The Motivation to Collude vs. Collaborate in Academic Medicine – by Marielle年代. 格罗斯，医学博士，大英帝国勋章

[The first of two articles.]

The Brutal State of Nature

当我了解到这一点时，我还是个14岁的柔弱少年，在Shriners儿童医院的骨骼生物学实验室做志愿者 scientists don’t like to work together. “Why won’t they answer my emails?我问我的导师, as the techs in the lab next door, 他们同样致力于肌腱模拟，共同的目标是为有需要的儿童推进矫形技术, were ignoring my requests to see how they were mounting specimens for testing. “自从获得第一笔大额资助后……他们不想被认为是在帮助我，因为我已经…… 竞争的加剧他叹了口气。. 我很怀疑. “You mean that people with good ideas DON’T want to share them? 即使是和那些研究同样问题、关心同样事情的人? 难道他们没有意识到，通过共同努力，我们可以比单个部分的总和更大吗?“我天真得可爱.

年过去了, as I moved through pre-med, research assistantships, graduate and medical school, gradually appreciating how exceptionally bright, 善意的人们奉献自己的生命，让世界变得更美好——通常是默默无闻的, frequently grow averse to freely sharing 他们的想法 or precious data. The ‘why’ is simple: sharing, i.e. collaboration, is disincentivized. 不诚实的演员, of whom most meet their fair share, may ‘steal’ our ideas or data, convert them into financial or professional profits, leaving ‘us’ out of the loop. 仅仅是这种滥用的可能性就会促使今天的知识理念工厂囤积起来, rather than distribute, 他们的想法, 宁愿为了自我保护而牺牲科学进步，在这个世界上，他们已经在努力为自己的聪明才智和辛勤工作获得适当的奖励.

“要么发表，要么灭亡”的有害弱点是学术界的饥饿经济，在这种经济中，没有足够的资金来维持集体生存, 更别说繁荣了. 学术医学成为社会达尔文主义谬论的牺牲品:最适合的研究人员被迫消耗弱者, 大量吸收思想, 只有在符合个人当前最佳利益的情况下才促进合作.e., 对于一个人的可见性或可信度来说，公开合作比声称自己是合作成果的唯一功劳要好得多。, as opposed to collective benefits of research collaboration. Other things being equal, collaboration is perceived as something which inherently dilutes, 而不是丰富, the value of one’s contribution to humanity.  

This is really happening

As a junior health science researcher, 我的首席研究员(PI)曾指示我不要与统计学家合作以换取共同作者身份，因为这意味着即将发表的论文将有7位作者. 有7位作者, the value of publication would be disproportionately diminished for everyone involved, 一些最负盛名的期刊不接受每篇论文超过6位作者. I was already doing 95% of the work 我自己, for no pay (beyond the prospect of future first-author publication), my modest grant barely covering necessary supplies, and no funding available to pay a statistician’s hourly rate. 与此同时, 我的五位合著者, two (the PI and a co-I) brought necessary expertise, and another was primarily responsible for data collection and entry. The two others were at the proverbial table when we embarked on the project, yielding 社交礼仪上必要的 包容性，尽管他们只有一些专业知识，没有时间投入到项目中.

Was I, then a full-time surgical resident, supposed to perform statistical analysis 我自己? This hardly seemed appropriate use of human capital, 特别是因为我的最大努力必然会限制我们的分析质量，而不是与实际统计学家合作. 我发现这一建议不尊重统计学家在此类研究中发挥的关键作用. 这种缺乏动力的合作将项目的进展推迟了几个月，因为我逐渐拼凑了几个统计学家的时间, though paucity of hours and low priority for 公益性服务 student work required substantial narrowing of the scope of my analysis.

Once I had some pilot data analyzed, I met with one of the professional courtesy co-authors for feedback. 她同意初步结果证实了我们关于过度使用某些程序的假设，并建议应该减少这种程序. At that meeting she informed me, 自发的, 不幸的是，她无法有意义地参与这个项目，因此不应被视为任何最终手稿的合著者. 坦率地说, 我很惊讶:放弃共同作者身份对她的职业发展很有价值，但却花费了她微不足道的时间和精力. I had never heard of anyone pulling out of courtesy authorship specifically because, in their own assessment, they did not meet authorship criteria. Impressed with her integrity, I thanked her for her time and forthrightness. When sharing this update with my PI, 她耸耸肩, “At least we’re down to five authors, 这对我们都好.”

At long last, the statistical work was done. 一个偶然的机会, 我在统计学家的一份报告中发现了一个错别字，这可能会严重影响我们的结果. 对我们完整数据集的双重三次检查分析进一步证实了我们的假设，即我们可能做了太多的程序. Meeting with my PI to review the results, 我被告知, while data were promising and she agreed with our findings, 我们不应该在我们的手稿中提出这个结论，因为这些程序占了部门收入的很大一部分. Instead of reducing total number of procedures performed, we should focus on mitigating harmful sequelae of undergoing the procedure. She was not only concerned about blow-back from her superiors, 但那些评论我们论文的人也同样对这些程序的盈利能力有同样的看法, “少即是多”的结论可能会降低我们的论文被接受的积极性. 我在蛋壳上写字，让读者自己去读墙上的字. I solicited feedback from the co-authors. Most saliently, the remaining 社交礼仪上必要的 author wondered why we had not explicitly stated that, “we’re doing too many procedures,” the clear implication of our data from her perspective…

我们把手稿投给了一家知名期刊，经过同行评议，被礼貌地拒绝了. Perhaps it was my imagination, 但我在审稿人的评论中看到了我的PI的担忧:尽管有人赞赏我们对常规做法的挑战, 另一个则是对即使是默许的减少手术的建议也嗤之以鼻. I revised the manuscript, further erasing any trace of the financially unfavorable conclusion, without compromising the findings themselves, and sent it to the co-authors to sign off before resubmission. 令我惊讶的是，私家侦探在最终稿中只增加了一项内容:她加了她的丈夫, another professor with tangential expertise, as a sixth co-author and asked me to send it to him for comments. 这是 the incentive for collusion, rather than genuine collaboration, in academic medicine. Again feeling there was no alternative that wouldn’t hurt me in the long run, 我寄给他了, and did my best to address his eleventh-hour comments before resubmitting. 该项目随后进入了9个月的衰退期，在此期间我们还没有听到任何更新, including whether it would be considered for peer-review, despite multiple attempts to gently prod the editorial team along. 

结论

This personal narrative illustrates how academic medicine, 尽管它在很大程度上依赖于合作，以最大限度地增加知识和人类健康, behaves as a defunct market, disincentivizing collaboration and incentivizing collusion. 在这样的背景下, 我们发现自己有一个痛苦的漫长的管道，从新的想法到创造研究，然后激发临床护理的有意义的变化. 这种未能在学术医学研究中优化激励的做法对人类生命造成了严重后果，不应被容忍.

在后续文章中, 我将描述一个针对这个问题的新颖解决方案，该解决方案利用区块链和隐私保护计算来将学术医学新闻重新构建为一个激进的市场，促进合作，并根据优化人类健康的共同目标最大限度地减少勾结.

— Marielle年代. 格罗斯，医学博士，大英帝国勋章 is an OB/GYN and fellow at the Johns Hopkins Berman Institute of Bioethics 她的工作重点是应用技术和消除偏见，作为促进循证的手段, equity and efficiency in women’s healthcare (@GYNOBioethicist).