Editors and Owners—Stretching Reputation Too Far

As I write, we are in the extraordinary position that the 2 largest medical journals in the world are without editors in chief because the owners have taken exception to the positions and actions of those editors.

George Lundberg, editor of JAMA, was removed on January 15, 1999. On July 25, New England Journal of Medicine editor Jerome Kassirer was ousted from a position he held with distinction for 8 years,¹ and had expected to fill until 2003. Of the issues dividing owner and editor, the most important had to do with the application of the journal's impressive brand name to spin-off journals and to various consumer letters and magazines. These latter publications are advertised as being from "the publishers of the New England Journal of Medicine." A true enough statement, but misleading in that these publications would not have gone through the rigorous competitive selection process of peer review and revision necessary to satisfy the high standards of that journal's editors.

The issue has little to do with editorial freedom. Both publisher and editor went out of their way to say there had been no interference with the editorial content of the New England Journal of Medicine. So what is the problem? The danger is loss of credibility in the logo and therefore in the journal itself. Like that of an individual scientist, the journal's biggest asset is its reputation. This can be rapidly squandered, which is the danger here.

The reputation of the journal is what attracts the best authors. A peerless reputation cannot just be transferred or spread around to spin-offs. The editors feared the subsequent dilution of their journal's hard-won reputation, and rightly so. Editors, who come from the ranks of clinical researchers, are acutely aware of a fact that publishers might forget: only a small fraction of the effort necessary to produce a general medical journal is work done at the journal by people who appear on its masthead. The vast majority of the work is done by the tens of thousands of investigator-authors in their institutions, most of whom are rewarded for their efforts by a letter of rejection, and the thousands of reviewers around the world who are so vital to ensuring a journal's quality. Without these thousands of clinician-scientists, there can be no journal. We had a vivid demonstration of this following the dismissal of JAMA's editor in chief in January. The remaining staff were forced to work around the clock for months trying to allay the anxieties of those contributors and reviewers who wished to abandon JAMA because they feared its editorial independence had been hopelessly compromised. We believe that we have been successful, but the episode brought home to us how carefully researchers were watching. These researchers fight to get their best work into prestigious journals precisely because of that prestige. When the American Journal of Medicine seemed to be dominated by the drug company–sponsored supplements it published under its name and cover, researchers simply stopped taking it seriously and other journals overtook it in the impact factor stakes.^{2 - 3} The present editors of that journal face a formidable uphill task rebuilding its credibility.

The Massachusetts Medical Society apparently derived some 95% of its $73 million annual budget from publishing in 1998,⁴ so the success of the New England Journal of Medicine as a medical journal is reflected in massive revenues to its owners. Medical societies always have important and pressing agendas, political, educational, legal, and charitable. They always need more money, so there is increasing pressure on journals to produce even more profits for their owners. But the owners of the New England Journal of Medicine, in their natural desire to increase profits by milking the reputation of their journal, are in danger of losing the respect and confidence of those who make their journal what it is. And without reputation the owners will find they have nothing to sell.

How does this problem arise? The owners and editors of general medical journals naturally tend to differ in their experiences and their goals. Someone hired to maximize profits sees little problem affixing the New England Journal of Medicine's logo to products to increase their marketability. An editor has to believe in accountability, and this dictates that only what is approved by the editors goes out under the journal logo. A couple of years back, the American Medical Association in the short-lived Sunbeam affair learned a sharp lesson that endorsing products without rigorous testing—without credible peer review—was rightly perceived as being an exchange of name for money. We are fortunate at JAMA that for some years, all editorial content bearing the JAMA name has to have been accepted for publication by JAMA editors, after our usual rigorous review.

On August 4, a clarifying statement about the New England Journal of Medicine was released, the result of negotiations between the owners and editors.⁵ It seems to be a stop-gap arrangement, pending the agreement of the present executive editor, Marcia Angell, to be interim editor-in-chief, and the subsequent appointment of a more permanent new editor. Both sides are to be congratulated on reaffirming editorial independence and on going some way toward correcting the impression that the owners were bent on destroying their greatest treasure. The statement says that the editor-in-chief has "authority over the use of the name, logo, and content of the New England Journal of Medicine, in print or any form." Spin-off journals will not use the NEJM name in their titles. However, published products unapproved by the editors may still be identified as coming "from the publishers of the New England Journal of Medicine."

The process of looking for a new editor for the New England Journal of Medicine will start with the appointment of a search committee. The recent statement will ensure that, despite the distressing way in which the Kassirer matter was handled, candidates of suitable caliber may now think of applying. It doesn't take a seer to foretell that one question asked of all candidates will be along these lines: "Do you approve of marketing products carrying the NEJM brand name that have never been evaluated by the NEJM editors?" It will be interesting to see how candidates for the job of editor of the New England Journal of Medicine will answer this poser. If they say "no" they are unlikely to be appointed by the owners who got rid of Kassirer. If they respond with a "yes," they will be unlikely to get the vote of those clinical researchers and academics on the search committee, and will earn the enmity of those remaining editors who, with Kassirer, stood against such marketing arrangements. As a reader of, contributor to, and one-time deputy editor of the New England Journal of Medicine, I am saddened by the blow to the reputation of our sister journal and hope that the owners will listen carefully to what their authors, reviewers, and editors are telling them.