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Diagnosis out on ailing journal

THE BALTIMORE SUN

BOSTON - The world's most esteemed medical magazine is taking on a decidedly different look, one that almost ensures it will continue to be the center of controversy.

The first thing that's changing is the masthead. Gone, or soon to be, are prominent personalities who were part of the storied past at the New England Journal of Medicine, the journal that is cited more often and perhaps revered more widely than any other technical publication in the world. A number of senior editors and board members are being phased out in a move that the new boss says will bring fresh blood but that critics see as a bloodletting aimed at rabble-rousers.

Then there's the revamp of content. The criticism of alternative medicine is yesterday's crusade, along with the passion to keep researchers from profiting from their research. The battle now will be waged on behalf of cold, hard science like genetics; the passion will be to keep everyday doctors up to date on common conditions such as chest pain and backaches.

The most profound shift of all is one most readers will never notice: Dr. Jeffrey Drazen, who took over as editor-in-chief this summer, gets along with his bosses at the Massachusetts Medical Society. That is a contrast to concerns about crass commercialization sounded by his immediate predecessors, one of whom was forced out by the society a year ago while the other decided not to try to keep her job.

Clearly, the roller-coaster ride of the last year is coming to an end.

Drazen says his staffing changes will bring a "rejuvenation of thought." As for the Medical Society, which thanks to journal revenues is the richest state medical association in the U.S., Drazen says it "has been very generous with its resources and totally hands-off with any editorial policies."

Yet other journal watchers are worried. "What Dr. Drazen told me when he called me up and fired me is that he wants to make a clean break from the Relman-Kassirer- Angell era of the journal. But I think those three earlier editors set the highest scientific and moral standards," says Dr. Thomas Bodenheimer, one of the journal's three national correspondents.

The debate over the journal that is boiling to the surface today is essentially the same one that became public a year ago, when the Medical Society fired Dr. Jerome P. Kassirer after eight years as editor-in-chief. The narrow issue was whether the society was using the New England Journal's prestige to sell unrelated products and publications. More broadly, it was a debate over how much right the owners have to set their publication's direction and profit from it - and, from the other side, whether potential meddling by those owners must be curtailed when they are interested parties in many controversies the journal covers.

Even without that history of conflict, staff changes under way probably would come under close scrutiny, if only because they are wider and deeper than those made by previous editors. In the past, part-time postings like associate editor and editorial board member had no defined limits on length of service. Now, Drazen plans to put specific limits on them, ranging from six years for statistical consultants to three years for board members.

Drazen explains that term limits are standard fare for medical publications, and that he is simply bringing the New England Journal in line. Yet others worry about any tinkering with the 188-year-old journal.

As for those who are leaving, some were ready to go anyway. "I told [Drazen] I would like to retire by the end of the year, not because of any proposed changes or incompatibilities, but because I've been there almost 12 years and I am of the age where I would like to do something a little different before I cease being able to do anything at all," says the deputy editor, Dr. Robert Utiger, 69.

Dr. Walter Willett, a statistical consultant at the journal for nearly 20 years, says that it made sense for him too to step aside since he is moving abroad on a sabbatical from his teaching job at Harvard. But Willett adds that "there are great people there at the journal and these summary dismissals are troublesome."

Likewise Dr. Robert Mayer, an associate editor for more than 13 years, worries that "if you rotate us every four years, you will lose the memory of past papers and reviewers. ... You could make the assumption that this is a way to do housecleaning."

Others wonder if they may be replaced because of their outspoken criticism of the journal's direction and its owner, the Massachusetts Medical Society. Dr. Arnold Relman, who preceded Kassirer as the journal's top editor, is even more critical. "For the first in the long history of the journal . . . business considerations appear to weigh as heavily as editorial considerations," he says. "I worry about that, and a lot of people who care deeply about the journal worry."

Part of their worry is that other society-owned publications, like Hippocrates, are marketed as if they have the same impeccable editorial standards as the New England Journal, when that would be almost impossible. There also is a concern that the society, which bought the journal in 1921 and now gets 80 percent of its $89 million in annual revenue from it and other publications, cannot help but see the journal as a revenue source rather than a cherished trust.

Many critics complain that the society, which has a powerful lobbying arm that looks out for the economic interests of its 17,700 member physicians, is worried about articles like one Bodenheimer wrote recently charging that many academic researchers are unduly influenced by huge rewards they reap from drug companies.

Drazen, who himself had strong ties to the biomedical industry but shed them before he joined the journal, says that "despite all the negative publicity that has occurred over the last year there never was a hint that the society was trying to exert any editorial control over what we publish." And Dr. Virginia Latham, the society's president, says, "We would never do anything to commercialize the name of the New England Journal. ... It obviously is in our best interests to keep the New England Journal name as pure as possible."

The new team running the journal is determined to make changes, however, starting with actively competing against publications like Science and Nature for the latest breakthroughs on issues such as genetics. Yet it will steer those and other articles to practicing doctors who want "the good stuff that patients can benefit from," says Drazen, an asthma specialist who ran the pulmonary division at Brigham and Women's Hospital. There will be less focus on the causes of and controls for disease, with more on issues that affect average doctors and patients, like whether to use stress tests or CT scans to evaluate chest pain.

As for public controversies, Drazen says he shares the passion of Angell and other predecessors for curbing smoking, but is far less critical of alternative medicine.

Whether they support Drazen's moves or oppose them, all who are watching agree on one thing: It is too early to judge the product he oversees since he only started on the job in July and most current stories were in the pipeline before he arrived. Still, the reviews are beginning to come in based on his hiring and other early decisions.

"I'd like to hope that they've learned some lessons, but the underlying problem is not going away. The underlying problem is that the Medical Society regards the journal as a massive cash cow," says Willett, who teaches epidemiology and nutrition at the Harvard School of Public Health.

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