Ghostwriting myths

Ghostwriting in the medical literature is something of a favourite topic of mine. There are many articles discussing the problem of ghostwriting, but more often based on opinion and prejudice than on facts and evidence. A great many myths about ghostwriting are endlessly rehearsed in medical journals, and those myths formed the subject of a guest blog post I wrote for PharmaPhorum a few months back.

Those myths show no sign of going away, so I thought it might be handy to produce a numbered list of them. This will save me and others a great deal of time in responding to inaccurate articles about ghostwriting: rather than writing a detailed critique, I shall, in the future, simply refer to this blogpost with a list of numbers (eg “The article by Smith et al perpetuates ghostwriting myths Nos 1, 3, and 4”). Job done.

So, here goes. Some of these myths are also described in my PharmaPhorum post, sometimes in more detail than I have done here, so you might want to read that as well.

1. Ghostwriting is the same thing as professional medical writing assistance

No, it really isn't. A ghostwriter is someone who contributes to a published paper and whose contribution is invisible to the reader. Assistance from professional medical writers is not the same thing as ghostwriting, provided that their contribution is disclosed to the reader. This isn't just me saying this: the World Association of Medical Editors (WAME) state, in their position statement on ghostwriting, “editors should make clear in their journal's information for authors that medical writers can be legitimate contributors and that their roles and affiliations should be described in the manuscript.”

2. Anyone who wrote a paper and isn't listed as an author is a ghostwriter

Although contributors to papers must have their role disclosed to avoid ghostwriting, it is not always necessary to be listed as an author. A medical writer's role can quite properly be described in an acknowledgements section. In fact, it would often be inappropriate to list a medical writer as an author. While there is no universally agreed definition of authorship, the closest thing we have are the criteria laid down by the International Committee of Medical Journal Editors (ICMJE). Those criteria are quite strict, and require that 3 conditions be met, one of which is “substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data”. Medical writers may fulfil that criterion, but more often than not they don't. In those cases, the appropriate place to describe their role is an acknowledgements section. As the ICMJE criteria put it:

“All contributors who do not meet the criteria for authorship should be listed in an acknowledgments section. Examples of those who might be acknowledged include a person who provided purely technical help, writing assistance, or a department chairperson who provided only general support.”

(Emphasis added)

While the ICMJE criteria are the most common set of authorship guidelines, they are not universally accepted, and there are some who argue that a more relaxed definition of authorship is appropriate, which would allow medical writers to be listed as authors, most notably the journal Neurology. However, when publishing in the vast majority of medical journals, we must abide by the ICMJE criteria, which do not allow medical writers to be listed as authors in most cases.

3. 50% of all articles in the medical literature are ghostwritten

This statistic can be traced back to a throwaway comment by the psychiatrist David Healy. Healy himself has pointed out that he has been misquoted, and never claimed that his figure applied to the whole medical literature. His claim was rather that 50% of articles about drugs were ghostwritten.

But even that claim doesn't stand up to scrutiny. It is based on a single paper, looking at articles on a single drug (sertraline). We have no idea whether sertraline is representative of drugs in general. It probably isn't. But even more important, that paper used different methods for identifying ghostwritten and non-ghostwritten papers, in a manner that almost certainly led to the over-representation of ghostwritten papers in his sample.

The fact is there are no terribly reliable figures for the prevalence of ghostwriting in the medical literature, but that figure of 50% looks like a hideous over-estimate. My own research (see myth 4) suggested that 33% of contributions by medical writers were ghostwritten, and although that figure may be biased as a result of self-reporting and selection bias, and we don't know what percentage of papers are written with medical writing assistance, it hardly seems credible that 50% of papers are ghostwritten.

4. Ghostwriting is becoming more common

It's actually becoming less common. Together with my colleague Cindy Hamilton from the American Medical Writers Association, we have surveyed professional medical writers in 2005, 2008, and 2011. Although I wouldn't like to claim too much accuracy for our absolute figures of ghostwriting prevalence because of the biases inherent in the survey design, we did use the same methods in the 3 surveys, so I believe that comparisons over time should be robust. We found that ghostwriting prevalence decreased from 2005 to 2008 and again from 2008 to 2011. (The 2011 results were presented as a poster at last year's AMWA conference, and the full publication is in preparation).

In addition, a paper published by the editors of JAMA found that the prevalence of ghost authorship (which is not quite the same thing as ghostwriting, although there is some overlap) declined significantly between 1996 and 2008.

5. There are many defenders of ghostwriting

Not that I've ever found. Many articles about ghostwriting make statements such as “defenders of ghostwriting claim...”, and yet they never seem to say who these defenders of ghostwriting are. Such arguments are invariably straw men. As far as I can tell, everyone agrees that ghostwriting is a bad thing.

6. Ghostwriting is encouraged by the medical writing profession and the pharmaceutical industry

Wrong again. There are various guidelines and position statements from both the medical writing profession and the pharmaceutical industry that make it very clear that ghostwriting is unacceptable.

7. Medical journal editors are the only ones taking a brave stand against ghostwriting

See myth 6. But also, while some medical journals do have sensible anti-ghostwriting policies, I really think that journals could do a lot more to combat ghostwriting. They are in the front line. If journals refused to publish ghostwritten articles, then it would be a lot harder to get them published. Now, journals don't necessarily know whether articles are ghostwritten, because ghostwriting is, by definition, hidden. However, very few journals, with one or two splendid exceptions, actually take the trouble to ask. I and some colleagues have produced a practical checklist designed to help journal editors discover ghostwritten articles. It might not discover all articles, but it would require authors to be actively dishonest in concealing a ghostwritten article. At the moment, all an author needs to do to submit a ghostwritten article is simply omit to mention that the article was ghostwritten. There is a world of a difference between failing to mention something that you've not been asked about and telling a deliberate, blatant lie in response to a direct question.

Sadly, few, if any, journals are using the checklist. I find that very disappointing.

8. The best way to deal with ghostwriting is to ban medical writing assistance

There are two problems with that. One is that it probably wouldn't work, and the other is that it would have harmful consequences.

Banning medical writing assistance may make ghostwriting more likely, by simply discouraging authors who have used assistance from declaring it. But worse than that, it would mean that authors would no longer have all the benefits of medical writing assistance. Perhaps the most important benefit is that it frees busy investigators from the chore of having to write papers, and makes it more likely that the papers will actually get written. When we are faced with a serious problem of trials that are done but not published, banning the people who can help get them published would be utterly perverse. We also have evidence that medical writers can improve the quality of publications and make it less likely that papers will be fraudulent.