Politics and Independence — The Collapse of the Canadian Medical Association Journal
http://www.100md.com
《新英格兰医药杂志》
On February 20, 2006, when John Hoey, editor-in-chief of the Canadian Medical Association Journal (CMAJ), returned to the Ottawa headquarters of the Canadian Medical Association (CMA) after a vacation, 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 members' "valid concerns" about CMAJ editorials; Erlick, its former 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-émile 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 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.
Source Information
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.
This article was published at www.nejm.org on March 15, 2006.
References
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.)(Miriam Shuchman, M.D., an)
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 members' "valid concerns" about CMAJ editorials; Erlick, its former 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-émile 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 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.
Source Information
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.
This article was published at www.nejm.org on March 15, 2006.
References
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.)(Miriam Shuchman, M.D., an)