We start a new series with this issue.

The Looking Glass

The Looking Glass will depict how others look at medical practice, its practitioners, mental health workers and philosophers. It will also reflect on happenings in the world of Medicine and Science.

We start with Medical Journals. The CMAJ...

A Look At CMAJ: A Misty Image Indeed

The date: Feb 20, 2006. Medical publishing was rocked by the sudden dismissal of the Editor In Chief of the CMAJ (Canadian Medical Association Journal) John Hoey, and a Senior Deputy Editor Anne Mary Todkill. The Editor appointed in the interim, Stephen Choe and another Deputy Editor Sally Murray, also resigned in a week's time, on 28 Feb to be precise. Along with them also went Jerome Kassirer, a former CMAJ editorial board member and a former editor of the New England Journal of Medicine (NEJM), appointed to frame regulations or governance plans about editorial independence.

All these are well-respected professionals in the field of biomedical publication and there has been a huge outcry, both in the medical as well as popular press, at their abrupt sacking.

If this were not enough, fifteen out of the nineteen members of the editorial board of the CAMJ also resigned, precipitating a grave crisis. In the meanwhile, the CMA, in an attempt at damage control, appointed an interim Editor, Noni Macdonald, along with an Editor Emeritus, Bruce Squires, who has been an earlier editor of CMAJ, and a founder member of WAME. A retired Chief Justice of the Canadian Supreme Court has been appointed to chalk out a Governance Plan for Editorial independence. Changes are also envisaged in the JOC (Journal Oversight Committee). The CMA President is exhorting everyone concerned to move on, and has assured a policy of editorial independence. The atmosphere, at the time of writing this, is combative and smoldering, and a distinct unease prevails.

Long Standing Feud

There has been a long-standing feud between the CMA, the organisation that owns and tries to control CMAJ, and the Editor of CMAJ over editorial independence. John Hoey has been asking for greater editorial independence since the journal, although belonging to the CMA, according to him, actually belongs to the whole world of medicine and science, and is, really speaking, accountable mainly to them.

John Hoey, in nearly a decade at the helm (he was hired in August 1996), has brought CMAJ from a modest journal to one whose impact factor is today fifth in the world of general medical journals, only less than that of the NEJM (38.6), JAMA (24.8), Lancet (21.7) and BMJ (7.0). He brought it from an impact factor of 1.6 in 1997 to an impressive 5.9 in 2004. (It has since gone to 7.4 in 2005. See About CMAJ at: http://www.cmaj.ca/misc/about.shtml).

What has happened with the CAMJ closely approximates what happened with JAMA in 1999 when George Lundberg, the editor for 17 years at JAMA (Jan 1982 onwards), and who brought it to scientific respectability, was summarily sacked by the executive vice-president of the American Medical Association (AMA), E Ratcliffe Anderson, Jr., during the Bill Clinton oral sex episode. He was sacked because he fast tracked an article on college students' perception whether oral sex constituted sex (Sanders and Reinisch, 1999). A predominant section, 59%, felt it did not. Now this coincided with the Bill Clinton-Monica Lewinsky episode, for which the Republicans wanted to impeach the President. And the publication of such a report in a prestigious Journal like the JAMA may have acted to blunt the opposition. The AMA, which owns the JAMA, predominantly supported the Republicans. Such a fast track publication by the powerful Editor was thought to be a political move by the Association Office bearers. Although, mind you, it was peer reviewed and accepted for publication in a proper manner. But the fact that it was fast tracked to coincide with this episode was enough to precipitate the sacking. And no amount of outcry that the Journal fast tracked not for any other reason but that it was topical convinced the Association to change its stance.  For further reading connected to this, please refer to Hoey, Caplan, Elmslie et al (1999); Smith (1999a, 1999b); Van Der Weyden (1999); Kassirer (1999a); and Horton (1999).

The same year, Jerome Kassirer, Editor of NEJM, was sacked because he insisted the Massachusetts Medical Society, which owns the journal, not use the name of NEJM for ancillary products as it may increase the credibility of the latter but ran the danger of reducing the credentials of the former, carefully developed and crafted by Editors and their Boards by decades of hard work. Well, the argument too did not cut much ice with the association wanting to cash in on the NEJM name, and he was fired too.  Marcia Angell, who came as interim Editor-in -Chief, too did not last long at the helm. For those who need to be updated, she went on to write the reasonably well read, The Truth About Drug Companies: How They Deceive Us And What To Do About It (Angell, 2004) after that, as she appeared fed up with the way pharma tried to manipulate medicine, and medical journals too. Kassirer too, interestingly, went on to write his own book on a similar theme: On the Take: How Medicine's Complicity with Big Business Can Endanger Your Health (Kassirer, 2004). For details of the Kassirer episode at NEJM, see Parmley (2000), Hoey (1999), Kassirer (1999b) and Angell (1999).

The salutary effect of sacking the editor of JAMA was establishment of an Editorial Governance Plan (Signatories of the Editorial Governance Plan 1999; DeAngelis and Maves 2004), as well as discussion on editorial governance and independence by concerned academicians and editors (Davies and Rennie, 1999). The JAMA since then has had a relatively smooth sailing.

What Sparked It All

The CMAJ episode was sparked off by two separate but related incidents (although, to be fair, the CMA and the CMA Media Inc President deny any such links).

One was in September 2005, when a Plan B morning-after pill (levonorgestrel), a pill for contraception to be used by females, was investigated in the CMAJ. (It is not only a morning after pill. Well it is in a way, for supposed to be taken morning after, but effective if taken up to even 72 hours later). The pharmacists had a big stake in the product. It was changed from a prescription to a non-prescription emergency contraceptive drug, but with an important rider. The pill was costly enough, but the pharmacist was supposed to charge almost an equal amount for counselling about the appropriateness of the drug. Moreover, they were supposed to collect personal details, including sexual history, during this counselling. The CMAJ probed this by asking a few ladies whether they approved of this, which obviously they did not (Eggertson and Sibbald, 2005). The Canadian Pharmacists Association objected, saying a medical journal had no business to do investigative journalism. The CMA, the controlling body, concurred with the pharmacists for obvious reasons. Also, they probably wanted a stick to beat an uncompromising editor with. The article was published with alterations suggested by the CMA. But the Editor wrote an editorial on 3 January 2006 (early release 12 December 2005), denouncing the act, accusing the publisher of editorial interference since they removed a sidebar to the journal's news article which suggested that pharmacists were infringing on women's privacy rights by demanding and registering personal information on the Plan B contraceptive (CMAJ, 2006):

We have a transgression to report. While the Dec. 6, 2005, issue was in preparation, the editorial independence of the journal was compromised when a CMA executive objected strenuously to a news article we were preparing on behind-the-counter access to emergency levonorgestrel (Plan B). The objection was made in response to a complaint from the Canadian Pharmacists Association, who had learned about the article when they were interviewed by our reporters. The CMA's objection was conveyed to CMAJ's editors, and to our publisher, who subsequently instructed us to withhold the article.

The stated objection was to our reporting method; as one component of the story, we had asked 13 women from across Canada to attempt to purchase Plan B from a pharmacy in their community and then tell us what the experience was like. The CMA questioned the propriety of our investigation and the boundary between news reporting and scientific research. Our story was not scientific research, however, but legitimate journalism (CMAJ, 2006).

[Read further at:

http://www.msmonographs.org/article.asp?issn=0973-1229;year=2006;volume=4;issue=1;spage=21;epage=33;aulast=Singh ]