Threats to the Integrity of the Croatian Medical Journal

The Croatian Medical Journal (CMJ) was founded in 1992. It aims to present medical research from small scientific communities and developing countries (1), and serve as an educational site of excellence to foster research and discussion in academia (2).

Internationally, the journal became indexed in Medline in 1998 and in the Thomson Scientific (formerly Institute for Scientific Information) databases in 1999 (3). Its impact factor (0.823 for 2006) puts it in the middle of the Thomson Scientific Journal Citation Reports category “Medicine, General and Internal” but our primary goal is to publish the research from the so-called “scientific periphery” and to make this research available to the world by providing free access to all our content (4). The CMJ is a member of the International Committee of Medical Journal Editors (ICMJE), and Croatia is the place where the first ICMJE statement on the registration of clinical trials was formulated (5).

Our work as journal editors was shaped by the examples of active social engagement of leading international general medical journals, journals that envisioned their roles and responsibilities as extending beyond the elemental priorities of publishing scientific health research. Following the belief of Hugh Clegg, editor of the BMJ from 1947 to 1965, that “a subject that needs reform should be kept before the public until it demands reform.” (6), we opened our pages as a forum for questioning scientific and publishing practices in the academic community (7). As university professors, we fostered this dialogue in public (8) and in our teaching of research methods and critical reading in the graduate medical curriculum of Croatian medical schools (9).

As one of our goals was to define the role of a journal in a small scientific community and improve the standards of editorial work, we carefully studied and then defined the legal position of the CMJ in relation to its owners – four medical schools in Croatia – and the responsibilities of its editors, owners, publishers, and other stakeholders (10). This happened at the time of several international scandals of firing editors from large influential journals such as JAMA and New England Journal of Medicine (11,12), and our effort was internationally recognized as “valuable for any journal needing a clear documentary guide for its governance and operation“ (13). The four medical schools in Croatia accepted this proposal and endorsed the governance mechanisms (Figure 1) designed to ensure successful functioning of the journal (10).

Figure 1.

Governance structure of the Croatian Medical Journal (10). The numbers by the arrows pointing to the Joint Management Board indicate the number of representatives from each medical school. There are four security loops in the legal structure of the journal, which ensure its transparent and successful functioning.

Unfortunately, the journal’s governance structure and editorial tenure is now questioned because of our active engagement in promoting socially-relevant issues in the journal and in public via interviews and articles in the media. This editorial explains the origins of the threat to the journal and our proposal for resolving any open questions with the journal owners.

Introducing the culture of research integrity

We were aware that drawing the attention of the public to the issues needing reform and keeping these issues before them would not be an easy task. Reform is often resisted, especially by those it threatens most. Nonetheless, as editors we sought to bring these issues to the pages of the CMJ and attract the attention of the general public.

Thus, our journal helped to present the outstanding work of physicians during the devastating 1991-1995 wars in Croatia and Bosnia and Herzegovina (14-16). At the same time, in a country where corruption is a major obstacle to the entry in the European Union (17), we thought it important to explore corruption and nepotism in the Croatian academic community. We were not surprised to discover that cheating (18) and plagiarism (19) were common among medical students in Croatia, as they are elsewhere in the world.

In collaboration with the experts from the Office of Research Integrity in the USA, we began to actively engage the CMJ to emphasize concepts of research integrity in everyday culture, education, and practice of research in Croatia (20-22). In 2001, we appointed the first Research Integrity Editor, Prof. Mladen Petrovečki (21). He was succeeded by Prof. Vedran Katavić (22), who later became the president of the Committee for Ethics in Science and High Education, the highest national body for research ethics, which is appointed by the Croatian Parliament (23).

From the moment we publicly announced both in the CMJ (20-23) and our education efforts (9), that advocacy for research integrity would be one of our major goals, we and the Journal have been the target of editorial pressures and personal harassment. It started with rumors that were often contradictory – that we publish exclusively the work of authors considered either Croatian nationalists or former communists, politically conservative or radical left, and that we prefer either authors coming from the birth places of Prof. Matko Marušić (Split in Croatia) or authors from Serbia and Bosnia and Herzegovina. We did not pay attention to such rumors because our editorial work is always done transparently and according to international standards and we have always answered any official appeal from authors or reviewers (22). However, things became serious after we declined to publish an article from a senior colleague at the Zagreb Medical School because he and his coauthors refused to address reviewers’ criticism. Following this, the senior author accused five editors of the CMJ of scientific misconduct and used his faculty position to instigate the investigation against the editors.

Although the editors reported the case to the Dean, first Prof. Boris Labar, and then Prof. Nada Čikeš, there was little protection of the editors’ rights. While Dean Labar downplayed the case until the end of his term, Dean Čikeš actively supported these allegations, although it was obvious that the accusation against the editors was not done in good faith, that no proofs of misconduct were offered, and that the existing procedures of the School were not followed.

The editors complained about this breach of their editorial and scientific rights to the Ministry of Science, Education, and Sports, which funded their research, and submitted the complete documentation about their research, including raw data, for inspection. The Ministry asked three independent international experts to judge the case, and officially sent the reports to the editors and the Rector of the University on 1 February 2007 (document class # 052-01/05-01/00063, reference # 533-07-07-0016). In their reports, which were unfavorable for the School, one of the experts (their identity remained anonymous) went so far as to describe the behavior of the School toward the editors and other colleagues as “team mobbing” (24). The Ministry also asked the national Committee for Ethics in Science and Higher Education to evaluate the case, along with the international reports and original data documentation from the researchers. In their ruling from November 2006 (25), the Committee advised the Medical School to drop the charges against the editors. Although repeatedly asked by the Ministry to close the case (most recently on 25 October 2007, official document class # 052-01/05-01/00063, reference # 533-07-07-31) the Dean, Prof. N. Čikeš, still refuses to do so, quoting the independence of the academic community and disputing the authenticity of the national research ethics committee investigation. The documentation of this case is extensive – some of it is available in the public domain (24,25) and we will make other documents public as a web supplementary material in the following journal issue.

The Kurjak plagiarism case

We believe that the current challenges to the journal’s quality and integrity are related to the role of our journal in the recent plagiarism case publicized in the BMJ (26).

After Sir Iain Chalmers, one of the founders of the worldwide Cochrane Collaboration, accused Dr Asim Kurjak, a professor of the Zagreb School of Medicine, of repeated plagiarism and criticized the University of Zagreb for the lack of action in dealing with these cases (26), both the CMJ and BMJ were obliged by international standards of scientific conduct and publishing to scrutinize all of Kurjak's published articles (27). At the same time, the Dean of the Zagreb Medical School, Prof. Nada Čikeš, asked the School’s Research Committee to investigate Sir Iain Chalmers' allegations. After a great deal of public turmoil and pressure, the School’s Committee confirmed both cases of plagiarism in November 2006, which was reported widely in the Croatian media.

In the CMJ we used the ethics guidelines of the Committee on Publication Ethics (COPE) (28) to identify five possibly redundant publications of Prof. Kurjak and his colleagues among the ten published in the CMJ and available on PubMed. To make sure that there could not be any, even perceived, conflict of interest, we asked COPE and the Ethics Committee of the World Association of the Medical Editors (WAME) to give their expert opinion and direction for editorial action. Both expert groups classified three publications as redundant (each had been published two times in different journals) and advised their retraction. Prof. Kurjak and his colleagues were informed of all these actions and asked for an explanation; their reply confirmed the redundancy of the published articles. As two of the articles were published in the CMJ after acceptance or publication in other journals, we retracted them (29,30). The third article was first accepted in the CMJ and we notified the other journal about the findings of the WAME and COPE experts so that it could be retracted from the indexed literature.

The BMJ also investigated the single article it published by Prof. Kurjak and found no ethical misbehavior; the BMJ and CMJ made the findings of their investigation public (31). Following the COPE ethics guidelines, one of us (Prof. Matko Marušić) also wrote a full report and officially sent it, with all documentation, to the Dean on 14 March 2007. Soon after, in May 2007, the national Board for Ethics concluded their investigation of all Kurjak’s published research articles, confirming Sir Iain Chalmers’ allegations and identifying a number of other unethical publication practices (32). Based on the Board’s findings, the Ministry of Science, Education, and Sports terminated the funding of Prof. Kurjak’s research grant (33).

After the publication of Dr Chalmers’ article in the BMJ, we were under great pressure to stop the investigation; this pressure included using an anonymous letter to the media to make another accusation against one of us. Dr Chalmers also received an anonymous letter accusing one of us for “far worse actions” than Kurjak. We also heard outrageous rumors at the School that we were the ghost authors of Sir Iain Chalmers’ paper in BMJ.

For the time being, we do not want to go into all details of this story, but will only describe the incident which brought our editorial freedom and academic integrity into question. After the president of the School’s Research Committee, Prof. Boris Labar, had publicly spoken about the Committee’s investigation of Kurjak, and after one of us (Prof. Matko Marušić) had also publicly spoken about the state of affairs at the Zagreb Medical School, the Dean, Prof. N. Čikeš, issued a faculty-wide ban on any further communication with the media about “any case that has not been closed by the School” (official document from 7 December 2006, administrative # 01-70/196-2006). When we asked her if this applied to us as editors of a journal representing not only Zagreb Medical School but also other three medical Schools in Croatia (10), the Dean answered that it applied to us as employees of the School. We refused to be silent on this important ethical problem. Following international best practice, we published the retractions (29,30) before the conclusion of the case by the School.

Challenge to the integrity of CMJ

In October 2007, two important events occurred. First, the Zagreb Medical School's Court of Honor, the body charged with providing legal opinion about breaches of the School’s Ethical Code, concluded the Kurjak case by dismissing it (34,35). Second, one of us (Prof. Matko Marušić) was interviewed about the corruption in the academic community in the main Croatian Catholic newspaper (36).

Following these two events, we learned with surprise that one of the items on the agenda of the regular monthly meeting of the School’s Council would be “Collaboration with the Croatian Medical Journal.” Neither of us (co-editors in chief) received an official invitation for this agenda item.

The Dean, Prof. N. Čikeš, informed the Council that the Kurjak case was dismissed by the Court of Honor and asked the Court’s Chair, Prof. Branimir Jakšić, to read the entire ruling on the case. The ruling did not address the CMJ’s report from March. To Prof. Matko Marušić’s query about this, Prof. Jakšić said that he had no knowledge of such a report, and the Dean stated that this was the first time she had heard about the CMJ’s report: an astonishing statement because our report was formally submitted, had an official administrative number (#01-1086/07 from 14 March 2007), and was sent to the Dean through usual official procedures. Ten days later, the Dean sent an official letter (#02-107/133-2007 from 7 December 2007), stating that she did receive the CMJ’s report on the Kurjak case. She added that she forwarded it to another body, the School’s Committee for Academic Integrity, but did not specify when this had happened or what the outcome of this action had been.

Also, to the question about the findings of the national Committee on Ethics in Science and Higher Education on this case, the Dean gave a reply which could be interpreted as expressing doubt on the pertinence of the Committee’s report. Prof. Jakšić, the chair of the Court of Honor, denied that the Court received the findings of the Committee from the Dean. Such an oversight or decision by the Dean is in contrast to her public statement to the BMJ from May 2007: “As at the beginning of this week the dean of the medical school, Nada Cikes, said that she had still not received a copy of the Committee’s opinion. However, she confirmed that she was aware of its content, she said. All she could say was that it would be considered by the university’s ‘court of honour.’ ” (37).

Under the Council agenda item on the CMJ, the Dean stated that there had been public media appearances from the “platform of the CMJ” in the past months which adversely affected the reputation of the School and that she thought it was time to question the collaboration of the School with the Journal. She declared that she asked a successful scientist and an unbiased colleague who has never published in the CMJ to assess the present quality of the journal.

Our colleague, Prof. Slobodan Vukičević from the Zagreb School of Medicine, presented about 40 PowerPoint slides criticizing the quality of the CMJ and its international relevance, arguing that the impact factor of the journal was low and that the journal is not respected in the international scientific community because it does not attract quality manuscripts. He also questioned the integrity of both editors in chief in their public appearances. On the basis of his presentation, the Dean asked the Council to support her proposal to a) question the position of the School in relation to the agreement about the journal among four Croatian medical schools (10) and the revision of the agreement, and b) to question the suitability of editors in chief.

Since Prof. Vukičević’s presentation contained both false information and a biased interpretation of facts, Prof. Matko Marušić asked for permission to respond to his allegations. His request was denied. Dean Čikeš insisted that the Council vote on her proposal. The votes were not counted and, as we managed to see, there may have been no quorum for the voting.

Invitation for dialogue

These odious events are offensive and disturbing to us as editors in chief and professors and indeed to the entire editorial office. However, it is our sole decision as editors in chief to present the current situation to the public on the pages of the CMJ. The CMJ’s work, integrity, and quality have been publicly challenged by one of its owners: The CMJ’s pages are the most appropriate place for discussion since the procedure of challenging the term of office for editors in chief prescribed by the agreement between the owners (10) was not followed.

Because gossip may often have a stronger effect on human decisions than direct observation (38), we want to present facts and answer all questions about the journal and about our activities as academics. This discussion will also provide a forum for addressing both the potentials and problems that exist in our Croatian academic community and serve as an experience for other academic communities (39). It will be open to the public. We hope it may also help other journals address their practice and strategies in similar situations.

We do not want, however, to misuse our position as editors to exclusively promote our personal views and interpretations on the pages of the CMJ. We hereby invite Prof. Slobodan Vukičević to publish his critique of the CMJ and its editors in the next issue of the journal. We also invite the Dean, Prof. Nada Čikeš, to formulate her dissatisfaction with the CMJ and its editors on our pages. We will publish both their articles as they write them, unedited. We also ask the other three owners of the journal to voice their concerns and suggestions for the resolution of the situation. Finally, we invite authors and readers of the CMJ, as well as colleague editors, to write about the CMJ and our public actions as editors. We will be happy to publish all of them in their original form.

We will also publish our response to the allegations of Prof. Vukičević and the Dean, and post all relevant official documentation as supplementary material on the CMJ web pages. If Prof. Vukičević and the Dean do not accept this invitation or remain silent until January 15, 2008, we will publish our response to Prof. Vukičević’s presentation from the Council meeting.

We will keep our readers informed on further developments in the cooperation of the CMJ and Zagreb University School of Medicine and its other three owners. All evidence will be presented so that the public can make a fair judgment.