Jerome P. Kassirer

Optimal medical care is critically dependent on clinicians' skills to make the right diagnosis and to recommend the most appropriate therapy, and acquiring such reasoning skills is a key requirement at every level of medical education. Teaching clinical reasoning is grounded in several fundamental principles of educational theory. Adult learning theory posits that learning is best accomplished by repeated, deliberate exposure to real cases, that case examples should be selected for their reflection of multiple aspects of clinical reasoning, and that the participation of a coach augments the value of an educational experience. The theory proposes that memory of clinical medicine and clinical reasoning strategies is enhanced when errors in information, judgment, and reasoning are immediately pointed out and discussed. Rather than using cases artificially constructed from memory, real cases are greatly preferred because they often reflect the false leads, the polymorphisms of actual clinical material, and the misleading test results encountered in everyday practice. These concepts foster the teaching and learning of the diagnostic process, the complex trade-offs between the benefits and risks of diagnostic tests and treatments, and cognitive errors in clinical reasoning. The teaching of clinical reasoning need not and should not be delayed until students gain a full understanding of anatomy and pathophysiology. Concepts such as hypothesis generation, pattern recognition, context formulation, diagnostic test interpretation, differential diagnosis, and diagnostic verification provide both the language and the methods of clinical problem solving. Expertise is attainable even though the precise mechanisms of achieving it are not known.

Failure to disclose all sources of financial support in biomedical publications has been the focus of media critiques of authors, journals, and professional societies. In this issue, David Resnik properly calls attention to the need in many cases for an archaeological dig to discover all the companies that fund a particular research project. Disclosure is widely considered the best disinfectant for relationships between investigators and industry, but even though disclosure is necessary and all funding sources should be exposed, disclosure is not a real solution to dealing with conflicts of interest. Here the author calls attention to the more dangerous problem--namely, the existence and persistence of the financial conflict even despite full disclosure. The author makes the point that the vast attention paid to failure to disclose is misplaced, and that more attention must be focused on the financial conflicts themselves and their consequences. He avers that the best approach to financial conflicts is to have none, and that those individuals who are free of financial ties to industry should be the ones appointed to major decision-making roles in journals, clinical practice guideline committees, FDA panels, and professional societies.

Ghostwriting occurs when someone makes substantial contributions to a manuscript without attribution or disclosure. It is considered bad publication practice in the medical sciences, and some argue it is scientific misconduct. At its extreme, medical ghostwriting involves pharmaceutical companies hiring professional writers to produce papers promoting their products but hiding those contributions and instead naming academic physicians or scientists as the authors. To improve transparency, many editors' associations and journals allow professional medical writers to contribute to the writing of papers without being listed as authors provided their role is acknowledged. This debate examines how best to tackle ghostwriting in the medical literature from the perspectives of a researcher, an editor, and the professional medical writer.

Do doctors neglect death and the dying, choosing instead to focus on flogging the last bit of life back into patients? Jerome Kassirer looks at a new book on the subject

Professional medical societies have become increasingly dependent on pharmaceutical, device, and biotechnology companies for ongoing support of their programs, but the internal influence of this financial largesse on medical societies' practices is well hidden. Many examples exist in which societies' educational products, including clinical practice guidelines and professional publications, have been tainted by involvement by industry-paid individuals. These examples show that professional judgments of organizations can be affected in ways that are not in the best interests of our patients. Society leaders should develop policies that leave critical decisions, especially those that affect patient care, in the hands of members without financial ties to industry. Society leaders should not accept funds designated for specific industry-recommended projects unless such programs are already part of their planned agenda. These leaders, who typically serve for only a year or two, should delve into arrangements that salaried society executives make with industry, and insure that no promises are made that compromise an organization's professional goals. Professional societies should also find ways of reducing the vast, embarrassing industry involvement at their national meetings, especially the vulgar circus-like displays and the drug company-sponsored symposia. We must reduce commercialism and restore professionalism to our medical meetings.

The violation of editorial independence by the CMA seriously damaged trust in CMAJ and raises questions whether the CMA can operate a truly independent journal.