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The Motivation to Collude vs. Collaborate in Academic Medicine – by Marielle S. Gross, MD, MBE

Posted in: Guest Essay

Misaligned Incentives art

[The first of two articles.]

The Brutal State of Nature

I was a tender 14-year-old volunteering in the skeletal biology laboratory at Shriners Hospital for Children when I learned that scientists don’t like to work together. “Why won’t they answer my emails?” I quizzed my mentor, as the techs in the lab next door, who were similarly working on tendon mimesis with the common goal of advancing orthopedic technology for children in need, were ignoring my requests to see how they were mounting specimens for testing. “Ever since that first major grant…they don’t want to be perceived as helping me since I’m the competition,” he sighed. I was skeptical. “You mean that people with good ideas DON’T want to share them? Not even with others who are working on the same problems and who care about the same things? Don’t they realize that by working together we could be greater than the sum of our individual parts?” I was adorably naive.

Years passed, as I moved through pre-med, research assistantships, graduate and medical school, gradually appreciating how exceptionally bright, well-intentioned people who devote their lives—often thanklessly—to making the world a better place, frequently grow averse to freely sharing their ideas or precious data. The ‘why’ is simple: sharing, i.e. collaboration, is disincentivized. Dishonest actors, 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. The mere potential of such abuses motivates today’s intellectual idea factories to hoard, rather than distribute, their ideas, preferring to sacrifice scientific progress for self-protection in a world in which they already struggle to be appropriately rewarded for their ingenuity and hard work.

The pernicious underbelly of “publish or perish” is academia’s starvation economy in which there is not enough for collective surviving, much less thriving. Academic medicine falls prey to the fallacy of Social Darwinism: the fittest researchers compelled to consume the weaker, gobbling up ideas, fostering collaboration only insofar as it suits individuals’ immediate best interests (i.e., it’s better for one’s visibility or credibility to openly collaborate than to claim sole credit for the product of collaboration), as opposed to collective benefits of research collaboration. Other things being equal, collaboration is perceived as something which inherently dilutes, rather than enriches, the value of one’s contribution to humanity.  

This is really happening

As a junior health science researcher, my Principal Investigator (PI) once instructed me not to collaborate with a statistician in exchange for co-authorship because it would mean seven authors on forthcoming manuscripts. With seven authors, the value of publication would be disproportionately diminished for everyone involved, and some of the most prestigious journals do not accept more than six authors per manuscript. I was already doing 95% of the work myself, 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. Meanwhile, of my five co-authors, 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 de rigueur inclusion, although they had only tangential expertise and no time to devote to the project.

Was I, then a full-time surgical resident, supposed to perform statistical analysis myself? This hardly seemed appropriate use of human capital, especially as my best attempt would necessarily limit quality of our analysis compared to collaborating with AN ACTUAL STATISTICIAN. I found the suggestion disrespectful of the critical role statisticians play in such research. This disincentivized collaboration delayed the project’s progress by several months as I gradually pieced together the bare minimum with several small grants of statisticians’ time, though paucity of hours and low priority for pro bono 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. She agreed that preliminary results validated our hypothesis about overdoing certain procedures and suggested fewer of such procedures should be done. At that meeting she informed me, unprompted, that she was unfortunately unable to participate meaningfully in the project and thus should not be considered a co-author on any final manuscripts. Frankly, I was surprised: relinquishing co-authorship that was both valuable for her professional advancement and cost her negligible time and effort. 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, she shrugged, “At least we’re down to five authors, all the better for us.”

At long last, the statistical work was done. By chance, I caught a typo in one of the statisticians’ reports that would have significantly impacted our results. The double-triple-checked analysis of our complete dataset further substantiated our hypothesis that we were likely doing too many procedures. Meeting with my PI to review the results, I was informed that, while data were promising and she agreed with our findings, we shouldn’t suggest this conclusion in our manuscript because these procedures comprise a substantial portion of the department’s revenue. 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, but also that those reviewing our paper were similarly situated regarding the procedures’ profitability, and that a “less is more” conclusion could disincentivize our manuscript’s acceptance. I wrote on egg-shells,  allowing readers to read the writing on the wall for themselves. I solicited feedback from the co-authors. Most saliently, the remaining de rigueur author wondered why we had not explicitly stated that, “we’re doing too many procedures,” the clear implication of our data from her perspective…

We submitted the manuscript to a leading journal, and, after peer-review, it was politely rejected. Perhaps it was my imagination, but I saw my PI’s concerns borne in the reviewer comments: while one appreciated our challenge of routine practices, the other was spitting nails at even the tacit suggestion that fewer procedures be performed. 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. I was surprised when the PI made only one addition to this final draft: she added her husband, another professor with tangential expertise, as a sixth co-author and asked me to send it to him for comments. This exemplifies 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, I sent it to him, and did my best to address his eleventh-hour comments before resubmitting. The project then entered a 9-months-and-counting period of senescence wherein we have yet to hear any updates, including whether it would be considered for peer-review, despite multiple attempts to gently prod the editorial team along. 


This personal narrative illustrates how academic medicine, although it is deeply dependent on collaboration for maximally increasing knowledge and human health, behaves as a defunct market, disincentivizing collaboration and incentivizing collusion. Against this backdrop, we find ourselves with a painfully protracted pipeline from new ideas to create research to then inspire meaningful changes in clinical care. This failure to optimally align incentives in academic medical research has serious consequences for human lives and should not be tolerated.

In a follow-up piece, I will describe a novel solution for this problem which harnesses blockchain and privacy preserving computation to reframe academic medical press as a radical market which fosters collaboration and minimizes collusion in accordance with the mutual goal of optimizing human health.

Marielle S. Gross, MD, MBE is an OB/GYN and fellow at the Johns Hopkins Berman Institute of Bioethics where her work focuses on application of technology and elimination of bias as means of promoting evidence-basis, equity and efficiency in women’s healthcare (@GYNOBioethicist).