Key Opinion Leaders

I wrote “Transparency at the Top: British Psychiatry” in April 2015 but did not share it publically as I wanted to give the Royal College of Psychiatrists time to improve the governance of financial conflicts of interest. Over the last 2 years improvements have been made by the Royal College of Psychiatrists however the system in place is unsearchable, costly, and bureaucratic. It also does not help determine how much of the £340 million that the pharmaceutical industry pays each year for “promotional activities” goes to the “top” educators (key opinion leaders) in UK psychiatry.

Sir Professor Simon Wessely has been an outstanding President and has carefully listened to the concerns that I have kept raising on this issue. This week he hands over the Presidency of the Royal College of Psychiatrists to Wendy Burn.

Tomorrow, the International Congress: Psychiatry without Borders begins in Edinburgh. I will be protesting outside because I remain concerned about the considerable reach (to the many) of a handful of educators: “The Law of the Few”.

  Here follows my original transcript, dated 25 April 2015:

The Chief Executive of the GMC recently confirmed in the BMJ:

To ensure public transparency of financial payments to healthcare workers and academics both France and America have introduced a Sunshine Act. In the UK we do not have such statutory basis to transparency. Royal colleges rely on Guidance such as this guidance, CR148, by the Royal College of Psychiatrists*:

The Royal College of Psychiatrists Guidance, like The GMC, gives clear and unambiguous guidance*:

The Royal College of Psychiatrists has recently expressed that, in addition to such clear and unambiguous College guidance (CR148), that the Association of the British Pharmaceutical Industry (ABPI) “central platform” to be introduced in 2016, will ensure transparency that will “so avoid some of the criticisms of yesteryear”:

The ABPI “Central Register” has no statutory underpinning and any healthcare worker or academic can choose to opt out of revealing any financial payments made from industry.

It is perhaps then an opportune time to consider whether the Royal College of Psychiatrists is correct to express confidence that we may be able to “avoid some of the criticisms of yesteryear” in regards to transparency in regards to the relationship between industry and psychiatrists. To consider this, we might do well to look at some of the key College leads. So to start at the top this should include the current President of the Royal College of Psychiatrists. Such a consideration should also include the current Chair of the College Psychopharmacology Committee. To be properly representative of College leads, this consideration should also include a Psychiatrist who is today widely considered as a ‘key opinion leader’ in British psychiatry.

The only purpose of this consideration is to attempt to examine if our College leads are exemplars in transparency and to attempt to establish if they have followed College guidance CR148.

Sir Professor Simon Wessely was elected last year as President of the Royal College of Psychiatrists and took presidential office on the 26th June 2014. The week after his appointment, Professor Wessely was interviewed on BBC Radio 4 and, as part of this public broadcast, was part of a discussion with James Davies, University of Oxford:

This is an emphatic statement made publicly by the President of the Royal College of Psychiatrists.

In fact Wessely has been transparent about “Financial Disclosures” as given here following a co-authored review paper published in JAMA in 2014: “Dr Wessely has received financial support from Pierre Fabry Pharmaceuticals and from Eli Lilly and Co to attend academic meetings and for Speaking engagements.”

This full transparency helped Joel Kauffman consider the 2004 JAMA Editorial and this can be read in full here. But meantime, here is the relevant extract:

Those at the top of British psychiatry would appear to have a range of definitions of “transparency”? It is certainly very clear that Sir Professor Wessely does not have anywhere like the volume of working relationships with industry as some of the other current College leads. Last year Wessely gave the keynote lecture “Psychiatry under fire” at the following conference. This was not a sponsored talk as the programme makes clear. The Conference was organised by Professor Allan Young who confirms that the “objective” of this symposium is to provide “independent” education to help “achieve personal CPD objectives and in your everyday clinical practice”.

Professor Allan Young is also Chair of the Psychopharmacology Committee of the Royal College of Psychiatrists and his declarations are publicly available here where he confirms that he is paid for “lectures and Advisory Boards for all major pharmaceutical companies with drugs used in affective and related disorders”. Professor Allan Young may well be one of the most influential ‘key opinion leaders’ in British psychiatry. In this role, as a most influential educator Professor Allan Young has recently been considered here and here.

Also giving a talk at this 2014 “Latest Advances in Psychiatry Symposium” is Professor Guy Goodwin who is also considered to be a “key opinion leader” and who is undoubtedly one of those at the “top” of the hierarchy of British Psychiatry.

Professor Guy Goodwin featured centrally on the BBC Panorama programme in the following month. This programme was titled “who is paying your doctor” and Dr Goodwin came under considerable scrutiny. However it should be the case, that such scrutiny should include not just a single, individual “key opinion leader” but those like the Chair of Psychopharmacology Committee and the President of the Royal College of Psychiatrists. For patients to have trust in the medical profession it should be the case that such leads are exemplars when it comes to transparency of financial interests.

Following the Panorama programme in which Professor Guy Goodwin featured, the Head of Professor Goodwin’s University Department, had an article published in the BMJ where he expressed the view that the media harm caused by raising the subject of transparency “may outweigh any good”. An alternative view is given here. As a result, Dr David Healy, Director of the North Wales Department of Psychological Medicine offered a proposal to ensure wider consideration of transparency in British Psychiatry. This proposal for a “proper and open debate” was copied to a wide range of individuals including Professor Goodwin and had previously been discussed with Sir Simon Wessely. The correspondence can be read here .

As President of the Royal College of Psychiatrists, it is clear that speaking proportionally, most of the research Professor Wessely has been involved in has not involved working with the pharmaceutical Industry. Wessely is after all a professor of psychological medicine at the Institute of Psychiatry, King’s College London and head of its department of psychological medicine. Compared to some of the psychiatrist colleagues around him, and in particular “key opinion leaders” it is no doubt the case that Wessely has worked less with industry. However, it is not the case that he has “never worked with industry” as he emphatically stated on Radio just after becoming President of the Royal College of Psychiatrists.

In the past, Professor Wessely has helped prepare review articles through “educational grants” from the pharmaceutical industry. It perhaps may be argued that this is not “working” with industry. Though College guidance CR148 does seem to be much clearer in what it expects in terms of transparency. This was one such article involving Wessely and another one can be accessed here.

A few years before College Guidance CR148 was introduced, and long before Wessely was elected President of the Royal College of Psychiatrists, he gave his personal view on ‘working’ relationships with industry and insisted that it was “time we doctors grew up”. At the time, the BMJ published a range of views, and one of these has been included alongside Wessely’s to demonstrate this range. Professor Wessely’s personal view is now over a decade old and it would be helpful to know if his views have changed over this period of time.

Summary:
Is it the case that calling for transparency regarding financial payments may cause more harm than good? Some of those at the top of British psychiatry would appear to have put forward this view, arguing that such will damage public trust. Yet the GMC are clear what they expect of their professional group, namely doctors. Is it not time that we had an open public debate about this involving more than those just at the top?

*Since writing this CR148 was replaced in March 2017 by CR202


Update of 11 June 2017: “The Law of the Few”


From: Wessely, Simon [mailto:simon.wessely@kcl.ac.uk]
Sent: 15 April 2015 00:04
To: Gordon, Peter J

Peter
Just been forwarded your last e mail

Remind me when I partnered GSK?

could be that my memory aint what it used to be, but I don’t recall any links with GSK. And a search of my e mails reveals nothing – I don’t have any emails before 2001 (computer disaster) but nothing turns up when I search on GSK.

Simon


From: Wessely, Simon [mailto:simon.wessely@kcl.ac.uk]
Sent: 15 April 2015 17:52
Subject: RE: Pierre Fabry Pharmaceuticals and Eli Lilly and Co

Peter
Thanks for your words of encouragement, I am doing my best, and its bloody hard work I can tell you – I am still doing my day job as well as taking on the college role

OK, to what you are asking.

Its no secret that I have in my life done a handful of non promotional talks sponsored by pharma – and by handful I mean a handful over a career lasting 30 years – I have done more for royal british legion, hay festival, mother unions, Royal Navy, you name it, I have done it. I would guess that 0.1% have been for pharma, I have no objection to doing pharma talks but they rarely if ever ask me because i am not helpful to them – my expertise is in exactly what they don’t want – psychological therapies

And I declared it clearly in 2004 when I wrote an editorial, not a paper, on SSRIs and suicide because Lilley do produce an SSRI, and I did a talk for them, and pierre fabry must be the same, although I think they were trying to produce a treatment for fibromyalgia rather than depression. I sent you the editorial earlier

What you have attached is irrelevant – its not a paper by me….it is someone entirely unknown to me writing a summary of some recent research, and including a quote from the very editorial that I sent you. quite why they need to also reproduce my COI statement in that is beyond me, but there you go. I have no idea if the original research that I was myself editoralising in JAMA was funded by GSK – and it doesn’t matter a jot, because its not my research, its by Hershel Jicks. If you are implying that I need to have declared a connection with GSK because I wrote an editorial concerning a piece of original research that was, for the sake of argument , funded by GSK, then I am afraid you are losing the plot

I will not be declaring the actual COI that I did declare in 2004 in the JAMA paper, which I repeat did not involve GSK, at the International Congress, because it happened a decade ago, and was declared at the time. As you know, there are various definitions of COIs, i one we use is the BMJ, which says 3.5 years previous and 1 year in the future. And it also says it must be specific to the paper – so if I am writing as I do on the history of neurasthenia, I don’t need to say something irrelevant to that topic – for example that I am a trustee of Combat Stress.

If you look at my papers, which you haven’t, you will see that most of my recent work is in the military sector, and I routinely and tediously deStressclare my grant support from MOD, various charities,that am advisor to MOD and a trustee of a military charity, so I don’t need any lecturing about COIs.

There is absolutely nothing to hide here, and I haven’t hidden it – unless you call putting in the world’s largest medical journal, JAMA, hiding.

And when I said I don’t work for pharma, I don’t why would they have me? I work for King’s College London. I haven’t worked for pharma., I don’t advise them, I am not an opinion former, I don’t receive consultancy fees, I don’t own shares, I don’t sit on boards, don’t do trials, I don’t even prescribe their products these days etc etc – I have received a couple of speaking fees which were declared at the time, and no longer need to be declared. But yes, you might think I could have phrased it a bit better and I might agree with you- If I did the interview again I might perhaps say “yes, done a couple of talks a decade ago on psychological treatments, but I have never worked for pharma and have no links with them so I think I am well placed to respond to your accusation that pharma controls psychiatry” gmc numbe
. As it was I did give the longer version at a debate on the same subject a couple of weeks later when I had more time.

So could we please call a truce now …I really do have other things to do – and one of them is to steer through what you wanted, and which I agree we should have done before, which is to make people’s COI declarations more publically available, including my own, when they speak at RCPsych meetings

You are trying to shoot the wrong fox on this one.

Simon


From: Gordons [mailto:pgsg@bridgeofallan.plus.com]
Sent: 15 April 2015 19:02
To: ‘Wessely, Simon’
Subject: Transparency and healthcare

Dear Professor Wessely,
Thank you for this detailed reply. I happily accept your call for a truce although I did not think we were at war. I do not go around shooting foxes but if I did I would not choose to pursue you.

I have tried to explain the background of my interest in transparency. Unfortunately it has been my experience across the board that discussing this issue generates a huge amount of defensiveness. I would hope that you share my view that those who lead our profession should set the best example in this area that they possibly can. I would welcome some acknowledgement from you and the Royal College of Psychiatrists that there have been close relationships between British psychiatry and the pharmaceutical industry and a clear indication that, to ensure public trust and the integrity of science, we must now do our very best to be transparent. I am pleased that the College is making efforts to address this but my view is that there is a lot of work still to be done. One outstanding issue is the culture within healthcare (psychiatry is certainly not alone in this) that somehow discounts the evidence that involvement with the pharmaceutical industry influences practice. This happens to be covered in this week’s BMJ: Forever indebted to pharma—doctors must take control of our own education
http://www.bmj.com/content/350/bmj.h1965

Just to be clear: I was seeking clarification of the statement you made on radio and was not linking this to the forthcoming International Congress.

It would inform my on-going consultation with the Scottish Parliament if the College could keep me up-to-date with planned revisions to the College Guidance, CR148.

I very much appreciate your constructive approach and for taking the time to respond to me personally.

Kind wishes
Peter


16 April 2015 (early hours of the morning from Simon Wessely) (I had not sent any further communications and so this reply was unexpected)

“No. Absolutely not. Not a penny. JAMA don’t pay for invited editorials although frankly one could argue they should. After all they make money from publishing. But anyway they didnt and don’t. And as to the idea that pharma would pay me for writing an invited editorial for Jama. Well…what can I say? I genuinely not entirely sure how they even could since the invite comes from the journal, but just to make 100% clear. No. no one paid me, directly or indirectly or via telepathy or sealed envelopes or whatever. Zilch, zero,nada, niente…”

Simon


On the 26th March 2015, following a previous post by Hole Ousia, the Royal College of Psychiatrists stated that it “‏is committed to our Conflicts of Interest policy.” 

principles-of-rcpsych

This policy advises that:

cr148-guidance1

and that:

cr148-guidance3

Dr Ben Goldacre in his book “Bad Pharma” suggested that:

008

This is advice I have tried to follow, but have found that it is much harder than I realised. Ben Goldacre also gave this advice:007

I have written to the Royal College of Psychiatrists for a number of years now as I have concerns that extant College Guidance is not being followed. Recently the President of the Royal College of Psychiatrists reassured me that “our team are on the case”. 

Here are the twenty members of the Organising Committee for the forthcoming International Congress in Birmingham. The linked biographies demonstrate that 19 out of 20 have so far not provided any declarations of interest.  At the same time there appears to have been no difficulty in offering sponsorship opportunities in advance of the conference.

Organising Committtee International congress 2015

Here is the view of the Editor of the BMJ this time last year. A year on and it appears that there is still a need to hold the applause.

002

Through research for my petition to the Scottish Government for a Sunshine Act I have collected evidence that fully supports Dr McCartney’s claim that, one way or another, “doctors’ education is

paid for almost exclusively by industry

 

012

Dr Ben Goldacre is of the same view.

KONICA MINOLTA DIGITAL CAMERA

This is the Royal College of Psychiatrists response to the Association of the British Pharmaceutical Industry (ABPI) “Central Platform” which intends to set up a central, open-access register of payments. However any healthcare worker or academic can simply opt out of disclosing any payments on this registeravoid some of

In recent social media correspondence with the President of the Royal College of Psychiatrists, Dr Ben Goldacre‏ made a series of comments:

“Surely the problem here is the College calling this a problem of the past while failing to implement basic COI transparency? It’s such a dull ancient thing to have to gripe about.”

“I’m surprised that the declarations that have been made aren’t publicly posted?”

“I am very concerned about the reputational consequences for the profession of casual false reassurance on these issues.”

“I really wish the Royal College of Psychiatrists would show some leadership and do Conflict of Interest declaration properly. Not hard, happy to help. It’s unnecessary and embarrassing to be resistant on this issue, we need to be seen to be clean by our patients.”

The President of the Royal College of Psychiatrists replied: “Give us a break Ben. We are chasing and everyone speaking will do so with a full COI. Which will largely be empty”006

 

Unless we have transparency it is impossible for any of us to know who might be paid to educate us. We know in one year that the pharmaceutical Industry paid £40 million to healthcare workers in the UK.


 

Last year at a Royal College of Psychiatrists Conference, one speaker was Professor Allan Young. Professor Young’s declarations can be accessed from the webpage of the Psychopharmacology Committee of which he is currently chair.Prof Allan Young, Chair

 

Below is Professor Young’s “bio” as an organiser for the International Congress. As is the case for 95% of the organising committee, this does not yet include the declarations above:Prof Allan Young as organiser of RCPsych Conf

This is a post that I never wanted to write. I should not have had to. This is a governance issue. It is the Royal College of Psychiatrists who should be ensuring that their policy CR148 is being followed.

We need our College to lead on transparency otherwise we risk a dark “mark” which may be “exceptionally” difficult to rub off.

This letter has been published in the current edition of The BMJ:Quetiapine adverse reactions

Reading this letter my thoughts returned to a lecture given by Professor Allan Young at a Royal College of Psychiatrists, CPD-approved conference, in September 2014.

Professor Allan Young gave no declarations of interest in his speaker biography:

 

 

Professor Allan Young’s speaker biography demonstrates that he is a “key opinion leader”:Prof-Allan-Young1

At the start of his talk Professor Allan Young put up this slide of his declarations of interest. Professor Allan Young did not talk through his declarations and the slide was not up long enough for the audience to read it through:

Prof Allan Young declarations 26-9-14

I recorded these quotes made by Professor Allan Young as given by him on 26 Sept 2014:

“For those of you who watch Panorama I do not give my consent for you to film this”

McQueen, 2011 “They missed out my trial” [Embolden trial]

CropperCapture[1]

NICE, for not taking it into account at all [Embolden trial] is rather questionable”

“Quetiapine as a mood stabiliser is the Holy Grail for Bipolar Depression” commenting on work “adapted from Peters”:

“Major Depressive Disorder (“MDD”) will generally end up as Bipolar Disorder”

“A huge number of ‘bipolars’ are missed”

“SParCLE study demonstrated that Lithium is slower than Quetiapine”

Professor Allan Young’s “Key Points slide” for “the pharmacological management of Bipolar Depression”

P1030863

The forthcoming 52nd Maudsley debate. The motion is “This house believes that long term use of psychiatric medications is causing more harm than good”. One of those arguing against the motion is Professor Allan Young

52nd Maudsley debate 2015

 


 

The following MSc is advertised in PROGRESS in Neurology and Psychiatry, vol 21, issue 2, 2017:





Professor Pariante at 2016 BAP Summer Conference


Professor Nemeroff, who co-wrote “Neurobiology of Psychiatric Disorders” was invited by Professor Pariante to give this Inaugural lecture. There was much concern about this at the time:
 

Around this time I made this film about Professor Nemeroff :

Sails Blithely from omphalos.

Professor Pariante with Professor McCallister Williams at BAP Summer Conference:

 


 


professor-david-baldwin-and-bap-and-cpd


 

Professor David Nutt, former BAP President, has declared financial interests on the voluntary ABPI Register. Over the ABPI “disclosure period”, Professor Nutt has declared just short of £46,000 that he has received from Janssen-Cilag Ltd and Lundbeck Ltd.


NHS Lothian, St Johns Hospital, Livingston, 27 November 2015:

014

Professor David Taylor is an Academic Pharmacist and so not registered with the General Medical Council. Prof Taylor has had significant input into the development of UK-wide guidelines on prescribing in mental health. He has been open about his significant financial conflicts of interest

018

Professor David Taylor, paid by the Pharmaceutical Company Janssen, had earlier this year, given an “educational” talk to CPD teaching with my former employers:

008

I refused to go to this. Why? Well through much of the previous 6 months, my NHS e-mail in-box had received e-mails (not at my request) from the makers of Asenapine. Several “key opinion leaders” featured in these promotions, including Professor Alan Young (whom more of later) and Prof David Taylor. The following slide comes from this online powerpoint:002

The next in this slide demonstrates good practice as in it Professor David Taylor outlines his comprehensive, and well-spread, financial conflicts of interest:

003

Even though not a doctor, after I wrote to him, Prof David Taylor submitted his declarations to whopaysthisdoctor.com . We should commend this openness, as here Professor Taylor is a leading example of necessary transparency. It is important however that we consider that in “offering” “education”  Professor Taylor has significant financial under-writing. Professor Taylor has had a significant role in the development of UK-wide guidelines on prescribing in mental health.

Three years back: On the 17th May 2011 I wrote to NHS Forth Valley to say that I found that the link to the “Hospitality Register” was non-functioning. It took two years of polite inquiry for NHS Forth Valley to finally confirm that as an NHS Board it had NO register of interests for ALL staff. I was later to discover (through Freedom of Information requests) that this was a pattern spread across ALL twenty-two of NHS Boards in Scotland:

007

Eleven years back: in circular HDL(2003) 62 The Scottish Government stated that “Chief Executives are asked to establish a register of interest for ALL NHS employees and primary care contractors”: 

At annual appraisal and at five-yearly revalidation all doctors are asked to sign a probity section where each individual doctor confirms (or not) the following (this screenshot is from my recent Revalidation:

012

Before closing: the following example of an “educational” “CPD” event reveals a pattern that does not just involve those employed by the NHS such as charities and third-sector organisations:

021

Professor David Taylor (bottom right) at the BAP 2016 Summer Conference:

 


 

This is a Hole Ousia post of the 20th March 2016:

With careful thought, and backed with full supporting evidence,  I sent the following letter of the 2nd February 2016 to support my petition for a Sunshine Act for Scotland.

The Senior Clerk of the Parliamentary Committee was of the view that this letter did not comply with the Scottish Parliament’s policy on the treatment of written evidence. I was therefore asked to redact significant sections of the letter.

After considerable communications to and fro, I replied as per this e-mail of the 3rd March 2016:

I fully respect the right of the Scottish Parliament to determine 
what it publishes.

I feel very strongly that my letter without the highlighted text 
merely reiterates what I have already said, and fails to provide 
the evidence that I have repeatedly been asked for.

So my position is that I do not wish to amend my letter of 
the 1st February on PE1493.

My petition has since been closed. I therefore have decided to publish my letter to the Scottish Parliament in full along with supporting evidence. I have had professional advice that what is contained in this letter is not defamatory as it is based on veritas and has full supporting evidence:

Dear Mr McMahon
Petition PE01493: A Sunshine Act for Scotland

I realise that the Committee must receive a great amount of correspondence however I hope that the committee might agree that what follows is extremely important when considering PE1493.

Since I last wrote to the committee I attended, for accredited continuing medical education, the Royal College of Psychiatrists in Scotland Winter Meeting held on the 29th January 2016. It is this that has compelled me to write this update as it demonstrates beyond doubt that lack of transparency around financial conflicts of interest remains a serious issue. An issue with implications for both patient safety and healthcare budgets. It also demonstrates that Government action is the only way to address this.

The full powerpoint presentations of this Accredited meeting for 
Continuing Professional Development can be accessed here - but only
for members of the Royal College of Psychiatrists. 

I am a member of the Royal College of Psychiatrits and I am of the 
view, as a scientist, that these lectures should be available to 
all and not just to members.

One speaker highlighted the increase in prescribing costs in her health board area which was due to the high prescribing rate of a new antipsychotic injection, palperidone depot (XEPLION®). The next speaker demonstrated both the inferior effectiveness of this drug when compared to existing (far cheaper) depot medications and the perception amongst Scottish psychiatrists that it was more effective. Below you will see the flyer sent to mental health professionals in Scotland when this drug was launched:

002 Financial Conflicts of Interest, Scottish Psychiatry

I have highlighted one of the paid speakers, Dr Mark Taylor, because he also spoke at this week’s meeting where he reminded us that he was Chair of SIGN Guideline 131: The Management of Schizophrenia, which was published in March 2013.

At this week’s meeting Dr Taylor presented his declarations as follows: “Fees/hospitality: Lundbeck; Janssen, Otsuka; Roche; Sunovion”.

Dr Taylor commented on these declarations with the statement that “you are either abstinent or promiscuous when it comes to industry. Well you can see which side I am on”. Audience laughter followed.

The general question that arises is whether an influential professional such as a Chair of National Guidelines might earn more from the pharmaceutical industry than in his or her role as a healthcare professional? At present it is impossible for anyone to establish the scale of competing financial interests. To remind the committee the following avenues are not illuminating:

1. Royal College of Psychiatrists. This week’s meeting did not appear on the college database. In any case this database is neither searchable nor does it include specific details of payments and dates

2. NHS Boards. The committee has already established that, across Scotland, HDL62 is not being followed.

3. SIGN guidelines. The committee is aware of significant governance failings particularly in comparison with NICE which includes details of financial sums paid and associated dates.

4. Discussions with Senior Managers in NHS Scotland relating to the General Medical Council’s expected level of transparency has brought forth written responses describing my interest as “highly unusual” and “offensive and unprofessional”

5. The forthcoming ABPI register allows any professional to opt out of inclusion.

It is also worth repeating that the information provided to the public consultation on this petition failed to highlight most of the issues identified in points 1 to 5 above.

In terms of cost both to the public purse and the individual patient the Government’s stated wish for a “robust, transparent and proportionate” response would be fulfilled if a single, searchable, open register of financial conflicts of interest that has a statutory basis were to be introduced


 












 

Cowen, P J - Constructionism 24-5-2011Professor Philip J Cowen

A straightforward internet search would indicate that Professor Cowen has followed extant guidance regarding transparency. Here follows some of the material on Professor Cowen to be found in the public domain:

Cowen, P. J,CINP, 2016Cowen, P J - 3-3-2014Cowen, P J - 17-11-2014Cowen, P J - 19-5-2011Cowen, P J - 20112011, RCSPsych Int CongressCowen, P J - 2014 bCowen, P J - 2014Cowen, P J - 2015Cowen, P J - April 2014Cowen, P J - April, 2012Cowen, P J - Aug 2010Cowen, P J - Aug 2013Cowen, P J - Dec 2012Cowen, P J - ECNPCowen, P J - Jan 2015Cowen, P J - May 2012Cowen, P J - Nov 2012Cowen, P J - Nov 2012bCowen, P J - Nov 2013From “Our own window” published in BMJ rapid responses:<img class=”alignnone size-full wp-image-7100″ src=”https://holeousia.files.wordpress.com/2015/04/soft-rebuttal-2001.jpg” alt=”Soft rebuttal, 2001″ width=”570″