Exorcising the ghosts of medical writing

There’s been much rattling of chains lately on the subject of ghost writing in medical journals. The British Medical Journal has reported that studies presented at the recent Sixth Annual Congress on Peer Review and Biomedical Publication in Vancouver showed that almost 8% of articles in high impact journals are ghost written.

In one study, Professor Lisa Bero of the Institute of Health Policy Studies in San Francisco said that while many journals have policies proscribing ghost writing, many weren’t explicit enough to capture ghosts. ‘We need to hit authors hard with explicit questions. Was this ghost written? Were you or anyone paid to write this article? And this has to be done universally so this sort of stuff doesn’t get through.’

While the full extent of ghostwriting is still unclear, presenters at the Vancouver conference felt that it is probably underestimated. What is clear, though, is that the concept is widely misunderstood. While such organizations as the World Association of Medical Editors, the International Society of Medical Journal Editors, the American Medical Writers Association (AMWA), the European Medical Writers Association, and the International Society for Medical Publication Professionals (ISMPP) have all weighed in on the topic, some misconceptions still prevail.

In its Code of Ethics, ISMPP tries to dispel some of these by stating that when preparing or developing publications its members should “avoid and discourage the practice of ghost writing (i.e., circumstances where the contributions of professional medical writers are not identified or acknowledged).” Some of these organizations’ codes state that “unethical ghost writing should be clearly defined and avoided, with all involved parties aware of what is and is not acceptable.” And: “To prevent some instances of ghost authorship, editors should make it clear in their instructions to authors that medical writers can be legitimate contributors and that their roles and affiliations should be described in the manuscript.”

The AMWA guidelines even suggest, where writing and communications agencies are involved, the following wording: “The authors gratefully acknowledge the assistance of A. Brown of Brown Writing and Editing Services, in drafting and editing the manuscript. This study was funded by XYZ Pharmaceuticals, Inc.”

That this issue has reached the public media and yet is still in need of clarifying is exemplified by a recent editorial in the Financial Times. It read, in part: “Using professional medical writers and editors to improve clarity in manuscripts is acceptable and even desirable. Ghost writing, which conceals underlying authorship, influence, and financial support, is wrong. All those involved in an article should be cited; those without any significant input should not be mentioned as authors at all.”

And recently-appointed editor of the Philadelphia-based Annals of Internal Medicine, Christine Laine, MD, was quoted in a recent article in the Philadelphia Inquirer as saying she wants medical research centers to forbid ghostwriting. However, she also said, “We don’t think the writing assistance per se is bad. It’s when it’s not disclosed that it’s a problem.”

But Arthur Caplan, PhD, director of the University of Pennsylvania’s Center for Biomedical Ethics, says it’s not just about disclosure; it’s about having an appropriate relationship with the editor. The author has to put together the concept and take responsibility for the draft; then others help the author, with appropriate credit; after that, there’s what he calls an exposition phase – editing, grammar, re-write. The important thing, says Caplan, is that this phase should certainly not involve spinning or massaging what’s being written. There’s confusion over what constitutes a ghost, he believes. A benign ghost can help you improve the manuscript; an evil ghost is one whose role is not acknowledged and who may be manipulating the data.

As both a medical writer and editor of long standing, I’ve observed that most editors are kindly and lovable – but also fairly compulsive – souls who want their handiwork to be impeccable. Writers, on the other hand, scarred by editors’ rejections and machete-wielding cuts, may be a bit diffident. And so I say to editors: welcome the involvement and cooperation of writers and give them credit for it; and to writers: jump in as early as seems appropriate, keeping in mind the Financial Times assertion that what you do is acceptable and desirable. But also be true to your professional sense of what’s right. It won’t be easy to exorcise these ghosts; maybe we should start by excising the word ‘ghostwriting’ from medical writing, and just follow the codes of ethics.

Dr. Woods is CEO of BioscriptUS (www.bioscriptUS.com). He is also the former editor of Health Outcomes Communicator.