Another editor bites the dust

Earlier this week the Massachusetts Medical Society, owner of the New England Journal of Medicine, announced that Jerome P Kassirer, the editor, would be leaving. His tenure will end in eight months, but he will start a seven month sabbatical at the beginning of September. The Boston Globe, which broke the story, reported that Kassirer had been fired.¹ The society denied this and said his contract was simply not being renewed. His precipitous departure, seven months after the firing of George Lundberg, editor of JAMA,² is likely to cause another round of soul searching over balancing editorial independence and accountability.

Kassirer has fallen out with the Massachusetts Medical Society over the use of the powerful brand name of the journal, a battle also fought by his predecessor. The society wants to expand its publishing, using the brand name of the flagship journal (in the way that we have the BMJ Publishing Group). The editor of the New England Journal of Medicine is not responsible for the other publications spawned by the society and frets that the good name of the journal, built up over generations, will be debased. This central struggle undermines the relationship between the editor and the publisher, with the stereotype being a pure editor concerned with science and quality and a grasping publisher bothered purely with revenue and profit.

Doctors will recognise this stereotype. It’s similar to that of the doctor ethically committed to doing the best by an individual patient and the money driven manager trying to keep the hospital in budget (or in the United States increase profits). In a much appreciated editorial Kassirer argued passionately against doctors abandoning their commitment to individual patients.³ Sabin, another Boston based doctor, responded, however, that doctors had to think about both the individual and the population, particularly in relation to healthcare rationing: “Patients and society need clinicians to love both the individual and the collective and need to join them in deliberating about solutions to this painful but ultimately unavoidable conflict of the heart.”⁴ The reality is that any system—be it a hospital or a publishing group—that makes one set of players think about quality and another about cost will experience unresolvable conflict. A better system is to oblige all players to think about quality and cost, and that is the system in the BMJ Publishing Group, where the editor of the BMJ is also the chief executive of the publishing group.

Such an arrangement is not, of course, a panacea, and when the editors of the two leading American general medical journals have left rapidly in one year it’s time to think harder about balancing editorial independence and accountability. Kassirer has written two editorials in the past six months on this subject (itself probably a sign of unrest),⁵,⁶ and a new arrangement has been proposed to protect the editor of JAMA⁷—and criticised by the fired one.⁸

Some of the deepest thinking has come from Huw Davies, a management academic from Scotland, and Drummond Rennie, the deputy editor of JAMA.⁹ The key to resolving the inevitable conflicts that will arise between owners, editors, and other stakeholders in a journal (or a publishing group) is, they write, trust. “Trust exists when each party holds certain expectations of the other: expectations of competence, predictablity, and fairness.” But, they continue, a trusting relationship is slow to develop and easily damaged. Davies and Drummond identify nine features that can lead to “robust governance ... founded on trust.” They include mutual accountability among owners and editors, a shared vision, explicit strategic objectives, a free flow of information for communication rather than judgment, and informal mechanisms for resolving distes.

These are wise thoughts. Anything that builds trust is good. Anything that erodes it is bad—in all systems, including journals and hospitals. Both the Massachusetts Medical Society and the American Medical Association are looking for new editors for their prestigious journals, and both need to build systems of governance that encourage trust. If they don’t, they’ll never find good editors—and their journals will fade.

News p 273