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Am Fam Physician. 2014;89(3):151-152

Related editorial: AFP's Conflict of Interest Policy: Disclosure Is Not Enough.

Original Article: Dermoscopy for the Family Physician

Issue Date: October 1, 2013

TO THE EDITOR: I have some concerns regarding the editor's note at the end of this article. The editor, Dr. Siwek, stated that the article's first author, Dr. Marghoob, had initially failed to disclose some potential conflicts of interest. After they were discovered, the editors concluded that the article was “an unbiased and nonpromotional description” of dermoscopy. I would argue that it was self-promotional.

In the body of the article, the authors stated that “improvement in diagnostic accuracy is contingent on acquiring [formal] dermoscopy training.” Feeling that this may be something worthwhile for my practice, I did a quick Google search for dermoscopy courses. I found only three courses offered in the United States, and was disappointed to discover that Dr. Marghoob was the course director for two of them and guest faculty for the third. This leads me to believe that Dr. Marghoob certainly has much to gain professionally and financially by recommending formal training in dermoscopy.

I am not suggesting that family physicians should perform dermoscopy without training. My concern, though, is that there may have been an inadequate representation of the author's conflicts of interest and potential gains from publication of the article.

IN REPLY: Although I am pleased that some of the dermoscopy courses I direct were the first ones found on Dr. Jeppesen's search, there are other courses available, including an annual dermoscopy course at the Mayo Clinic in Scottsdale, Ariz., and courses at the American Academy of Family Physicians and American Academy of Dermatology annual meetings. I did not promote any specific dermoscopy course in my article. Instead, I was simply emphasizing the proven fact that formal training in dermoscopy improves diagnostic performance.14 Although I organize and teach a dermoscopy course sponsored by the Memorial Sloan Kettering Cancer Center in New York City, I receive no financial compensation for this work.

The most important message from my article is that dermoscopy has a critical role in potentially lowering the morbidity and mortality associated with skin cancer. Dermoscopy courses, irrespective of who teaches them, are an effective means of educating physicians about this technique.14

IN REPLY: I appreciate Dr. Jeppesen's careful reading of Dr. Marghoob's disclosure and the accompanying editor's note, as well as his desire to hold American Family Physician's (AFP's) conflict of interest policy to a high standard. To further clarify our policy, had Dr. Marghoob's affiliations been disclosed at the time of submission, we would not have considered his manuscript for publication. As it turned out, we discovered these affiliations at press time. At that point, the executive committee that deals with matters of editorial policy conducted an internal review. There were mixed views on whether to pull the article at that stage in publication, but ultimately the decision was to proceed with publication and run the detailed editor's note that accompanied the article.

AFP's conflict of interest policy is highly atypical among medical journals. Virtually all medical journals permit review articles and editorials written by authors with ties to makers of drugs and medical devices; they simply disclose those affiliations. At AFP, we believe that disclosure is not a sufficient safeguard against bias or the perception of bias, and thus do not permit such affiliations. Our experience is that this policy is often misunderstood, and that authors mistakenly believe that such ties are not disqualifying. For this reason, we ask authors to disclose all relevant financial affiliations before they begin writing for us, and then reconfirm those disclosures during the final processing of their manuscript.

For further clarification on AFP's “no financial affiliations” policy, see the accompanying editorial on page 161.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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