Travelling but never arriving: reflections of a retiring editor
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Richard Smith is stepping down as an editor of BMJ. This is an
interesting description of how things are changing in medical
publishing. A highly recommended read.
Jawad Asghar
mailto:jawad@alumni.washington.edu
--
BMJ 2004;329:242-244 (31 July), doi:10.1136/bmj.329.7460.242
Travelling but never arriving: reflections of a retiring editor
Twenty five years of adventure, discovery, and conservatism
http://bmj.bmjjournals.com/cgi/content/full/329/7460/242
When I arrived at the BMJ in 1979 the journal was set in hot
metal, there wasn't a computer to be seen, and it took three
months for copies of the journal to reach Australia. As I depart
a quarter of a century later, many more people access the jour-
nal through their computers than on paper, and Australians are
the first to read each issue because the British are abed when
it hits their screens. Yet my overwhelming impression is that
change has been slow. If resurrected, Thomas Wakley, the founder
of the Lancet who died in 1862, would instantly recognise both
his journal (despite its recent makeover) and the BMJ. We are
still at the beginning of the electronic revolution, and Drum-
mond Rennie, the deputy editor of JAMA, has castigated editors
for neglecting their craft and failing to innovate.1 2 We have
been an instinctively conservative crew.
It took me many years to realise that I completely misunderstood
what journals did. I imagined that doctors opened their BMJs on
Friday mornings, read of some innovation, and used it on the
next relevant patient. Many still seem to cling to this naive
view of the function of journals. In fact words on paper rarely
lead directly to changeand thank goodness they don't, consider-
ing the rubbish that journals often publish.3 What journals do
best is what the rest of the media do best: stir up, prompt de-
bate, upset, probe, legitimise, and set agendas. They are good
at telling readers what to think about but not what to think,
and theme issues may be particularly successful in putting im-
portant but neglected subjects to doctors. Increasingly I wonder
as well if there isn't something fundamentally misguided in
sending ordinary clinicians, who are not scientists, piles of
original papers that they mostly don't read, often aren't rele-
vant to them, and they are not trained to appraise.4 If we were
clearer about the purpose of journals then we might redesign
them completely.
Slowly the content of journals is shifting from being mostly
original studies (with only about 1% of them both valid and
relevant to clinicians3) to being more educational, review,
newsy, and debate materialmaterial that doctors actually read.
But it's slow because current business models work against the
shift: publishers such as the infamous Robert Maxwell, who was
found naked and dead in the Atlantic in 1991, have become rich
by selling value added by others (researchers) at high prices
and keeping their costs to a minimum.
The Robert Maxwells of this world have infuriated the academic
community with their business model of compensating for declin-
ing subscriptions by annually increasing prices above inflation.
I call this the "pay more, get less" model, and it couldn't be
sustained. It spawned the "open access" movement, which aspires
for all research, most of it funded with public money, to be
available free to all on the web. I've been arguing for nearly a
decade that this had to happen, and, interestingly, in the fort-
night before I step down a parliamentary committee in Britain
has called for open access and, more powerfully, a house commit-
tee in the United States has said that all research funded by
the National Institutes of Health should be published in open
access journals.5-6 Although we will start charging for access
to bmj.com in January, the original research articles will con-
tinue to be free and be passed directly to Pubmed Central. The
BMJ is thus an open access journal. (I will be able to continue
my interest in this subject as I am joining the board of the
Public Library of Science, which wants all research to be avail-
able to all for free and will in the autumn launch the new jour-
nal PLoS Medicine.)
The scientific value of the original studies published in jour-
nals has improved a little over the past 25 years as case re-
ports and series have given way to randomised trials (albeit,
most of them too small and badly done and reported7-9), but most
medical journals have kept to a narrow methodological range. Be-
lieving that the many questions of health and health care need
many methods, we have tried with the BMJ to broaden our range
into qualitative research, economic evaluations, ethnographic
studies, modelling papers, and quality improvement reportsbut
it's scientifically perilous getting to grips with new methods.
The forms of the BMJ have developed dramatically in the past
quarter century. bmj.comwhich appeared in 1994, when websites
were numbered in thousands rather than tens of millionsis the
finest flowering of the BMJ so farbut we are still in the jour-
nal equivalent of the early days of film: the talkies have yet
to appear. The site being free to all has, I think, hugely in-
creased the influence and usefulness of the journal. The stu-
dentBMJ, "the BMJ on speed," is a child of whom I feel enor-
mously proud and who is now fully grown. My recent involvement
has been simply to protect the editors. The local editions of
the BMJ, which began to appear in the mid-1980s, have given the
journal the capacity to reach the huge populations of China and
South Asia, and BMJ USA allows us to indulge in a little reverse
colonialism.
In my early days at the BMJ we had perhaps a hundred reviewers,
almost all of whom were British and whose names were handed down
in an oral tradition. Now we have many thousands of reviewers,
most of them not known to me. They come from all over the world,
and data about them are compiled in our electronic manuscript
tracking system, which allows us to cope with more than 8000
submissions a year compared with perhaps 2000 25 years ago. One
result is that authors may have a study rejected within 20 min-
utes of submitting it, an experience that not all of them enjoy.
Our acceptance rate has had to fall steadily, but we recently
debated with our editorial board whether we should increase it
now that there are no limitations on space. All studies are now
published online first.
Our ELPS (electronic long, paper short) experiment has been
praised but not much copied,10 again because it is thought to
increase costs but not revenue. The idea is to avoid the long-
standing dilemma of researchers wanting much more information
and most readers much less. The logical conclusion is for all
singing, all dancing electronic versions of studies with multi-
media, full data, and the software used to manipulate the data
and short, journalistic versions in the paper journal. Logic
will, I hope, prevail before I die.
Peer review is still in the dark age with most journals,11 12
and the BMJ has not progressed far. After centuries of being un-
examined, the sacred process of peer review has been shown
through research to be slow, expensive, ineffective, a lottery,
biased, incapable of detecting fraud, and prone to abuse.11 12
Evidence for its upside is sparse. Through our collective fail-
ure of imagination it is still, however, the least worst system,
and the best strategy seems to be to try to improve rather than
replace it. My vision has been that a clumsy black box should
become an open scientific discourse conducted in full view and
real time on the web. This vision is not widely shared, and even
with the BMJ we've got only as far as letting authors know the
name of reviewers.
The appearance of structured ways of presenting scientific stud-
iesfor example, CONSORT,13 QUOROM,14 STARD,15 and MOOSE16has
been an important development, countering the problem that many
reports of studies lack basic information.8 9 17 But most jour-
nals have not required authors to use them, reminding us yet
again that editing is largely an amateur business. One day
you're a professor of cardiology, the nextwithout any training
and often little supportyou're the editor of a million pound
journal: it wouldn't be possible the other way round. At the mo-
ment we have too many intellectually poor journals making large
profits for Robert Maxwells and learned societies. We'd be bet-
ter off with fewer, better journals that concentrated on readers
not authors, with original research made available for free on
the web.18
Authorship is another issue with which we've seen little pro-
gress. It long ago became clear that many studies included au-
thors who had done little or nothing and excluded people who had
done a great deal of work.19 Attempts to separate authors from
non-authors have been based more on power than contribution, and
the arguments for contributorship rather than authorship seem to
me unanswerable,20 but most journals have stuck with authorship.
Journals didn't begin to think about conflict of interest until
the 1980s, and even the most "advanced" journals didn't actually
implement policies until after the millennium.21 Most journals
still don't have policies. Yet substantial evidence has accumu-
lated on the powerful influence of conflicts of interest,22 and
it is at least arguable that medical journals are more an exten-
sion of the marketing arm of pharmaceutical companies than inde-
pendent scientific forums. (I will be arguing exactly that at a
meeting a meeting of Healthwatch in October: everybody's wel-
come).
Journals have also largely failed, I believe, in other areas,
including managing ethical problems, responding to misconduct,
and recognising the increasing role of patients in health care.
Journals should aspire to lead rather than follow, but medical
practice has been well ahead of journals with involving pa-
tients. Editors have perhaps been too insular and precious, and
for the BMJ the creation of an international editorial board, an
advisory group for patients, and an ethics committee have been
hugely beneficial. Similarly the arrival of professional bodies
like the World Association of Medical Editors and the Committee
on Publication Ethics is helping to raise the standards. I'm
grateful to everybody who has put time and energy into these
bodies.
I may sound grouchy as I disappear into history, but actually
I'm not. Arrival is boring, as is perfection. It's the journey
that counts, the quality of the search. "As you set out for
Ithaca," wrote C P Cavafy in a marvellous poem, published in
1911: "Hope your road is a long one, Full of adventure, full of
discovery..." It was.
Richard Smith, editor
BMJ
--
Competing interests: RS has been the editor of the BMJ and the
chief executive of the BMJ Publishing Group, accountable for
both the content of the journal and the business of the group.
He steps down on 30 July. In September he will join the board of
the Public Library of Science, a non-profit organisation of sci-
entists and doctors committed to making the world's scientific
and medical literature a freely available public resource. Ref-
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--
Rana Jawad Asghar MD. MPH.
Coordinator South Asian Public Health Forum
mailto:jawad@alumni.washington.edu
http://www.DrJawad.com
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