White Coat Underground

The current insanity at JAMA has been well reported elsewhere (also see these links: here, here, here, and here). I’ll give you a thumbnail sketch. A professor from a small university wrote to JAMA (the Journal of the American Medical Association) to let them know that an author of an antidepressant study appeared to have an undisclosed conflict of interest (COI). When he didn’t hear back from JAMA he wrote to a more prestigious journal, the British Journal of Medicine (BMJ) who published his letter. This caused the editors at JAMA to completely lose their shit, threatening the letter writer, calling his dean, insulting him with juvenile taunts (“you’re a nothing and a nobody”) and banning him from publishing in JAMA (irony alert—he had his letter published in a much better journal, BMJ).

The links above will lead you to most of the prurient details, but I’d like to look at one of the most idiotic results of this incident.

JAMA has always been a second tier journal (after the New England Journal of Medicine, Annals of Internal Medicine, the Lancet, BMJ) and JAMA has never liked this position. Despite their second-tier status (or perhaps because of it), the editors of JAMA seem to think they have some sort of superpowers, powers that allow them to reach out a punch some one in the nose publicly and then claim to be the aggrieved party. Rather than stepping back from the fray to find a way to dig themselves out of this particular cesspit, they have continued to dig furiously, compounding every error, and showing a stunning lack of competence and yes, frank stupidity.

The worst of the arrogant stupidity is to be found in an editorial in JAMA, apparently the official response to the situation.

This editorial would be amusing if it didn’t make me wonder which institution the editors had escaped from. Let’s examine it briefly (all emphasis mine):

As a result of these recent events we are making the following modifications to our already rigorous approach for investigations into allegations of unreported potential conflicts of interest. JAMA will require that the individual bringing the allegations provide a written detailed explanation of the unreported conflicts of interest and provide documentation to support the allegation. The person bringing the allegation will be specifically informed that he/she should not reveal this information to third parties or the media while the investigation is under way, will be informed about progress of the investigation, upon request, as appropriate, and will be notified when the investigation is completed. In addition, once the investigation into unreported conflicts of interest is completed and the letter of explanation and the correction are finalized, those documents will be immediately posted online and linked from the article, and then subsequently published in the print journal.

This paragraph would make sense in your basic totalitarian society. After all, one of the first rules of a dictatorship is “control the press”. The press monitors the government, and monitors its competitors. A free press is critical to democracy. If JAMA were the only medical journal in the world, they could set whatever draconian rules they wished, and the coercion to follow them would be future ability to publish in the world’s only journal. This is of course, not the case.

As this case shows, when a journal is suspected of having undisclosed COIs, its competitors can scoop them. There is no need to go directly to JAMA to complain about the error—you can go straight to another outlet. This bothers JAMA, and causes them to make ridiculous pronouncements that are sure to be laughed away in seconds. If I find an error in JAMA, I have even less incentive now to write them to let them know. I’ll just write to the New England Journal, or put it right here in my blog. In fact, I think all medical writers and bloggers should give JAMA increased scrutiny and publish every little error we can find.

If you want a piece published in a particular journal, you must follow whatever guidelines they lay down. A journal has complete control over its content. This control does not extend to the rest of the world, no matter how overblown your sense of importance is. The difference between JAMA and Superman is that when Superman leaps off a building, he flies. When JAMA’s editors jump, their is a resounding “splat” after which we all go back to drinking our coffee and reading our paper.

Comments

  1. #1 ERV
    March 24, 2009

    What are going to be the repercussions for JAMA? Why would anyone, other than someone with a COI to hide, publish there now? Or is the field going to overlook this ‘just to get papers out’?

    Im just wondering if something as spectacularly stupid happened with, say, Journal of Virology, I would have the guts to not submit there anymore. Does JAMA have that kind of clout?

  2. #2 Bob O'H
    March 24, 2009

    If it’s second tier, there should be plenty of other journals to submit to. I’ve decided not to submit to one particular stable of second tier journals, because their manuscript handling sucks and they charge for the privilege. But that’s OK because there are enough other journals (e.g. their British rivals) that I can go to instead.

    I wonder if the AMA will do anything about this – I could imagine their members getting quite upset.

  3. #3 PalMD
    March 24, 2009

    Most AMA members probably won’t even know about this or care….most are not researchers but everyday in-the-trenches docs.

  4. #4 DrugMonkey
    March 24, 2009

    crossposting from Respectful Insolence:

    What a classic example of how not to respond to legitimate criticism when you’ve screwed up.

    I want to underline what commenter Ryan said @ Orac’s place. Journal staff (particularly journals run by professional editorial people) are obsessed with their alleged reputation. To the point that they are incapable of discerning when a critique is well justified and when it is not. These COI cases (one of the little whoopsies in my areas was detailed here) put a very fine point on a more general problem, however.

    This defensiveness is a complicating feature when there are accusations of data falsification for a paper as well. Journals are motivated to downgrade the ultimate resolution as best they can, to avoid doing anything if possible, to make a correction when it should be a retraction, etc. And above all else, even when there is a retraction, to avoid anything that suggests identifying fault.

    These stances, which ultimately are charged to the desire to preserve journal repuation, are corrosive to the conduct of science. Because they allow erroneous findings to persist, uncorrected, for far too long which is bad enough. Worse, such foot dragging lowers the cost of fraud by decreasing the rate of identification and by minimizing overt blame.

  5. #5 chezjake
    March 24, 2009

    I certainly agree with your overall assessment. From what I’ve observed over more than 45 years of watching/studying the medical literature, JAMA’s primary function seems to be to serve as a vehicle for carrying big pharma’s ads to the largest possible audience of practicing, prescription writing physicians.

    However, there seems to be one very minor improvement in JAMA’s policy revealed in that editorial — apparently under the new policy those who complain about conflicts of interest will now at least get an acknowledgment that their correspondence has been received. Whoop-de-doo!

  6. #6 samantha
    March 24, 2009

    It’s weird – I had no idea that that’s how physicians and scientists viewed JAMA! As a layman, I was under the impression that it was the the New York Times of medical journals – the most prestigious one, journal of record, etc.

    What accounts for this difference between layman and professional opinions?

  7. #7 DrugMonkey
    March 24, 2009

    What accounts for this difference between layman and professional opinions?

    snobbery and point scoring?

  8. #8 bob koepp
    March 24, 2009

    “What accounts for this difference between layman and professional opinions?”

    I’m sure that snobbery and point scoring play some role, but there’s also the public misperception that the AMA is the THE professional organization for medical professionals. It ain’t. I haven’t actually conducted a poll, but my impression is that a clear majority of the MDs with whom I’ve worked declined membership in the AMA.

  9. #9 The Blind Watchmaker
    March 24, 2009

    “JAMA has always been a second tier journal (after the New England Journal of Medicine, Annals of Internal Medicine, the Lancet, BMJ) and JAMA has never liked this position.”

    – This is kind of the equivalent of “short man syndrome” (appologies to the vertically challenged).

    “JAMA’s primary function seems to be to serve as a vehicle for carrying big pharma’s ads”

    – Well, my wife likes the cover art.

  10. #10 antipodean
    March 24, 2009

    There’s no fucking way the BMJ is more prestigious than JAMA. Go check out the impact factors.

    However, the relative pecking order may have just tipped the other way…

  11. #11 Marilyn Mann
    March 24, 2009

    Your explication of the hierarchy of medical journals was fascinating to me. I had no clue that BMJ and Annals were more prestigious than JAMA. I guess I generally knew that NEJM and The Lancet were more prestigious. Where does Archives fit in?

    Have you looked at the new journal edited by Harlan Krumholz and John Spertus? It is called Circulation: Cardiovascular Quality and Outcomes. It just started a few months ago, and it is really excellent. http://circoutcomes.ahajournals.org/

    The “splat” was a nice touch also.

  12. #12 Joe
    March 25, 2009

    I was interested by the hierarchy too. I thought AIM and Lancet were becoming woo-friendly.

  13. #13 Courtney
    March 25, 2009

    “the public misperception that the AMA is the THE professional organization for medical professionals. It ain’t. I haven’t actually conducted a poll, but my impression is that a clear majority of the MDs with whom I’ve worked declined membership in the AMA.”

    So what is the professional organization for medical professionals?

  14. #14 PalMD
    March 25, 2009

    As to the “hierarchy” of journals, there is no set agreement, although i think most internists would list NEJM above JAMA and put Archives somewhere near the bottom of IM journals.

    Most docs belong to their own specialty’s org. I belong to the American College of PHysicians, the official internists org.

  15. #15 antipodean
    March 25, 2009

    PAL

    Sorry. Should have done this yesterday. This is the hierarchy of general medical journals, although I agree that may not be the same as the clinical utility of the articles to practicing physicians. It’s pretty clear who the top three are though. JAMA is one of them and as you say the NEJM is the top journal in medicine.

    Journal citation reports for 2007 (2008 comes out about August)- Internal and general medical journals. For others reading this comment: the Impact Factor is roughly the average number of citations each article gets in the two years after publication. It’s got problems, but it’s still the chief way to tell how important a journal is.

    Name Impact Factor

    New Eng J Med 53
    Lancet 29
    JAMA 26
    Ann Int Med 16
    Annual Rev Med 13
    PLoS Med 13
    BMJ 10
    Arch Int Med 8

  16. #16 Prometheus
    March 27, 2009

    To underscore what Bob Koepp said, a few years ago (2005) I looked at AMA membership and discovered that their membership was less than 18% of licensed US physicians. When you consider that the AMA membership counts medical student members (and they aren’t licensed), the AMA probably represents less than 18% of US physicians.

    I was surprised to see the impact factor of JAMA so high. Even so, it is less well-respected than the BMJ, primarily because of some well-documented editorial and political shennanigans a few years back. They are anxious to regain their clout, but keep going about it exactly the wrong way (as this episode illustrates).

    Prometheus (not an AMA member)

  17. #17 Marilyn Mann
    March 28, 2009

    http://online.wsj.com/article/SB123819137827260883.html

    MARCH 28, 2009

    Medical Group Seeks Probe of Its Journal

    By DAVID ARMSTRONG
    The American Medical Association said it has asked an oversight committee to investigate charges that the top editors of its well-known medical journal threatened a researcher who publicly faulted a study in the publication.

    The move by the AMA follows criticism of the actions of top editors at the Journal of the American Medical Association, known as JAMA.

    The AMA, in a statement, said JAMA operates with editorial independence. However, the association said it has “formally referred” the matter to a seven-member Journal Oversight Committee, comprised primarily of medical academics, to investigate the actions of JAMA editors. The oversight committee is a standing body that has editorial responsibility for JAMA, including evaluating the performance of the editor in chief.

    A Tennessee researcher, Jonathan Leo, says top JAMA editors threatened him and his dean after he published an online letter earlier this month in the British journal BMJ that criticized how results were reported in a JAMA study last year that looked at the use of the antidepressant Lexapro in stroke victims. Dr. Leo also said JAMA didn’t disclose the author of the study’s financial relationship with Lexapro’s maker, Forest Laboratories Inc.

    Dr. Leo is a professor of neuroanatomy at Lincoln Memorial University in Harrogate, Tenn. Forest acknowledged that it had paid the author for speeches, but said his Lexapro research was independent.

    Dr. Leo said JAMA editors demanded that he retract the letter. In addition, he says JAMA’s executive deputy editor, Phil Fontanarosa, told him, “You are banned from JAMA for life. You will be sorry.” Dr. Fontanarosa, through a spokeswoman, has said Dr. Leo’s version of the conversation is “inaccurate.”

    Dr. Leo’s dean, Ray Stowers, says JAMA Editor in Chief Catherine DeAngelis threatened in a telephone conversation earlier this month that she would “ruin the reputation of our medical school” if he didn’t force Dr. Leo to retract the BMJ letter and stop talking to the media. Dr. DeAngelis, through a spokeswoman, has denied threatening the dean.

    The AMA statement said it takes the concerns raised over the Dr. Leo matter “very seriously.” It said the AMA board will “give careful consideration to whatever is reported to it” by the oversight committee.

    The AMA action comes a day after a nonprofit group that monitors industry links to medical research called for the suspension of the JAMA editors, and an investigation into their treatment of Dr. Leo.

    In an editorial posted on the JAMA Web site last week, Drs. DeAngelis and Fontanarosa responded to the controversy over their handling of Dr. Leo’s criticisms by accusing the researcher of a “serious breach of confidentiality” by writing about the problems with the JAMA study while the medical journal was still investigating the matter.

    Dr. Leo said he identified the undisclosed conflict of interest through a quick Internet search. The editors said that, going forward, anyone complaining of an author failing to report a conflict of interest will “be specifically informed that he/she should not reveal this information to third parties or the media while an investigation is under way.”