Healthy Skepticism Library item: 3869

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Publication type: news

CMAJ board member quits, editorial independence questioned
CBC News Online 2006 Mar 14
http://www.cbc.ca/story/science/national/2006/03/14/cmaj-kassirer060314.html

Keywords:
CMAJ CMA

Notes:

Ralph Faggotter’s Comments:

The CMAJ saga rolls on.

And the further it goes, the more it appears that the world-wide issue of medical journal editorial independence is being fought out in microcosm in a life-and-death battle at the CMAJ.

Included below are also a Perspective article for the NEJM entitled-
‘ Politics and Independence- The Collapse of the Canadian Medical Association Journal’
and a recent CMAJ Editorial entitled-
‘Is Medicine still a Profession?’
(which provides some idea of the floavour of the challenging opinions expressed by the CMAJ which in the past have made the CMA feel less than comfortable.)

Full text:

CMAJ board member quits, editorial independence questioned
Last Updated Tue, 14 Mar 2006 13:45:58 EST
CBC News
A fourth member of the editorial board of the Canadian Medical Association Journal has resigned over editorial independence at the publication.

Dr. Jerome Kassirer, a former editor of the New England Journal of Medicine, sent a letter of resignation to the president of the association.

The CMAJ is considered Canada’s leading medical journal.
Kassirer said he doubts editorial autonomy will be respected at the journal.

“You have demonstrated unequivocally that the current leaders of the Canadian Medical Association are incapable of allowing a first-class academically credible journal to flourish, and thus that the CMA is unfit for ownership,” Kassirer said in his resignation letter to CMA president Dr. Ruth Collins-Nakai.

“I fully appreciate that a single resignation is unlikely to have a salutary effect. Nonetheless, I can no longer associate with an organization whose leaders are so disrespectful of openness and so committed to hidden agendas.”

This is the latest in a string of events at the journal. On Feb. 20, publisher Graham Morris abruptly fired editor Dr. John Hoey and senior deputy editor Anne Marie Todkill.

Kassirer said the firings “indefinitely marred the trust of readers in the content of the CMAJ.”

In a commentary published in the journal’s online edition on Feb. 28, Kassirer and other members of the editorial board said the CMA suppressed politically sensitive stories. The association represents doctors across Canada.

Morris has said the journal wanted to make “some changes in emphasis,” and the dismissals weren’t related to concerns over specific stories or Hoey’s approach.

Hoey, Todkill and three other editors who resigned since the firings are unable to talk about their reasons for leaving because of a confidentiality agreement.

FROM MARCH 7, 2006: CMA looks to ex-Supreme Court judge to guide governance at journal

Last week, the CMA announced Antonio Lamer, a retired chief justice of the Supreme Court, will head a panel to study governance at the journal.

The 95-year-old journal is considered the leading Canadian medical journal.

—————————————————————————————————————————————

Perspective
The NEW ENGLAND JOURNAL of MEDICINE
march 30, 2006
Politics and Independence- The Collapse of the Canadian Medical Association Journal

his journal was in excellent shape.
It ranked as the fifth leading general
medical journal in the world,
and it received more than 100 original
research papers per month, allowing
the editors to be highly selective
in what they published. It
had nearly 70,000 subscribers – representing the more than 85 percent
of Canadian doctors who are
CMA members. Yet Hoey’s decade
as editor would end abruptly that
afternoon when the journal’s publisher
fired him and his senior deputy
editor, Anne Marie Todkill.
The publisher, Graham Morris,
said that the firings were his decision
and denied that Hoey and
Todkill lost their jobs over specific
articles. “I just felt that it was time
for a fresh approach,” he said. Larry
Erlick, a CMA board member who
chaired the journal oversight committee
until mid-March, gave a
different explanation: “The issue
is . . . not about editorial independence – it’s about a relationship
between parties and their ability
to work together.” Yet to many
observers, the primary issue seemed
to be the editors’ independence.
The CMA has been divided over
whether it wants an independent
scientific journal with news and
commentary or a political organ
for its members.
There were early signs of trouble.
In 2001, the journal published
an editorial supporting the medical
use of marijuana, contrary to
the CMA’s position, and the CMA’s
general council complained to Hoey
about it. In 2002, another editorial
sparked a firestorm: a man
had arrived at a Quebec emergency
room in the midst of a myocardial
infarction, but it had closed at midnight,
and he died en route to an
open ER; the CMAJ editorial criticized
Quebec doctors for not having
staffed the ER. The case received
enormous media attention,
and the province responded with
a bill requiring general practitioners
to staff ERs around the clock.
Yet “a lot of Quebec physicians
were quite offended and felt undeservedly
judged by . . . that
editorial,” recalled Eugene Bereza,
former chair of the CMA’s Committee
on Ethics. CMA leaders considered
the editorial irresponsible,
said Larry Patrick, an Ontario physician
who was a CMA board member
at the time. The CMA’s president
called for a retraction, but
the CMAJ editorial board cautioned
the association that it was threatening
the journal’s editorial independence.
That year, the CMA board set
up a journal oversight committee,
but its functions were unclear. Former
CMA president Dana Hanson
said it was to address CMA mem-
Politics and Independence – The Collapse of the Canadian
Medical Association Journal
Miriam Shuchman, M.D., and Donald A. Redelmeier, M.D.
On February 20, 2006, when John Hoey, editorin-
chief of the Canadian Medical Association Journal
(CMAJ), returned to the Ottawa headquarters of the
Canadian Medical Association (CMA) after a vacation,
www.nejm.org 10.1056/NEJMp068056
Copyright © 2006 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org on March 15, 2006 . For personal use only. No other uses without permission.
PERSPECTIVE
2
bers’ “valid concerns” about CMAJ
editorials; Erlick, its current chair,
said it was to resolve disputes
among the editors, the publisher,
and the CMA; and CMAJ editors
wrote that it was to help them
maintain “harmonious relations”
with the CMA. Patrick, the committee’s
first chairman, said Hoey
wouldn’t work with the committee,
but others, including former
New England Journal of Medicine editor
Jerome Kassirer, found that
the committee was unresponsive
to the editors and was used by
the CMA as a new means to “complain
about CMAJ content considered
politically inconvenient.”1
Such content remained, and
conflicts persisted. Last November,
a dispute arose over a news report
on Plan B, the emergency-contraception
pill that had just gained
over-the-counter status in Canada.
The reporters asked women
throughout the country to try to
purchase the drug and found that
they were asked to reveal personal
information to pharmacists. When
one of the reporters interviewed
an official at the Canadian Pharmacists
Association, the group objected
to the article on the grounds
that pharmacists had been observed
unwittingly. The pharmacists’
association had a long-standing
relationship with the CMA.
The CMA’s chief executive officer,
Bill Tholl, sided with the pharmacists
and took his objections to
Morris, the CMAJ publisher.
Morris had come to the CMA
in 2004 after a decade at a large
media conglomerate, but he was
new to medical publishing. He
told Hoey not to run the Plan B
article, arguing that the women’s
observations could be considered
scientific research that had not received
ethics approval. It was the
first time Hoey’s bosses had told
him to pull a story. Facing a crisis,
the reporters offered to remove the
quotations from the consumers,
and the journal published a revised
article. Even so, it was convincing,
and after provincial privacy
commissioners expressed concern,
pharmacy groups instructed pharmacists
to stop requesting personal
information. But the precedent
stood: the CMAJ had changed an
article at the request of its publisher.
Hoey notified the journal oversight
committee afterward, but
he’d lost confidence in it and asked
Kassirer to lead an ad hoc committee
to assess what had happened.
The result was dueling oversight
committees, one serving the
editor and another apparently serving
the CMA. Larry Erlick, of the
CMA’s committee, said the editors
had cut his committee “out of the
loop.” But three months later, that
committee hadn’t responded to the
editors. “The issue is still on our
agenda,” Erlick said in early March.
Kassirer’s committee examined
documents, interviewed editors,
and concluded that editorial autonomy
at the CMAJ was “to an
important degree illusory.”
Tholl then became alarmed by
another article, an unflattering
profile of Canada’s new minister
of health, Tony Clement, that was
published on the journal Web site
two weeks before the CMA board
was to meet with Clement. Tholl
and Paul-õmile Cloutier, the CMA’s
communications director, went
to the CMAJ offices, and Tholl
spoke – loudly, witnesses report – to Todkill, the senior deputy
editor, allegedly making a disparaging
remark to her as he left.
Todkill reportedly complained to
CMA executives about the incident,
but the CMA will not comment.
Morris ordered Todkill to pull the
story off the Web, and a reporter
added some positive remarks from
the CMA president about the
health minister before reposting
it. The editors asked Erlick to call
an emergency meeting of the oversight
committee, but he declined.
They contacted members of the
Kassirer committee, who added
the incident to their report.
A week later, Hoey and Todkill
were fired. When asked about the
Plan B and Clement articles, Morris
said, “There was no connection
between those articles and the
change of staff.” Although he
maintains that he didn’t make his
decision to fire the editors suddenly,
it was clear that no plans
had been made for succession. To
most of Canada’s medical community,
the firings came as a complete
surprise. The journal had
achieved high visibility, and in
2004, CMAJ news reporters had
been nominated for one of Canada’s
highest journalism awards.
The remaining editors, including
an in-house deputy editor and
six associate editors stationed
throughout the country, felt devastated.
Deputy editor Stephen
Choi became acting editor-in-chief
and wrote a proposal to ensure
that the publisher and owner could
not make decisions about editorial
content; when the CMA did not
agree to the plan, Choi and the
journal’s editorial fellow resigned.2
With no one to oversee peer review
politics and independence – the collapse of the canadian medical association journal
www.nejm.org 10.1056/NEJMp068056
Copyright © 2006 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org on March 15, 2006 . For personal use only. No other uses without permission.
PERSPECTIVE
3
and publication, scientific papers
began piling up at a rate of 25 to 30
per week. Scrambling for a replacement,
the CMA turned to Bruce
Squires, the journal’s former editor-
in-chief. The 71-year-old Squires
meant to help, but under pressure
from editors of other journals, he,
too, left, urging the CMA to agree
to Choi’s demands.
The editors were unable to
speak about the matter publicly
owing to the CMA’s confidentiality
policies, so the editorial board
contacted the media. Journalists
have characterized the story as a
battle over editorial independence,
despite the publisher’s claims to
the contrary, and press coverage
has been widespread; leading international
scientific and medical
journals have run sympathetic editorials.
The sense of a battleground
was heightened by frequent postings
on the CMA and CMAJ Web
sites, including several “Messages
from the Publisher” and editorials
by CMA officers,3 the Kassirer
committee,1 and the remaining
editors.2 For two weeks, the 95-
year-old journal was at a standstill.
Anita Palepu, a Vancouver-based
associate editor who resigned in
early March over the CMA’s plans
for the journal, said of the CMA
leadership, “I don’t think they
expected how strongly most of
the editors would feel about this.
. . . I think they underestimated
that severely.”
On March 7, a resolution appeared
to be in sight: the CMA
announced that a former chief justice
of Canada’s Supreme Court
would lead a panel to examine the
journal’s management and make
recommendations within 90 days.
Until then, the CMA pledged to
honor several rules proposed by
Choi, including granting the editor-
in-chief total responsibility
for editorial content and requiring
editors to report to the publisher
only with regard to business
and financial operations. As
interim editor, the CMA named
Noni MacDonald, former dean of
the medical school at Dalhousie
University in Halifax, Nova Scotia,
and Squires agreed to serve as
editor emeritus.
Yet the CMAJ’s future remains
uncertain. The CMA president,
Ruth Collins-Nakai, said that the
CMA board doesn’t believe there
was editorial interference, but she
declined to say more about why
the editors were fired, citing “legal
and personnel constraints.” Kassirer
resigned from the editorial
board, accusing Collins-Nakai of
hiding “behind a veil of bureaucratic
legalisms” and of putting
“a gag order” on the editors. Other
board members said they also
planned to resign, and a professor
at the University of Ottawa called
for authors, peer reviewers, and advertisers
to boycott the journal.
The underlying fight within
the CMA between those who want
control over “their” journal and
those who favor the complete independence
that characterizes major
medical journals is likely to
continue. Organized medicine is
a political and social entity, and
Canada has emphasized its political
functions by doing such
things as giving provincial medical
associations the authority to
negotiate all fees for physicians’
services under universal health
care. So it shouldn’t be surprising
that Canada is now the epicenter
of the ongoing struggle
over the scope and limits of editorial
freedom at association-owned
journals.
This article was published at www.nejm.org
on March 15, 2006.
Dr. Shuchman is in the department of psychiatry
at SUNY–Buffalo. Dr. Redelmeier is a
professor of medicine at the University of
Toronto, Toronto. Dr. Shuchman has written
news articles for the CMAJ. Dr. Redelmeier
is a member of the CMA, the CMAJ Editorial
Board, and the Kassirer Committee on Editorial
Autonomy of CMAJ. Both receive financial
services from MD Management, a CMA
subsidiary.
Kassirer JP, Davidoff F, O’Hara K, Redelmeier
DA. Editorial autonomy of CMAJ. CMAJ
(in press). (Accessed March 9, 2006, at http://
www.cmaj.ca/cgi/rapidpdf/cmaj.060290v1.)
Choi S, Flegel K, Kendall C, et al. A catalyst
for change. CMAJ (in press). (Accessed
March 9, 2006, at http://www.cmaj.ca/cgi/
rapidpdf/cmaj.060276v1.)
Erlick LS, Cloutier LMC. Editorial governance
plan for CMAJ. CMAJ (in press). (Accessed
March 9, 2006, at http://www.cmaj.
ca/cgi/rapidpdf/cmaj.060294v2.)
1.
2.
3.
politics and independence – the collapse of the canadian medical association journal
www.nejm.org 10.1056/NEJMp068056
Copyright © 2006 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org on March 15, 2006 . For personal use only. No other uses without permission.
———————————————————————————————————————————————
Is Medicine still a Profession?

There must be something to this question, given the
increasing number of medical associations that are
issuing proclamations to promote professionalism.
Among these is a report published in the UK late last year by
the Royal College of Physicians.1 In that document, a panel
of experts defines the core values of the medical profession
as integrity, compassion, altruism and excellence. No argument
there. But these are glued to a set of “values,” including
teamwork and continuous improvement, that seem to
have more to do with modern managerial concepts than
with the core components of medical professionalism.
It seems that the venerable model of the wise and trusted
physician is being prodded by watchwords like “quality,”
“timeliness” and “accountability.” An increasingly skeptical
public is demanding that professional societies set practice
standards, measure adherence and publish individual report
cards. The credentials of age, experience and reputation are
being replaced by continuing education credits and practice
audits of increasing specificity.
The social analyst Jane Jacobs perceives two broad types of
work ethic in modern societies: the “commercial moral syndrome”
and the “guardian moral syndrome.”2 Each, according
to Jacobs, works within a system of values. Guardians
value tradition, altruism, hierarchy and exclusivity. Medicine,
at least as practised up until about 30 years ago, aligns well
with the attributes of the latter category: physicians are
guardians of a body of knowledge that is largely exclusive to
themselves.
But today, the exclusivity of that domain is being
breached on two fronts. First, there is a leakage of physicians’
authority resulting from the better education and empowerment
of patients. Some patients suffering from a single
disease may be better informed about their condition
than their physicians, who must keep track of hundreds. Second,
an erosion of guardianship is resulting from commercialization
of the medical knowledge base. Medical science,
especially as it applies to practice, is increasingly controlled
by private companies whose values, belonging to the “commercial
moral syndrome,” are competitive, contractual,
thrifty and industrious. More and more, those values are
shaping how medical knowledge is amassed: from the
choice of proposals to evaluate, to the design, analysis and
publication of research, commercial interests introduce a
bias toward initiatives that will have a positive impact on
profits first and on populations second.
Further, to keep up to date with modern medical science,
physicians have to rely (and indeed are encouraged to rely) on
various summaries of that science in the form of narrative
and systematic reviews in peer-reviewed journals, clinical
practice guidelines and continuing medical education. But
these, too, are being increasingly distorted by commercial
self-interest. Thus, not only is the privileged knowledge the
profession once possessed no longer exclusive (a good
thing), but the integrity of that knowledge is being corroded
by commercial interests (not a good thing).
At the same time, excellent health care requires more than
a quickly accessed digest of randomized clinical trials. At the
bedside of a sick patient it requires judgment, based on training,
experience and insight into each patient’s particular
predicament. The core value of intelligent and well-informed
altruism is at the heart of medical professionalism, and it is
this value that is slipping on the grease of commercial interests
and their distortion of the knowledge base.
The profession and their professional associations can
probably do little to patch the leaks resulting from the commercialization
of applied medical science, but they can do a
lot to stop the flow from distorted and biased continuing education.
Physicians and their professional associations would
do well to follow the lead proposed by a group of experts in
the US and cut the ties between commercial interests and the
profession’s knowledge base.3 They propose that the profession
set standards that would eliminate commercial gifts, free
samples, participation by faculty on speaking bureaus and on
hospital formulary committees when they have a financial
conflict of interest, professional participation in various activities
of research consulting and research contracts that have
no specific deliverables, and that would erect unbreachable
walls between industry and continuing medical education in
all its forms. In short, to restore the scientific integrity of
medicine as a profession, we must regulate and in some cases
eliminate the influence of commercial interests whose values
require a primary commitment to increasing value for shareholders,
not patients. – CMAJ
REFERENCES
1. Horton R. Medicine: the prosperity of virtue. Lancet 2005;366:1985-7.
2. Jacobs J. Systems of survival: a dialogue on the moral foundations of commerce
and politics. New York: Random House; 1992.
3. Brennan TA, Rothman DJ, Blank L, et al. Health industry practices that create conflicts
of interest: a policy proposal for academic medical centers. JAMA 2006;295:429-33.
Editorial
DOI:10.1503/cmaj.060248
CMAJ • March 14, 2006 • 174(6) | 743
© 2006 CMA Media Inc. or its licensors
Is medicine still a profession?
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