eBMJ -- The sacking of JAMA

The sacking of JAMA

At 0815 h Chicago time last Friday Jan 15, George Lundberg was dismissed as editor-in-chief of JAMA during a brief telephone call to his home from the executive vice-president of the American Medical Association (AMA), E Ratcliffe Anderson, Jr. In a statement posted on the AMA website (www.ama-assn.org), Anderson said that "through his recent actions, [Lundberg] has threatened the historic tradition and integrity of JAMA by inappropriately and inexcusably interjecting [it] into a major political debate that has nothing to do with science or medicine". Although Lundberg and his "fine staff" had advanced the stature of JAMA", Anderson observed that "over time . . . I have lost confidence and trust in Dr Lundberg’s ability to preserve that high level of credibility and integrity". A deputy editor, Richard Glass, and a senior editor, Phil Fontanarosa, were appointed "interim co-editors". Anderson apologised to readers and contributors for what he believed had been a misuse of the journal for "political leverage". Lundberg had been editor since January, 1982. What happened?

The trigger for Anderson’s action was an article in the Jan 20 issue by Stephanie Sanders and June Reinisch from the Kinsey Institute for Research in Sex, Gender, and Reproduction at Indiana University.1 They had submitted a paper to JAMA in November, 1998, in which they reported data from a survey of almost 600 college students in 1991. Asked "Would you say you ‘had sex’ with someone if the most intimate behavior you engaged in was oral-genital contact?", 59% of students said that they would not. The only type of behaviour producing almost universal agreement about what constituted sex was "penile-vaginal intercourse". The authors argued that their findings had important implications for health-care workers taking sexual histories or those involved in health education. A JAMA press release noted that "This issue is of particular interest and debate now because of recent presidential statements". It was this conjunction of a sex survey with President Clinton’s impeachment that infuriated Anderson.2 He accused Lundberg of dealing in "sensationalism here, not science." In the paper Sanders and Reinisch write that "recent public discourse regarding whether oral-genital contact constitutes having ‘had sex’ highlights the importance of explicit criteria in contrast with implicit assumptions in this area".

When I talked with Anderson this week, he was steadfast in his view that he had made the right decision. He first saw the embargoed paper and accompanying press release on Tuesday Jan 12, while he was in Florida. He immediately contacted Randolph Smoak, the chairman of the AMA’s Board of Trustees. A conference call with the Board took place the next day. Smoak made clear that the final decision lay with Anderson, who told me that he had the "near unanimous support of the Board of Trustees" to sack the editor. Lundberg fell and broke his elbow on Wednesday and was receiving hospital care on Thursday. Only by Friday was he well enough to take Anderson’s call. Anderson admitted that "It’s the most painful and difficult decision I have ever made". But, he added, "It is not one person’s journal".

The reaction to Lundberg’s dismissal has been largely condemnatory. Iain Chalmers, a member of JAMA’s editorial board, told me that "JAMA is what it is today because of [Lundberg’s] leadership". He described Lundberg’s demise as a "tragedy", a word also used by Arthur Caplan, director of bioethics at the University of Pennsylvania. Reinisch reportedly said that she was "absolutely shocked" and invoked "issues of academic freedom". Magne Nylenna, chief editor of the Norwegian Medical Journal, who spent a sabbatical at JAMA several years ago, was "disgusted" by the AMA decision. Lundberg "had produced a truly international journal in terms of authorship and readership", he said. Richard Smith, editor of the BMJ, said that the AMA had damaged itself and medical journals". Lundberg’s colleagues at JAMA are upset, angry, and, plunged into a state of abysmally low morale, horrified at what they see as Anderson’s mission to fire their editor over what some believed to be little more than petty personal jealousy. JAMA staff emphasised that the Kinsey research had been properly peer reviewed and appropriately expedited to publication, given the current debate about Clinton’s definition of "sexual relations".

The result of these events is that JAMA is no longer part of a free press, which is why last week’s events should matter to all physicians and medical scientists. Its decisions are governed by the partisan politics of US health care. The AMA is a deeply politicised organisation. Its political action committee has, according to the Chicago Tribune, spent US$14 million on Congressional candidates since 1989, over twice as much money going to Republicans as to Democrats. AMA executives have been desperate to shore up their political capital after a year of embarrassing press criticism. And with Clinton on the impeachment rack, to publish a paper that might lend support to the president and jeopardise Republican efforts to unseat him was impossible to tolerate. The only way to pacify their allies in Washington was to lose Lundberg. Anderson’s actions may have preserved the AMA’s lobby power, but he has now made it impossible for physicians to trust JAMA under his tenure as excutive vice-president.

Still, there are fair questions to be asked about the Kinsey report. How relevant and generalisable are 1991 data to physicians practising today? Was the paper being published on public-health grounds or, as Lundberg’s critics allege, for more opportunistic political purposes, since JAMA itself pointed out the current political relevance of the paper? An editorial exploring these issues further might have helped.

But the Kinsey study was only a small part of what an AMA spokesperson said was a more widespread "displeasure in the direction the journal had been taking". Anderson put it to me this way: "If this had been the only issue, I would not have taken the action I did".Two additional recent events were being discussed in news reports as likely contributors to Lundberg’s downfall. First, in November, 1998, JAMA published a theme issue on alternative medicine,3 which caused the teeth of AMA officials to be ground heavily. If this choice of subject had indeed led to questions about Lundberg’s editorship, why has Fontanarosa, a cosignatory on the alternative medicine editorial, been promoted? Second, in an interview in the New York Times Magazine on June 28, 1998,4 Lundberg was portrayed as a ruthless self-publicist. Larry Altman, the senior medical news correspondent at the New York Times, said that "Lundberg courts the press for the same reasons that everyone does, because he wants publicity to attract advertising".4 Did executives at the AMA see their editor as a liability?

The AMA has good reason to be sensitive to outside opinion. Through its own reckless mismanagement, the association signed a contract with Sunbeam Corporation in 1997 to provide exclusive endorsement of its products in return for royalty payments on sales.5 The press reaction was catastrophic6 and the AMA was forced to withdraw from the deal.7 The result was that the AMA lost six top executives, settled with Sunbeam for US$9·9 million, and paid US$3·3 million in legal and administrative costs. This crisis came on top of the AMA’s continued decline in membership and the strong perception that it was more concerned with enhancing financial interests of doctors than protection of patients. In December, 1997, a Committee on Structure, Governance, and Operations was set up to rethink the AMA’s strategy. It concluded that there were "serious flaws in the AMA’s decision-making process" and that the association needed to spend more time listening to the views of others before acting. That lesson has been quickly forgotten.

The man appointed in May, 1998, to sweep aside the old bureaucracy and to deliver this new, listening AMA was Anderson, a former US Air Force Surgeon-General and chief executive officer of a health centre in Kansas City. Although Anderson has said that "I really believe the very best decisions are those that are made corporately, based on consensus", evidence available to the AMA Board of Trustees suggests otherwise. American Medical News8 reported that Anderson had been fired from his job as dean of the University of Missouri at Kansas City Medical School and had become embroiled in litigation with doctors at the local teaching hospital. AMN noted that "Both controversies stem from his attempt to make significant changes in the management of the institutions".8 Thomas Reardon, then chairman of the Board of Trustees, admitted that he had investigated these matters carefully but "Quite frankly, when we interviewed him and discussed that, we liked that". Reardon praised Anderson for being a forceful administrator"—so forceful that the AMA has now lost a public figure whose independence sustained the integrity of one important AMA activity during the terrible months of the Sunbeam scandal.

Last week, although Smoak offered strong support for his executive vice-president, the consensus-minded Anderson said that the sacking was his decision alone. "What they pay me for is my judgment," he said. But the journal's present high standing has been won largely thanks to Lundberg's pursuit of an editorial view independent of the AMA, signified by a statement over the editorial pages that the opinions expressed are "not those of the American Medical Association". Lundberg has done what editors should do namely, to put their journals at the centre of medical debate. In 1998 alone, JAMA announced forthcoming special issues on computers and the internet in medicine, cancer, medical education, health promotion and obesity, and violence. Lundberg has thrown his weight behind politically controversial positions, such as rethinking US tobacco policy 9 and facing up to medical mistakes as revealed by necropsies.10 He has made JAMA a leader in the development of research methodology relevant to clinical practice; he has worked collaboratively with other editors to produce global theme issues;11 he has developed the journal's connections with medical students and patients; 12 and he has given editorial colleagues freedom to develop their own interests, enhancing the reputation of the journal 13 and inspiring loyalty among his team.

This record apparently counted for nothing with Anderson in his haste to depose an editor who knew his own mind. A moment's reflection or a few hours' consultation by the AMA's "forceful" new executive vice-president might have persuaded him to arrive at a different conclusion from the one he did. When I asked him what he might have done differently, Anderson said that "Perhaps I could have earlier on conveyed to Dr Lundberg the seriousness of my expectations and the potential results of his actions". He remarked, somewhat ruefully, that "I lost the services of a very brilliant senior editor". And he ended our conversation  by noting that "If the Board of Trustees came to me and said, "Andy, I regret to tell you that we don't need you any more," I'd understand".

Sometimes doctors should rejoice when the editors of their journals get fired. Editors who, by their consistently rash actions, lose the confidence of readers, contributors, or colleagues deserve to go. But by sacking Lundberg on grounds of "bad judgment", without actively seeking the views of JAMA's editorial board, Anderson has needlessly wounded the journal's editorial independence, foolishly put the journal's reputation in a perilous position, brutally treated an internationally respected editor, and brought the AMA to what most observers thought was impossible -a new and sinking low in its history. There is only one way to begin the repair of the AMA's most important asset. Anderson must now go, voluntarily or by the decisive action of the association's Board of Trustees.

Richard Horton
The Lancet, London WC1B 3SL, UK

1.Sanders SA, Reinisch JM. Would you say you "had sex" if  . . . ? JAMA 1999; 282: 275-77.
2.Kolata G. AMA journal editor dismissed over sex survey article. New York Times 1999; Jan 16: www.nytimes.com.
3.Fontanarosa PB, Lundberg GD. Alternative medicine meets science. JAMA 1998; 280: 1618-19.
4.Shell ER.The Hippocratic wars. New York Times Magazine 1998; Jun 28: 34-38.
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6.Rich F. Hypocritic oath. New York Times 1997; May 29: A19.
7.Firshein J. AMA struggles to regain its footing. Lancet 1998; 351:196.
8.Klein SA. AMA chooses new executive vice president. American Medical News 1998; Jun 1: www.ama-assn.org.
9.Koop CE, Kessler DC, Lundberg GD. Reinventing American tobacco policy. JAMA 1998; 279: 550?52.
10.Lundberg GD. Low-tech autopsies in the era of high-tech medicine. JAMA 1998; 280: 1273?74.
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12.Glass RM, Molter J, Hwang MY. Providing a tool for physicians to educate patients: the JAMA patient page. JAMA 1998; 279: 1309.
13.Rennie D, Flanagin A. Congress on biomedical peer review. JAMA 1998; 280: 213.