For Thomas Wakley, the founder of the Lancet, an important function of his journal was to reform medicine, which he saw as full of incompetence, quackery, corruption and nepotism. He wanted to reform as well as inform. But can journals reform? Can they lead? Are medical journals important for leadership in medicine? Or is this grandiosity on the part of editors? Aren’t journals there to follow, reflect and comment rather than to lead? These are the questions I want to explore in this brief chapter.
I never used the word leadership until I spent a year at the Stanford Business School in 1989-90 and discovered that people studied leadership. It is a word that wasn’t used in Britain until recently. Doctors certainly didn’t use it. But now leadership is seen as something central to the reform of the National Health Service (NHS). There are programmes to train leaders, particularly clinical leaders, throughout the NHS.
There is no simple definition of leadership, which is one source of confusion in research into the subject, but a working definition is that leaders have two main tasks — to set a path, goal or vision for the people who are being led, and to motivate people to pursue and eventually achieve the goal. For Mahatma Gandhi, one of the great leaders of the 20th century, the goal was to free India from the British. For Winston Churchill it was to defeat Germany in the Second World War. For lain Chalmers, one of the founders of the Cochrane Collaboration and one of the leaders of medicine, the goal is to organize medical information and to create a medicine practised on evidence not tradition. All of these are goals that can be achieved only through effective leadership of large numbers.
But could editors or editorial teams have such specific goals? Some do. Tobacco Control, a journal within the BMJ Publishing Group, has one aim — the reduction and perhaps even eradication of the damage caused by tobacco. The goal is clear and the journal provides material (both research and advocacy) for those who share its aims. It is read by all those who might be regarded as leaders in the antismoking movement, and it provides a forum for them to debate with and motivate each other. It does seem to me that the journal and its editor, Simon Chapman, are leaders. Something similar might be said of another journal the BMJ Publishing Group publishes, Injury Prevention. Its goal is the reduction of injuries everywhere and in all age groups. This is a more diffuse goal than that of Tobacco Control and involves many different groups, many of whom do not read and have never even heard of Injury Prevention.
And when it comes to general medical journals they inevitably have diffuse goals and must cover a huge intellectual territory. It would be wrong for such a journal to become too obsessed with too narrow a goal, but can it provide leadership on particular themes? Some years ago I asked various editors if they could provide me with examples of where journals had shown leadership.
George Lundberg, who was then editor of JAMA, thought that JAMA had led on promoting a tobacco — free society, preventing nuclear war, drawing attention to the plight of the uninsured in America, promoting the control of violence and encouraging research into peer review. (In chapter 3 I discussed how political journals should be: four of these five issues are political in the broadest sense. They are far from clinical.) The New England Journal of Medicine had led, said Lundberg, by describing and deploring the industrialization of medicine, encouraging health reform and drawing attention to the importance of conflict of interest. The BMJ had led on fighting tobacco, calling for a ban on boxing (this was actually the BMA not the BMJ) and improving the standard of statistics in medical journals. The Lancet had led with reducing the risk of nuclear war and encouraging the internationalization of medicine. The Canadian Medical Association Journal had shown leadership by publishing a highly influential series of articles on critical appraisal of scientific papers.
Suzanne and Bob Fletcher, former editors of the Annals of Internal Medicine, agreed that the New England Journal of Medicine had led with its articles on the industrialization of medicine. JAMA had led on the prevention of disease and the promotion of social justice. The Annals of Internal Medicine had led on health services reform and the promotion of clinical guidelines.
Laurel Thomas, former editor of the Medical Journal of Australia, thought that her journal had led with antismoking campaigns, promoting reform of the World Medical Association, AIDS awareness, aboriginal health and traffic safety.
Magne Nylenna, who was then editor of the Norwegian Medical Journal, thought the Lancet had led on nuclear war, the BMJ on smoking, and his own journal on promoting medical education, particularly in the campaign to start a new medical school in Tromsø.
The most interesting response came from Stephen Lock, my mentor and predecessor as editor of the BMJ. He wrote:
There are no examples of where medical journals have led. Nor is it the journal’s role — which is to provide a forum for debate and to publish checked data. In fact, despite what editors say, I doubt whether any publication has done much leading — for instance, the Socialist landslide in [the British general election in] 1945 was probably due to the WEA [Worker’s Education Association] influence in the forces during the war rather than the Daily Mirror, while Ernest Hart’s [great editor of the BMJ in the 19th century, see below] successes owed more to the BMA Parliamentary Bills Committee, and his numerous social contacts, than to the BMJ and even Robbie Fox’s [great Lancet editor of the 20th century] often cited role in the introduction of the NHS was secondary to Moran’s [Lord Moran, Churchill’s doctor] leadership at the RCP [Royal College of Physicians] and in the Lord’s [House of Lords] debate. Think of the contemporary issues — AIDS, health reform in the USA and the current NHS debate — and you’ll realize how little influence the journals are having, can have, or should have.
Stephen, as always, put his case powerfully, and there is much truth in what he says — but I want to continue to explore the question. One advantage of having asked those editors about examples of leadership nearly 10 years ago is that it’s now possible to take a longer-term look at whether they were examples of leadership. I will define leadership as effecting a change that wouldn’t otherwise have happened.
Ironically the best two examples of leadership from the list involve Stephen himself. Stephen together with Drummond Rennie from JAMA and John Bailar, statistical adviser to the New England Journal of Medicine, played a central part in prompting the study of peer review. This process, which is fundamental to all of science not only in deciding which papers to publish but also in the giving of research grants, was largely unstudied until these three urged that it should be. There have now been five international congresses on peer review (organized by Rennie and JAMA) and a body of research has been completed (73). This has happened almost entirely within biomedicine, but its results are beginning to percolate to other areas of science. I cannot see that this would have happened without the leadership of Lock, Rennie, Bailar and their journals.
Similarly the work to improve the quality of statistical reporting was led by Lock and the BMJ together with other journals. The Lancet published an important series on statistics by Austen Bradford Hill, the BMJ published a series called ‘Statistics at Square One’ (which later as a book sold over 100,000 copies), and Lock and other editors involved statisticians in the peer review process. Many studies showed that the standard of statistics in medical journals was woeful and it’s now better (although still far from perfect). This has an importance way beyond journals themselves. Bad statistics means false conclusions. Doctors and patients were thus being misled.
These two examples of leadership are of course to do with journals themselves. It is easier for journals to reform themselves and closely related activities than to reform the broader world. Another subject close to the journals where another journal — this time the New England Journal of Medicine — has shown leadership is over conflict of interest (74). It led the way in encouraging journals, and medicine in the broad, to consider this important issue, although, as I wiII discuss in chapter 11, the state of play is still that most authors have conflicts of interest but much of the time don’t declare them.
Journals have also been important in campaigning against smoking and nuclear war. All the major journals have published on these subjects, but they have been far from alone. Many medical bodies have been prominent in campaigning against the dangers of tobacco and International Physicians for the Prevention of Nuclear War won the Nobel Peace Prize for its work.
History can help us with trying to answer the question on whether or not journals can lead, and rather than considering Wakley this time, as I did extensively in chapter 3, I want to examine the work of Ernest Hart, editor of the BMJ from 1867 to 1898, and the closest the BMJ has come to a figure as important as Wakley (9). Hart was a major public figure in a way that no BMJ editor had been before or has been since. He was highly controversial, believing (like Wakley) that: ‘An editor needs, and must have, enemies; he can’t do without them. Woe be unto the journalist of whom all men say good things.’
Hart tried to lead on many issues, but two of his most prominent campaigns were against ‘baby farming’ — giving infants (often bastards) over to carers for money, knowing that the carers often neglected and even murdered them — and ‘secret remedies’ — medicines that did not declare their constituents.
Baby farming was first raised in the BMJ in 1865, two years before Hart became editor (9). In his first year as editor the journal carried a story on the inquest on four children who had all died under the care of the same ‘nurse’. The journal also published several leading articles on the subject. In 1868 Hart put an advertisement in a newspaper as a father-to-be, offering money for adoption. He received 333 replies and identified Mrs. X, who had seven malnourished infants living in her care in dreadful squalor. In the previous two years she had registered seven deaths of infants under one year. Articles in the journal led to questions in parliament. More cases were reported in 1870 and Hart formed with others the Infant Life Protection Society. He was also appointed chairman of the BMA’s Parliamentary Bills Committee in 1872. A bill was drafted and enacted in 1872. It proved to be a weak bill and a much stronger bill was passed in 1877.
The problem was not solved. In 1896 Mrs. Dyer of Reading was executed for strangling her charges and throwing them into the Thames. The BMJ published a six-part series on ‘baby farming and its evils’. The child protection movement grew enormously at this time and the National Society for the Prevention of Cruelty to Children was founded in 1889. The problem still persists at the beginning of the 21st century — indeed, the week that I wrote the first draft of this chapter the first BMJ editorial described a failure of the authorities to prevent the killing of a child (75).
Ernest Hart and the BMJ didn’t defeat baby farming on their own, and Lock argued in his quote above that it was less Hart’s role as editor and more his chairmanship of the BMA Parliamentary Committee and his social contacts that led to the change. But Peter Bartrip in his history of the BMJ concludes: ‘The Journal did not singlehandedly cause the Infant Life Protection Act to be passed, but it undoubtedly exerted a powerful influence’ (9). We can probably never separate out the role of the journal from broader influences, but, as I argue below, journals seem to be good at putting issues onto the professional and public agenda.
At the end of the 19th century proprietary medicines that contained poisons and addictive substances were freely available. In 1890 the BMJ published a leading article that proposed a ban on any proprietary medicine unless all the ingredients were listed (9). In 1891 the BMA Parliamentary Committee, which was still chaired by Hart, demanded prosecutions. It conducted analyses of the medicines and sent them to the government. Prosecutions followed.
This campaign was continued by Hart’s successor, Dawson Williams, and in 1903 the journal published the constituents of remedies, beginning with treatments for epilepsy. ‘With one exception they are weak preparations of well known drugs supplied at considerably more than the usual cost, and administered without the adjustment of dose to the needs of the particular patient. which is, after all, the most essential part in the treatment of epilepsy by bromide salts. The exception contains an old fashioned herb once praised by the superstitious, but abandoned time and again even by them’ (9).
These analyses were gathered together and published in 1909 in a book called Secret remedies: what they cost and what they contain. Despite newspapers, which were profiting from advertisements for the remedies, refusing to advertise or review the book it sold out in one month: by 1910 some 62,000 copies had been sold. A parliamentary committee was appointed to consider the problem, but then the war interrupted activities. It was another 20 years before quack remedies were brought under legal control. Again the BMJ played a prominent part in this process, although many other groups participated.
This question of whether journals lead or follow is similar to the question of whether the mass media lead or follow, and some in the discipline of ‘media studies’ have addressed exactly this question. The story of Watergate is often cited as a classic case of the media leading people on what to think. It was in June 1972 that five men broke into the campaign headquarters of the Democrat party. The incident received extensive publicity from the Washington Post, but initially there was little public interest. Yet the press kept on and by April 1973 over 90% of the American population knew the word ‘Watergate’. In 1974 President Nixon was forced from office.
Did the media depose the president? Clearly they didn’t do so alone, but they played a crucial role. Maxwell McCombs and Donald Shaw, two pioneers in media studies, have developed the theory of ‘agenda setting’ (76, 77). This means that: ‘We judge as important what the media judge as important.’ Bernard Cohen, a political scientist from the University of Wisconsin, puts it this way: ‘The press may not be successful much of the time in telling people what to think, but it is stunningly successful in telling its readers what to think about.’ This chimes with a saying of Hugh Clegg, editor of the BMJ from 1947 to 1965, ‘A subject that needs reform should be kept before the public until it demands reform.’
McCombs and Shaw analysed the 1968 presidential race between Richard Nixon and Hubert Humphrey to see if they could work out whether the media were leading or reflecting public opinion (76). They looked at nine print and broadcast media used by Chapel Hill residents and ranked stories by position and length. They considered five major issues: foreign policy, law and order, fiscal policy, public welfare and civil rights. They then looked at how undecided voters ranked these issues and found that they ranked them exactly the same as the media.
But which came first, the media agenda or the voters’ agenda? There have been many subsequent studies and the general finding is that the media interest comes first (77). Later work suggests that agenda setting works best when people are interested in a subject but very uncertain about what to think (77). For example, I own a dog and hence I am interested in animal experimentation, but I am very uncertain about what the risks and benefits might be.
Nobody, as far as I know, has conducted any studies like this with medical journals, but it might be that the findings can be generalized from the mass media to general medical journals. If so, journals can put issues on the agenda and do have some influence on how people think about them — a limited form of leadership.
Another insight into leadership can be gained from studying campaigns. Many campaigns fail, but some succeed spectacularly. Why? The Institute for Healthcare Improvement in the United States is running a campaign to reduce unnecessary deaths in hospital, many the result of medical error. The campaign is called ‘The 100,000 Lives Campaign’, and its slogan is ‘Some is not a number, soon is not a time’. Before launching the campaign the institute studied political campaigns — and identified six essential features: platform, measurement, communication, field, funds and values. The start is a clear, scientifically sound, highly developed platform or message. Measurement is essential to know if the campaign is succeeding, and communication must be constant, two way and involve many different media. Impact will depend on signing up many people and institutions (creating afield force), and The 100,000 Lives Campaign has signed up some 2000 hospitals. Funds are essential, but so are explicit values; the values of The 100,000 Lives Campaign include ‘all in’ but ‘staying on message’.
I don’t know of a medical journal that has campaigned so carefully, and perhaps a more important question than ‘Whether journals can lead?’ is ‘What must they do to make change happen?’
Studies on leadership emphasize five characteristics of leadership and I want to end this chapter by seeing if journals have displayed them and shown leadership.
The first characteristic is that leaders set a vision. The BMJ did this with wanting to abolish baby farming and secret remedies. The vision was clear and understandable, as it is with wanting to get rid of smoking. But often it’s much harder to paint a clear vision, especially when the aim is to create rather than abolish something. Abolition we can all grasp, but to convey a compelling vision of something entirely new is hard. Stephen Lock and Drummond Rennie had a vision of the processes that lead to journals being based on evidence, but what is the aim, for example, with healthcare reform? In the United States it might be ‘universal coverage’, but what is the vision for the majority of countries that already have universal coverage?
The second job of leaders is to motivate people to want to achieve the vision. This is difficult for journals. They do not want to commit the cardinal sin of boring their readers, but they have to keep returning to the subject. They must come at it in different ways. The BMJ kept on with the subjects of baby farming and quack medicines for more than 20 years, finding different ways to cover the subjects. Some journals struggle now to remind readers of the gross inequalities in the world, but they have to avoid ‘compassion fatigue’ by finding new ways to present the subject.
Third, leaders inspire trust. Journals try hard to achieve trust, but at the same time they must show all sides of debates. The BMJ asked doctors in Britain whom they trusted, and they replied that they trusted journals much more than they trusted the government or the NHS. Trust may come not from sticking relentlessly to a point of view but from being open and truthful, even when what is being published undermines your traditional message. Trust is, of course, one of the main arguments for editorial independence. Readers trust that editors have a fair peer review process and are independently making decisions on what to put before their readers. If there is any hint that hidden political or business processes are influencing those decisions, then trust can be lost. And trust takes years to build but can be destroyed in an instant.
Fourth, leaders empower and journals can do this by providing information on which their readers and others can take action. This was the case with both baby farming and particularly with the quack medicines where the analyses were useful to both individuals and organizations. Tobacco Control is doing this now by providing its readers with a constant flow of information that is useful ammunition in the battle to prevent the enormous harm from tobacco.
Finally, leaders work with others — other media and other organizations. Again this happened with both baby farming and quack remedies. The BMJ in 2003 planned a campaign to refresh and promote academic medicine worldwide. We realized that if we were to have the faintest hope of success we would need to work with as many other organizations as we could muster. We did so and yet the campaign achieved very little.
I must confess that most of my conscious attempts to achieve change through the BMJ failed. We were part of the Rationing Agenda Group which argued for open debate on the inevitability of rationing healthcare. England and Wales do now have the National Institute for Health and Clinical Excellence which makes semi-transparent decisions on which treatments will be available within the NHS — but it refuses to use the word rationing. The BMJ participated in the development of the Tavistock Principles, which was an ethical code for everybody in healthcare not just individual professions. After a flurry of activity the principles were forgotten.
These campaigns may have failed because the leaders were too far ahead of those they were trying to lead: they were proposing action on subjects that seemed unimportant to those who might have followed. The research in Chapel Hill suggested that the media could be only slightly ahead of their readers. Leaders must somehow create their visions from a deep understanding of the thinking of those they would lead. The vision can then be compelling.
My cautious conclusion is that journals can lead, in limited ways. And perhaps — as both Thomas Wakley and Ernest Hart clearly believed — they have a duty to do so. It may be hubris, but I believe that medical journals can lead — less by achieving precise reform but more by putting issues firmly on the agenda. I also have a hypothesis that journals are most likely to achieve real change when they concentrate on subjects that are close to them and work together. Thus real progress has been made with studying peer review and improving statistics in medical journals, subjects close to journals and where they have worked together. Where journals worked together on subjects that were not close to them — like ageing and emergent diseases — they have made little progress. Similarly, if a journal promotes a change close to the journal but alone it will achieve little. The BMJ‘s campaign for open peer reviews is perhaps an example. Where journals campaign alone on subjects not close to them they are perhaps bound to fail — as my stories in the previous paragraph illustrate.
In my years at the BMJ we tried lo lead by promoting evidence-based medicine, encouraging doctors and patients to work in partnership, reminding the rich world constantly of its obligations to the poor world, battling against research misconduct, hastening the flow of information to the developing world, securing the independence of medicine from the pharmaceutical industry, promoting patient safety and emphasizing the importance of a ‘good death’. History will attempt to judge if we had any success, but even its judgement will be uncertain.
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