Effective Clinical Practice
Effective Clinical Practice, July/August 2000.
H. Gilbert Welch, MD, MPH
For author affiliations, current addresses, and contributions, see end of text.
After 2 years with ecp, I'm beginning to have second thoughts about being a journal editor. For most of the past decade, journal editing had been the most prominent of my career aspirations (to the extent that I had any). But I'm feeling a little differently now. It has nothing to do with our associate editors (who are, admittedly, a rough bunch), our copy editors (ditto), or our publisher. Instead, it's because the past 18 months makes me wonder whether medical journals are on the wrong track.
First, after 17 years as Editor of JAMA, Dr. George Lundberg was fired in January 1999. (1) Although the final straw was his decision to expedite publication of an article dealing with the definition of "having sex" during the impeachment proceedings, comments from both sides suggest that there was more to the story. Dr. Lundberg was later quoted as saying, "I don't think a day went by in considering what to publish that I and my editorial staff didn't have to worry about offending AMA members, AMA politicians, and the AMA Washington office by what we published." (2) And the person taking immediate responsibility for the firing, the executive vice president of the AMA, was quoted as saying, "If this had been the only issue, I would not have taken the action I did." (3) Many prominent editors of competing medical journals quickly condemned the firing. (3-8) While the immediate concern was about the firing process (the JAMA editorial board was allowed no input), the overarching fear was the threat to editorial independence.
Seven months later, in July, Dr. Jerome Kassirer's contract for the editorship of the New England Journal of Medicine was not renewed. Although not formally fired, he was awarded a "sabbatical" from the remainder of his contract. (9) This decision also met with vigorous opposition. (10-13) Here the crux of the issue was about marketing: Should the journal's logo appear on spin-off specialty journals (e.g., The New England Journal of Cardiology)? Dr. Kassirer thought not. After what sounded like a very difficult 10-day negotiation, Dr. Marcia Angell--previously the executive editor under Kassirer--agreed to become the interim editor only after being given the authority over the publication's name, logo, and content. (14) However, she subsequently withdrew as a candidate for the permanent post. (15)
What's Going on Here?
If there is a common thread to these stories, it's something about control--control of powerful and profitable institutions. Our major medical journals are increasingly being seen as commercial businesses--businesses that might be expected to steer clear of politics on one hand and maximize their earning potential on the other.
Should we be outraged about the infringements on editorial independence and the aggressive merchandising of medical literature? Or should we be pleased that these archaic institutions are being brought into the modern world of business? How you view these events ultimately depends on how you view the product medical journals provide.
What Do Medical Journals Do?
The goal of a medical journal differs little from that of other print media. Editors edit--that is, we try to enhance communication between the investigator and the reader. At ecp, the effort involves language ("keep it simple, stupid"), visual display ("a picture is worth a 1000 words"), and anticipating the questions engaged readers would pose to investigators (which may range from, "Are these patients like mine?" to "How would I ever do this in my practice?"). Journals also often foster and encourage public debate (as in this issue's Letters) and attempt to provide basic education (as in this issue's Primer).
But unlike other print media, medical journals serve as a filter for medical science. The filter really involves two basic questions. The first is about the certainty of the inference made by the authors. But there's more to knowledge than valid inferences. So the second question deals with importance. And certainty and importance may be inversely related. In general, it's a lot easier to be certain about the not-so-important (what the effect of drug A is on serum sodium) than it is to be certain about the very-important (what the effect of multiple drugs is on a population of patients). Finding the right balance to this tradeoff is an important function of the major journals.
Should Journals Receive Public Support?
I would argue that this filtering process serves not only the interest of the medical profession, but increasingly serves the interest of the general public (particularly as the Internet makes the content of journals more accessible to consumers). You might reasonably argue that it is in my own self-interest to do so. I would argue that we ought to consider supporting it with public funds. You might argue that I live in the wrong country (or, worse yet, the wrong century).
What's wrong with alternative sources of support? Perhaps the most obvious source of income is subscriptions. But for medical journals, the number of physician subscribers (the immediate market) and the large number of end users (the universe of potential patients) are assymetrical. Even by using the Internet, the costs of providing well-edited, well-vetted content is high. At the same time, because of the Internet, the need for an individual to have a subscription is declining. For most media, generating revenue through individual subscriptions is a strategy of the past. (16)
Next, there are real concerns about the standard alternative source of income: advertising. This has worked well for the general press because of the broad array of industries interested in advertising. This diversity ensures that, for any particular story, most advertisers will be disinterested in its content. But the range of industries that support the medical press is very limited --predominantly pharmaceutical and device manufacturers. And they have such strong economic interests in what is being reported that it is unreasonable to expect them not to exert an influence over the process. In fact, a major concern about the new editor of the New England Journal of Medicine is that he is too closely tied to the pharmaceutical industry--a fear made more real by reports that his salary largely comes from industry and by his advocacy of relaxing Harvard Medical School's conflict-of-interest policy. (17)
Finally, there is a genuine public interest in counterbalancing the current commercialism in medicine--the focus on selling products and making money. Although many U.S. markets are commercial, the typical counterbalances that exist in other markets simply aren't present in medicine. Patients are largely insulated from the cost of individual health services (although they are exposed to the overall costs). Thus, there are multitudes of new products and few economic incentives for patients and physicians not to consume them. Relative to most other markets, consumers are ill-informed and generally not well-placed to make judgments about the utility of therapy. As a result, they (and their providers) fall back on the commercial paradigm that "new," "improved," and "more" are better. In addition, there's a lot of money available to the system. It's an unfettered, unbalanced market. Independent journals (and editors) can serve as a counterbalance. If we are going to live in the wild, wild West, we could use a few U.S. marshals.
1. Jackson B. Top JAMA editor is fired. Chicago Sun-Times. 1999;Jan 15:1.
2. Ballingrud D. AMA chief defends editor's firing. St. Petersburg Times. 1999;February 23:3B.
3. Horton R. The sacking of JAMA [Editorial]. Lancet 1999; 353:252-8.
4. Smith R. The firing of brother George [Editorial]. The AMA has damaged itself by sacking JAMA's editor. BMJ. 1999; 318:210.
5. Kassirer JP. Should medical journals try to influence political debates? [Editorial]. N Engl J Med. 1999;340:466.
6. Fletcher SW, Fletcher RH. Medical editors, journal owners, and the sacking of George Lundberg [Editorial]. J Gen Intern Med. 1999;14:200-2.
7. Hoey J, Caplan C, Elmslie T, et al. Science, sex and semantics: the firing of George Lundberg [Editorial]. CMAJ. 1999; 160:507-8.
8. Davidoff F. The making and unmaking of a journal [Editorial]. Ann Intern Med. 1999;130:774-5, 1999.
9. Altman LK. Editor forced to resign in dispute over marketing of medical journal's name. New York Times. 1999;July 27:A12.
10. Rennie D. Editors and owners-stretching reputation too far [Editorial]. JAMA. 1999; 282:783-4.
11. Smith R. Another editor bites the dust. Trust is needed to balance editorial independence and accountability [Editorial]. BMJ. 1999;319:272.
12. Horton R. An unwilling exit from the NEJM [Editorial]. Lancet. 1999;354:358.
13. Hoey J. When journals are branded, editors get burnt: the ousting of Jerome Kassirer from the New England Journal of Medicine [Editorial]. CMAJ. 1999;161:529-30.
14. Kno RA. A deal clears way for journal; Interim editor given control. Boston Globe. 1999;Aug 5:B1.
15. Altman LK. New England Journal of Medicine names third editor in a year. New York Times. 2000;May 12:A20.
16. Greg's glasnost. Economist. 2000;May 20:23.
17. Knox R. At NEJM, clash over connections new, old editors differ on conflict-of-interest regulations. Boston Globe. 2000; May 18:A1.
H. Gilbert Welch, MD, MPH, Effective Clinical Practice, VA Outcomes Group-111ECP, White River Junction, VT 05009; telephone: 802-291-6271; fax: 802-296-6325; e-mail: firstname.lastname@example.org.