The Plagiarists

After a day at work and a one-hour drive home, the last thing Doug wants to do is work on rewriting his clinical study. The sixteen-page manuscript is filled with corrections and comments from a journal editor. All the remarks and corrections are highlighted in red ink. To him it looks more like a blood bath on paper. He probably could have avoided a lot of editing if he sent his study results to a less well-known journal. But Doug feels his findings need to reach a more expansive audience of healthcare professionals. The Lancet seems an appropriate journal yet the outcome was very unexpected.

Doug Vinci works as an ambulatory clinical pharmacist at San Francisco General Hospital. He was hired ten years ago to help fill a healthcare provider shortage issue and to develop creative programs in ambulatory care. The medical chief of the clinic, Dick Mendel, M.D., was not totally impressed with Doug when he first started work at the clinics.

“I was looking for a nurse practitioner!" Dr. Mendel exclaims, meeting Doug for his first day at work, “not a clinical pharmacist! Please tell me, what does a clinical pharmacist do?"

Doug was shocked, speechless. After a few seconds, he muttered, “I will assist you in this clinic to do whatever it takes to optimize patient care.”

Those words seemed to appease the chief…for the moment.

The fact was, aside from prescription dispensing roles, there were no defined additional duties for ambulatory care pharmacists at that time. Although there were some meaningful roles for pharmacists in the inpatient settings, there was very little literature pertaining to a pharmacist serving in the outpatient arena. A few reports described non-dispensing roles of a few pharmacists working for Indian Health Services. When Doug reviewed the papers, they provided insights and a springboard for what he could develop at S.F. General. Now, after a decade of work, his role has become an essential and necessary part of the adult medical clinics.

Doug is a non-assuming person. He is laid back yet personable. He stands about six feet tall, somewhat slim with black hair and blue eyes. He welcomes his patients with a smile that puts most of them immediately at ease. His “bedside” manner has improved tremendously over many months thanks to the help of Dr. Dick Mendel and other providers of care. Dick is a stern task master. His primary goal is to provide optimal care for the people who seek help. A person may not only need healthcare, but possibly psychosocial services or financial assistance as well. The patient population consists of minorities, mainly indigent African Americans. Aside from Doug, Dick is the only other white person serving this patient population. He has a muscular frame, standing a couple of inches shorter than Doug. The thinning hair on Dick’s head is accentuated by the goatee on his chin. The wire-rimmed spectacles, the flower-pattern of his shirt, and the tan, square-toed boots appear to be a look that has carried-over from the sixties. It was never mentioned out loud, but the unwritten rule is no healthcare provider in the clinics should dress any better than the patients they care for.

Most of Doug’s work centers around monitoring and managing orally anticoagulated patients. These people are receiving the blood thinning drug warfarin, better known as Coumadin. This is a specialized group of patients with co-morbid conditions and taking several medications that could potentially interact with Coumadin. In addition, if the drug is not managed closely, patients can develop severe bleeding episodes or exacerbations of their underlying condition. Doug studies his patients intently, monitoring their responses to warfarin therapy, their potential and actual drug-drug interactions, effects of co-morbid conditions upon warfarin and vice versa, in addition to several other therapeutic indices. All these aspects of anticoagulation control have formed the basis for Doug’s latest clinical study. He has taken an exceptional amount of time to specifically analyze each patient’s response to warfarin for treating primary deep venous thrombosis. In simpler terms, patients are being treated for lower extremity blood clots.

It’s a Wednesday night and Doug finally arrives home from work at 6:30 pm. He was invited to join his old friends at the local bar for pizza and beer. But this night, as well as several to follow, is needed to clean-up his article and resend it to the journal editor. It is a laborious task, taking him away from socializing with his friends, playing city league basketball, or spending time with his lady friend. The weekend is no exception. Doug spends a total of fourteen hours from Saturday morning to Sunday evening reviewing patient profiles, lab reports, and related factors just to address all the concerns of the editor.

Finally, after 42 hours of detailed fact-finding, rewrites, and cleaning up many grammatical mistakes, Doug’s paper, entitled “The Proper Clinical Use of Warfarin” is mailed to the editor of Lancet. The study provides a new, advanced warfarin treatment algorithm for deep venous thrombosis, more in-depth evaluations of warfarin-drug interactions, significant biomarkers for co-morbid conditions, and appropriate patient follow-up intervals. He feels confidant his work will be acceptable for publication. Now, the waiting period begins.

Two weeks come and go. No contact from the editor. One month passes without a word. Then, finally after six weeks, Doug receives a letter from Lancet. The first paragraph praises him for the work he has accomplished and how important his contribution is to the medical literature.

The second paragraph is short and to the point: “We regret to inform you that your clinical paper is not suitable for publication. We thank you for your interest in choosing Lancet.”

Doug re-reads the first paragraph and interprets portions of the wording to mean a pharmacist cannot be an authoritative source for such a medical initiative. It should remain in the domain of physicians who are specialists with blood-thinning drugs. This hierarchical stance is not new to him since there has been jockeying for positioning between physicians and pharmacists for decades. Nothing more was done with the clinical study.

A few years have passed. Doug has moved on and is writing other clinical studies involving orally anticoagulated patients. It is a hectic workday with several patients whose blood tests are not in the expected therapeutic range. He decides to take a break from his work by resting in the medical library. As he sits in an easy chair, there, on the table beside him, is the recent edition of the Lancet. Doug picks it up and casually thumbs through the pages, stopping at page 39. Something catches his eye, the article entitled “Warfarin Treatment Guidelines”. Really?! He begins to read the article that two physicians from the east coast have authored. Beads of sweat begin to build up on the back of his neck. The wording seems all too familiar. The patient-specific data has been tweaked ever so slightly. But the number of patients, their demographics, concomitant disorders, lab results, and outcomes are the same as Doug’s data base entries from three years ago. Even the section about appropriate patient follow-up periods is the same. What to do? He ponders his next move. Yes! Write a letter to the Lancet editor suggesting that the two physician authors have plagiarized his work. Copies of his patient-specific data need to accompany the letter.

Another waiting period. However, to this day, 49 months and 7 days later, there has been no response from the journal.