In the past few decades there has been increasing pressure on medical journals to appease major advertisers, primarily pharmaceutical companies, as the journals expand to large, very profitable entities. There are trade-offs to this business decision since independent medical journalism can be a great advocate for patient health, but does not always support the quickest route to the industry profits - media and pharmaceutical in this case. Politics tends to take sides; public health, or industry. With fair regularity there are clashes between editors and publishers about journalistic independence and integrity as the often competing interests overlap and vie for the doctors' attention on journal pages.
The latest of these rows happened last month, as Dr. John Hoey and Anne Marie Todkill, the editor and senior deputy editor of the Canadian Medical Association Journal (CMAJ) (or JAMC (Français)) were fired from their posts on February 20. The publisher, Graham Morris for the Canadian Medical Association (CMA), indicated that the journal needed a "fresh start". His action provoked protests from doctors and editors across North America who view Morris' reason for the dismissal as specious, merely an excuse to rid the association of an editor who wasn't ideologically aligned with their interests. Three other editors have quit in the aftermath.
The firing was by some accounts instigated by a CMAJ poll, where women who ordered Plan-B medication at drugstores via prescriptions were asked to report back about their experiences. The journal found that the pharmacists were "collecting and recording personal information, including sexual history", as well as names and addresses in pharmaceutical company databases. (Montreal Gazette, February 23, 2006). The practice is apparently illegal. However when the journal editors went to publish their findings they were pressured by the publisher to alter the results because the Canadian Pharmaceutical Association complained about the report. They complied with the publishers demands, but the next week Hoey wrote about the compromise in an editorial, prompting one of the final rows between editor and publisher.
Dr. Hoey was the editor of the journal for ten years. During his tenure he was a strong advocate for better patient healthcare and en route, he eloquently and unabashedly challenged policies and practices that compromised care. In 2001, following the death of a 15 year old girl taking the Cisapride, a drug for heartburn that was taken off the market in the U.S. in 2000 after multiple deaths, the editor criticized Canada's drug oversight board for lagging behind the FDA. He noted that Cisapride was not the first drug Health Canada (the country's FDA equivalent) had failed to flag, "but it is the last time that we [CMAJ] will merely observe". The journal then posted all FDA warnings on its website and mailed the warnings to doctors.
The editor clashed with the publishers again in 2002 after writing an editorial on a legislative issue that would have required doctors to rotate through emergency rooms. The legislation was drafted following chronically understaffed emergency rooms and the death of a cardiovascular patient who was turned away from a regional hospital when its emergency room closed, then died on the way to a second hospital. In his letter, Hoey criticized the doctors for betraying patient trust and implicitly supported the bill: "the physician-patient relationship is based on trust, the physician-government relationship on necessity." The Canadian Medical Association of course opposed the bill and the publishers labeled his discordant view "repugnant". Hoey later reported that "they may have considered the option of firing me at the time". (Ottawa Citizen, November 26, 2002)
In an editorial following the incident, October 29, 2002 in CMAJ titled: "An Editorial on Editorials", Hoey explained the necessity of independent journalism:
"...the arm's-length relationship CMAJ has enjoyed with the CMA, a policy of editorial independence formally endorsed by the International Committee of Medical Journal Editors, of which CMAJ is a founding member...assures the autonomy of the journal and safeguards its credibility."
Dr. Hoey held the view that the journal's responsibilities extended beyond rote publication of medical research, to the doctor-patient relationships, to legislation, and to "health determinants", including politics:
"Some readers have expressed the view that any comment on international politics is inappropriate in our journal: the medical profession, or medical journal editors at the very least, they argue, should stay out of political debate. For our part, we fail to see how health can be viewed as apolitical, or how medicine can be practised in an ideologic vacuum. Even though medicine strives toward humanitarian ideals that it perceives as universal, all human action occurs in social and political contexts."
In the past couple of years the journal had increased the pressure on pharmaceutical companies. Hoey pressed for policies requiring authors to list their drug company affiliations when submitting research. In February of 2004 an editorial lambasted the pharmaceutical companies for not releasing negative clinical trial results and for "deceiv[ing] physicians, their patients and, perhaps, shareholders...a flagrant abuse of the trust." (The Montreal Gazette, February 17, 2004). The editorial noted that Health Canada was complicit to the practice. The editor took both the FDA and Health Canada to task over 'suppressed' Vioxx risk data. Most recently he came out against calls by physicians for a more privatization in healthcare, a position that was articulated on the online site in direct conflict of the views of the CMA, but than quickly revised, according to Lancet.
Hoey certainly had his share of publicly contentious, media worthy moments, but his leadership also successfully increased the stature of the journal; its impact factor more than tripled during his tenure and CMAJ received public service awards for its journalism. He was acutely aware of the risks of forthrightness but refused to stand down. After the dismissals of the editors New England Journal of Medicine and the Journal of the American Medical Association in 1999, he wrote in "When Journals are Branded, Editors Get Burnt, The Ousting of Jerome Kassirer from The New England Journal of Medicine"; "The international medical community was reminded of the perils of - and necessity for - editorial independence with the firing of Dr. George Lundberg as editor of JAMA in January of this year that followed his fast-tracking of a politically sensitive article". (CMAJ September 7, 1999)
Kaissirer, the NEJM editor was "sacked" in a dispute over a decision for the publishers to sell the NEJM brand for non-related products. Hoey supported the ideals Kassirer had failed to solidify at NEJM and was a staunch proponent for the lofty goal of medical journal "stewardship":
"...This is the notion of intellectual custodianship. In a prescient editorial written a month before he [Kassirer] was sacked, and echoing, perhaps, our own thoughts, Kassirer wrote: 'When a membership society's journal gains international respect. . . the journal in some sense transcends its local ownership and becomes the property of the worldwide professional community and the public. In such instances, the journal's owners have a formidable public responsibility as stewards....'That stewardship includes the responsibility to ensure, on the one hand, that a journal's reputation for reliability and scientific rigour is not diluted by specious association[s]...The reputation of the NEJM was built on the intellectual contributions and just plain hard work not only of its editors but also, and more importantly, of the authors who report research that is, directly or indirectly, funded by the public and of the reviewers, correspondents and many others who contribute to the journal without financial compensation."
Yesterday a former chief justice of the Supreme Court (Canadian) was appointed to help sort out the CMAJ upheaval; an appropriately authoritative figure, we suppose. The editorial board is reportedly holding out for a commitment to independence from the CMA that doesn't seem to be forthcoming. Although people are calling for the firing of the publisher and the reinstatement of the editor, we see these as unlikely future events. The world is decidely moving steadfastly towards more and more privatization, and privatization is a force to be reckoned with. But "fresh starts" don't always turn up daisies. The move may smooth the way for the CMA, but will it improve care? What is medicine about? Perhaps Canada should look across the border and see beyond the profits of the U.S. medical system, the muddy confluence of business, patient, physician, and for-profit insurance interests that collide in the messy landslide of patient care.
Medical journalism subsumed by business interests, follows the way of journalism subsumed by the same. Hoey wrote in "An Editorial on Editorials":
We don't believe that it behooves journalists in any guise to say things merely for the sake of being provoking. At the same time, if our commentaries caused no discomfort to anyone (including ourselves) we would worry even more than we usually do about how well we are doing our job.
Dr. Hoey's keen, well-written commentary and active role in the Canadian healthcare system via CAMJ will no doubt be missed.
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Last May, Acronym Required wrote about the increasingly interdependent relationship between pharmaceutical companies and medical journals in "Just The Facts....mmm....No! Not THOSE Facts: Science Reporting in Medical Journals".
