his previous publication and his company affiliation. The author of the article on microwave thermotherapy did not object to Gormley's commentary and our staff felt that it was insightful and well balanced.

Prompted by Dr. Grant's letter and guided by a moderate approach proposed by Kenneth Rothman (2), we will add one more step to our procedures for dealing with conflict of interest. In addition to asking invited commentators to confirm their expertise in the topic of the articles we send them to review, we will ask them to declare potential or actual conflicts of interest, in the following way: "If you have, or believe that readers might reasonably expect you to have, something substantive (e.g., grants, publications, money) to gain (or avoid losing) from the position you take in writing for us, please declare this as a conflict of interest and we will select another colleague to write for us on this occasion."

The editorial policies of ACP Journal Club are explicit and open for discussion by readers. If readers have observations or objections to what we are doing, please follow Dr. Grant's lead and write to us.

The Editor


1. Gormley GJ. Commentary on "Transurethral Microwave Thermotherapy for Bladder Obstruction" ACP J Club. 1993 Jul-Aug:15 (Ann Intern Med. vol 119, suppl 1). Comment on: Ogden CW, Reddy P, Johnson H, Ramsay JW, Carter SS. Sham versus transurethral microwave thermotherapy in patients with symptoms of benign prostatic bladder outflow obstruction. Lancet. 1993; 341:14-7.

2. The International Committee of Medical Journal Editors. Position statement: conflict of interest. Med J Australia. 1993;159:57-8.