Malpractice in Academic Medicine

Malpractice in scientific research was, for most of British history, rarely discussed and almost never attended to. The process of peer review, whereby other researchers in a relevant field adjudicate the worth of a scientific paper, had been considered reliable in the biosciences and—other than occasional complaints made by singular figures, such as Charles Babbage in the 1830s—remained fundamentally unchallenged. But the infallibility of this process has been called into question frequently over recent decades, perhaps most famously in the late 1990s, when Andrew Wakefield’s study suggesting a link between the combined MMR vaccine and autism was published in the Lancet, probably the world’s most prestigious and impactful medical journal. This article and the media furore it sparked raised major concerns about vaccine safety globally. The now notoriously discredited paper passed elite peer review standards and it took well over a decade for the Lancet to retract it.

Today, articles are sometimes retracted before they have even been published, and, thanks to the efforts of Retraction Watch, PubPeer and others, the fallibility of peer review is now openly discussed within the scientific community. Wakefield is an unusual example, as he is a medical doctor, rather than a scientist. Discourse on scientific misconduct within the medical profession is especially rare, and it is not well known that British doctors receive little scientific training. The pre-modern approach to medical research, in which physicians tried to figure out the basics of medical science and apply them to medical practice, has been superseded by specialised courses in biomedical sciences and medical statistics that train would-be scientists in the use of evidence-based techniques. Though medical students still have to attend a handful of seminars on medical statistics and the fundamentals of biomedical research methodology, doctors are primarily trained to diagnose illness and treat sick people and receive little formal instruction in good scientific practice.

The assumption that doctors are innately competent to conduct scientific research therefore appears to be a historical hangover. A 1994 case involving gynaecologist Malcolm Pearce brought the problem to public attention. A report published by the Royal College of Obstetricians and Gynaecologists the following year emphasised that doctors need preparatory training in the sciences to prevent such instances of research malpractice in future—yet no progress has been made on this front. Having only attended a few cursory undergraduate sessions during medical school—which may have taken place decades ago—doctors can apply for hundreds of thousands of pounds of public research funding, with no further scientific training.

Authorship, Credit and Responsibility

A recent case at Oxford University reveals the ease with which doctors can be involved in scientific malpractice and evade responsibility for it. Alexander Liu is a graduate of Imperial College Medical School in London and an award-winning researcher, most recently in the Cardiovascular Science department of the University of Oxford. It is common for doctors to conduct scientific research, either out of interest or to advance their careers, and securing research funding is an important step towards this aim. The ambition and indefatigability demanded by modern cardiology training is put to the test during this process. In 2015, Liu was awarded a prestigious British Heart Foundation (BHF) Clinical Research Training Fellowship, worth a quarter of a million pounds. Liu appeared to be a typical fellowship candidate, with a track record in scientific publishing. His work received awards from the American College of Cardiology in 2016 and from the Society of Cardiovascular Magnetic Resonance in 2017.

However, in September 2020, two of his research papers were retracted. Both papers had been published in the March 2018 issue of the Journal of the American College of Cardiology, arguably the most prestigious cardiology journal in the world. According to an internal investigation conducted by the University of Oxford, the reason for the retraction was research misconduct. The university authorities have not disclosed when or how they became aware of any concerns, but it is remarkable that only a single author has been held responsible. Liu is contesting the university’s findings and has filed a complaint with the Office of the Independent Adjudicator. The statement on the Journal of the American College of Cardiology’s website, however, alleges stark misconduct, including the fabrication of images, the gross manipulation of data and the failure to include control data. Liu was contacted for comment after the story was reported in Medscape News but apparently did not respond. This is regrettable, as Liu’s case clearly demonstrates the predictable problems that arise from the medical profession’s involvement in scientific research.

Perhaps it is unsurprising that doctors do not always perform research well, given their lack of training. But is it plausible that none of Liu’s co-authors—nine in one case and ten in the other—bear any responsibility for the manuscript’s flaws? It seems that in a world-renowned research unit run by multiple distinguished professors of cardiology, several of whom were co-authors on the papers in question, research manuscripts were approved without anyone noticing image fabrication and data manipulation. The allegation that Liu alone was guilty of research misconduct seems to contradict the JACC’s own policy, which states that all authors must approve the final version of a manuscript. This reveals a hidden side of academic medicine: when a piece of research is considered noteworthy, senior co-authors are keen to share the credit—but if the research is revealed to be faulty, they are permitted to eschew responsibility. After all, a professor of cardiology could surely never be responsible for research misconduct? Think of all the influential people and institutions who would be embarrassed by such a revelation.

Power and Self-Interest

The law of triviality—which states that the intensity of emotional investment is inversely related to the significance of the issue in question—seems to apply here. Doctors’ responsibilities to speak up when patient safety is at risk and to ensure the integrity of medical research receive barely a fraction of the attention given, for example, to the possibility of racial or sexual discrimination in the choice of medical leadership. This focus on the trivial aligns remarkably well with the interests of the groups in question. Academics have historically never faced formal retribution for dishonest work, given the absence of any professional guild to hold them to account. The General Medical Council can levy sanctions against doctors for research misconduct, but given that they issue, on average, only around 1 sanction per year for a population of approximately 150,000 doctors, the chance of getting punished is clearly close to zero.

Imagine agreeing to be part of a clinical study only to find that the doctors involved have little or no training in scientific research and might even be willing to bend the rules to make the manuscript sexier? Or being treated by a cardiology professor who won’t take responsibility for her mistakes? How many deaths have occurred due to research misconduct by the very doctors who are trusted to protect patients? As Retraction Watch’s Ivan Oransky has shown, there have been plenty of retractions in Covid-19 research already. Oransky argues that the most likely outcome for someone who commits scientific misconduct is a long and successful career. The medical profession’s deference toward careerist scientific research is unlikely to lead to much accountability for now. The cultural power that doctors wield is still enough to bend the arc of justice towards their interests. For the time being, the issue is simply a moral one.