Travelling but never arriving: reflections of a retiring editorBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7460.242 (Published 29 July 2004) Cite this as: BMJ 2004;329:242
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 journal 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 Drummond 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 change—and thank goodness they don't, considering the rubbish that journals often publish.3 What journals do best is what the rest of the media do best: stir up, prompt debate, 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 important 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 relevant 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 material—material 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 declining 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 fortnight before I step down a parliamentary committee in Britain has called for open access and, more powerfully, a house committee 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 continue 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 available to all for free and will in the autumn launch the new journal PLoS Medicine.)
The scientific value of the original studies published in journals has improved a little over the past 25 years as case reports 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. Believing 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 reports—but it's scientifically perilous getting to grips with new methods.
The forms of the BMJ have developed dramatically in the past quarter century. bmj.com—which appeared in 1994, when websites were numbered in thousands rather than tens of millions—is the finest flowering of the BMJ so far—but we are still in the journal equivalent of the early days of film: the talkies have yet to appear. The site being free to all has, I think, hugely increased the influence and usefulness of the journal. The studentBMJ, “the BMJ on speed,” is a child of whom I feel enormously 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 minutes 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 longstanding 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 multimedia, 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 unexamined, 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 failure 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 studies—for example, CONSORT,13 QUOROM,14 STARD,15 and MOOSE16—has been an important development, countering the problem that many reports of studies lack basic information.8917 But most journals 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 next—without any training and often little support—you're the editor of a million pound journal: it wouldn't be possible the other way round. At the moment we have too many intellectually poor journals making large profits for Robert Maxwells and learned societies. We'd be better 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 progress. It long ago became clear that many studies included authors 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 accumulated on the powerful influence of conflicts of interest,22 and it is at least arguable that medical journals are more an extension of the marketing arm of pharmaceutical companies than independent scientific forums. (I will be arguing exactly that at a meeting a meeting of Healthwatch in October: everybody's welcome).
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 patients. 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.
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 scientists and doctors committed to making the world's scientific and medical literature a freely available public resource.