FAIR: The Four-Letter F Word


Leonard Zwelling

One of my favorite authors is trying his hand at podcasting. That’s Michael Lewis of The Big Short, The Blind Side and Moneyball. The podcast is called Against The Rules and the first episode was posted on April 1. It’s called “Ref, You Suck.” It focuses on the new norm of NBA (and college) basketball of having a replay center in Secaucus, New Jersey oversee the calls made on the hardwood by the men in striped shirts to make sure they get it right.

This is a relatively new phenomenon. In the past, the refs called the games as they saw them, and, as Lewis points out, they were God. What they said went, even if flagrantly wrong. As we have learned this past post-season in the NFL, flagrant mistakes in officiating can be very costly to the team on the short end of a poor call. The NBA and the college basketball games are trying to minimize this through advanced statistics, studies of things like the racial bias of refs during games, and even more advanced technology. This is all because the fans have become so rowdy about missed calls that amping up the transparency and exposing the flaws in human eyes became a necessity according to the leadership of the NBA.

That’s what the podcast episode is about. But what it is really about is the fact that this has all come about in the atmosphere of Trumpism and his cry that the “game is rigged” against the little man and that he was going to change it. He was going to refocus the American Dream to give even the poorest and least educated among us the opportunity to overcome the raw deal the “refs” of society—on Wall Street, in Hollywood, and in DC—have inflicted on the little guy in America.

The campaign message worked. He won. So now, the deliverables.

So in the spirit of new ways to call balls and strikes—at the Supreme Court, for example—let’s ask whether the same thing ought to happen in science and medicine. Do we need new arbiters of what is right and what is fair in the realm of publications, grants and patient care? Does there need to be an academic biomedical replay center?

It seems to me that there is a new scandal every month about conflict of interest in major publications and research misconduct of other types as well. Clearly the refs in this domain known as reviewers and journal editors are doing a poor job keeping out the chaff. What’s the problem? Can’t the reviewers see through the falsified data and the lack of disclosure? Actually, no.

Most papers submitted to journals don’t really contain primary data but rather accumulated data in graphs and charts or example data selected for the excellence of the optics of the results of that experiment. Reviewers don’t see all the data. They also are rushed to turn the papers around quickly and, on occasion, review papers in fields with which they have scant familiarity. And how can editors know that authors DON’T disclose? All of this makes for the possibility of mistakes. So perhaps we need instant replay of the reviews and disclosures of those papers that are recommended for acceptance only. The rejected ones will be improved, putatively, and be resubmitted. It is the pesky ones thought to be good, that are the source of the misconduct that occurs. As for conflict of interest like those working for drug companies and not disclosing that in their papers, these folks need to have harsh penalties like three-years in the no publication penalty box when caught.

In the world of grants, unfairness has been the watchword for years. That’s not really the problem. It’s a combination of insufficient amounts of NIH and NSF money and the risk-averse nature of study sections or their reluctance to the funding of inexperienced investigators. The average age of a new RO1 recipient is in his or her 40’s. That’s crazy, but with a pay line around the 7th percentile, what do you expect? I’m not sure that more eyes on the applications will improve the funding or the results of the science leading to applicable discoveries. That’s really not the only goal of science, although it’s an important one. In the grant sphere the solution is more money, not more refs.

In clinical medicine the arbiters of success vary. Patients want good outcomes. Doctors do, too, but doctors also want fewer hassles in patient care and in paper work. The insurers want to minimize their financial risk exposure and pharma wants to maximize profits. Clearly the goals here are not aligned.

But perhaps in no human endeavor is fairness less likely than in clinical medicine. If you have insurance, you are better off than if you don’t. If you have cash and can afford a concierge doc, you are probably even in better shape. If you are poor or on Medicaid, best of luck finding a doc, let alone a receptive clinic.

The refs here are nowhere to be found. Everyone in the health care-industrial complex is out for him- or herself. No one is watching out to make sure the patient gets the best call he or she deserves. Only a new health care system that covers everyone, increases the number of care givers, improves access, controls costs and actually cares about quality is likely to play the role of the ref in this game.

In most of the rest of the world, the government is the ref. In America, no one is. Health care is a free-for-all and it certainly isn’t fair. Whether or not it can be will be a major point of contention for the next few years in the run up to 2020.

Oh yes. That’s only if the Republicans actually propose a health care plan before the election, something Donald Trump has eschewed until we re-elect him.

Leonard Zwelling