Tuesday, March 20, 2012

Abby Zuger's Two Rather Contradictory Pieces on NEJM

Yesterday two articles written by Doc-journalist Abigail Zuger came out in the Paper Of Record dealing with The New England Journal of Medicine and its ongoing influence as, well, the Journal Of Record for all things medical. These pieces, however, highlight two very different aspects of NEJM. The first is a warm birthday card of sorts as the Journal celebrates its 200th year of publication: a quick meditation on why it has remained at the top of the heap and continues to be equated with excellence not only among physicians but in the public mind as well. "It is an antique that outperforms all the newer models," Zuger writes, and she's right, which even a casual perusal of their website or a listen to their podcast makes clear. It remains the standard of excellence in clinical medicine, the venue where everyone with serious career aspirations wants to be published. (We're no different, often dreaming about seeing the name "Billy Rubin" in its pages.)

But also in the Times yesterday Dr. Zuger has a longer piece detailing the lives of two former editors of NEJM, Drs. Arnold Relman and Marcia Angell, and their relationship with the august journal is less chummy. Suffice it to say that Relman and Angell aren't likely to be brought back for the 200th anniversary party like an equivalent of former baseball players returning to the field for an Old Timer's game. Details can be found in the article, but the quick version is that Angell took a dim view of the increasing "contaminating influence of money, especially industry money" in the affairs of the Journal, and was eventually dumped from the Journal in 2001.

"Many physicians believed that the degree of separation the top editors demanded for the journal, and for its expert authors, was unrealistic and counterproductive," writes Zuger, although why these physicians believed that Angell was being unrealistic is not made fully clear. I can't claim to be an expert on the Journal's finances, but pretty much every doctor who reads medical journals with any regularity reads NEJM. Their subscription income should be more than enough to sustain its staff. Yet the Journal is rife with advertising and there has been ample evidence for years that industry ties create scientific bias.

So I can't quite figure out why Angell and her ilk are portrayed as being so rigid, and there's more than a touch of "oh, they're just crazy old bats" in the piece. Zuger doesn't say this herself, but quotes several hostile sources. Whether she feels that way personally I can't tell, but the chorus of criticism of Angell and Relman so clearly evident in the article is nowhere to be found in the "NEJM at 200" postcard.

The fact remains that, sterling reputation or no, NEJM is a multimillion dollar operation heavily subsidized by industry money--and at its 200th birthday, that creates grave problems for its editors, its readership, and ultimately the patients served by such a publication. Count me in as a fan, but likewise count me in as someone who's down with the Relman/Angell critique of how business gets done.

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