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August 24, 1999 THE DOCTOR'S WORLD Inside Medical Journals, a Rising Quest for Profits A generation ago, leading medical journals measured their profits in the tens of thousands of dollars. They were scholarly publications meant to help doctors keep abreast of scientific advances and share information on new remedies. The mission has not changed, but the journals have increasingly become cash cows for the medical societies and companies that own them, with annual profits in the tens of millions of dollars, largely from drug company advertisements. And the imperative to sustain and build those profits is changing how the journals do business -- and how the public learns about medicine -- in ways their founders could scarcely have envisioned. "When I came," said Dr. Floyd Bloom, the editor of Science, which is owned by the American Association for the Advancement of Science, "they told me it was a not-for-profit operation. And then they said in the same breath, 'But it is also a not-for-loss operation.' " Leading journals like The New England Journal of Medicine, The Journal of the American Medical Association and Nature have long been criticized for withholding information about their articles until publication. These embargoes, critics say, serve mainly to protect the journals' position in the marketplace. The journals respond that their efforts in evaluating and editing manuscripts justify the delays. But criticism has been increasing, particularly after the recent involuntary departures of the main editors of two weekly medical journals whose contents often make headlines. Few would say that articles in leading journals are distorted or unreliable, but the quest for profits raises several disturbing issues: the journals' increasing appetite for publicity; how a burst of publicity from an article can inflate the importance of a new finding; the drug industry's influence on journals through advertising revenues, and the reluctance of journals to account publicly for their profits and how they are spent. Last month, Dr. Jerome P. Kassirer, the top editor of The New England Journal of Medicine, resigned under pressure in a dispute with its owner, the Massachusetts Medical Society. In January, the American Medical Association dismissed the top editor of its journal, Dr. George Lundberg, for publishing during the Clinton impeachment hearings a survey on attitudes toward sex. Personality clashes played a role, but the common thread in the departures was unrelated to the journals' scientific mission. Dr. Kassirer was forced to leave in a dispute over the marketing of the journal's name as part of the society's growing publishing empire. Although Dr. Lundberg's dismissal was ostensibly over of speeding up publication of old research to fit a political context, it also reflected the need to satisfy the demands of a publishing empire with $54.7 million of advertising a year. Money is also changing the meaning of editorial freedom. To journal editors, the phrase has meant the freedom to publish a paper even if it counters an owner's beliefs. But "that idea is probably too restrictive in today's world, where journals have become such incredible money making enterprises," said Dr. Suzanne W. Fletcher, who until she resigned in 1994 was a co-editor of The Annals of Internal Medicine, owned by the American College of Physicians. "The journals' success has created an enormous new market force that is beginning to dominate the way medical societies are run," Dr. Fletcher said. In some not-for-profit societies, the business staff is gaining influence over editors, creating frictions between the two traditionally separate sides. "These societies were kind of frumpy and esoteric, and they are no longer that way," Dr. Fletcher said. "They are big businesses, and editors who traditionally worked with small staffs and had time to read a lot now go to meetings about new ventures." In 1992, The Annals of Internal Medicine published a study showing that advertisements in journals were often misleading about the safety and effectiveness of new drugs. Drug companies stopped advertising, costing the journal $1 million to $1.5 million, Dr. Fletcher said. The lost revenue was a factor in her departure, said Dr. Fletcher, now a professor at Harvard Medical School. Scientific journals, numbering more than 25,000, cover everything from esoterica to the common cold. Most make their money selling subscriptions, copyrighting and publishing findings received free from authors whose research is mainly financed by taxpayers, and selling reprints. Journals carrying advertisements often compete vigorously for papers, readers and circulation so they can charge top rates. Most journals have small editorial staffs, many of them volunteers, and send texts to scientists for unpaid criticism, a process known as peer review. Journals also charge authors a fee for each published page. Many journals are owned by not-for-profit professional societies, many others by commercial companies. For libraries, the subscriptions are big budget items, with some exceeding $10,000 a year. Most journals refuse to disclose profits. The New England Journal of Medicine did through 1979, when its earnings were less than $400,000 a year. Now earnings are estimated to be at least $20 million a year, with the A.M.A. journal not far behind. Even when the journals' financial statements are released, they are hard to compare because different accounting methods are used in preparing them, and many not-for-profit professional societies use varying amounts of journal profits to cover the owners' expenses. "It is not easy to find out how profitable one's rivals are," said Sir John Maddox, who retired in 1995 as editor of Nature. The profits of Nature, a for-profit journal published in London and owned by von Holtzbrinck Group of Germany, are not disclosed. Nature's "profits enabled us to do things we had not previously done," like expanding internationally and opening offices in several countries, Sir John said. The American Medical Association, the American Heart Association and the British Medical Association have long published specialty journals in addition to their main journals. Seeing their success, other publishers have made or considered similar expansions. Beginning in 1992, for example, Nature created profitable specialty journals like Nature Genetics. The New England Journal of Medicine, like many other leading journals, rejects far more papers than it accepts. Since the vast majority of papers are later published elsewhere, the officials of the Massachusetts Medical Society saw an opportunity to expand their publishing empire. The idea was to steer rejected papers to spin-off specialty publications to be created by The New England Journal -- a proposal that Dr. Kassirer and other editors opposed. At Science, Dr. Bloom said he had opposed a similar expansion of specialty journals because of lack of funds to hire more editors and concern that such a move would erode the journal's prestige. Journals have soared in number in recent years as the Government has paid for more scientific research and patient care and as publications are required for academic promotions and new grants. Some experts contend that the number of publications could be cut by two-thirds, in part because much second-rate research is being done and findings are split into multiple papers. In their quest to protect their market position or just to survive, many journals rely on embargoes, press releases and page charges. Embargoes owe much to a rule created in 1969 by the editor of The New England Journal of Medicine, Dr. Franz Ingelfinger, out of what he freely acknowledged was a "selfish" concern for protecting the copyright. Now known as the Ingelfinger rule, and widely adopted by other journals, it says a journal will not publish a manuscript if its findings have appeared elsewhere. In effect, this means that scientists are restricted in what they can say even before submitting a manuscript. And though some may say embargoes put all the news media on an even footing in reporting on such advances, many editors say the motivation is not so noble. Sir John said he imposed embargoes at Nature "shamelessly" because "it is entirely proper that if we are publishing a paper we should get a share of what publicity there is for it." "The reason for having an embargo is to be able to blow one's own trumpet a bit," he added. "It is silly to say there is some high motive of protecting authors' privacy and all that. It is just the thing journals do so as to protect their own images." Many journals lift embargoes if it is in their interest -- for example, when a paper on the same subject is about to appear in a rival journal. An increasing number of journals have recently begun issuing news releases to attract wider coverage of the contents of each issue. The Journal of the American Medical Association also holds news conferences to promote papers and issues video news releases. A standard practice is for many of the more specialized and lesser-known journals to charge authors for each published page. Usually, those charges are financed by the taxpayers, in the form of Federal grants to the authors. Federal health officials say they do not know the total cost. Editors have expanded the scope of their journals to include articles about political affairs, some of which oppose society positions. And as professional societies have become more involved in the politics of health care, many have engaged in lobbying, thus increasing their need for more money for such efforts. The threat to the journals' integrity and scientific credibility has led many experts to urge greater public scrutiny of the finances of journals and their publishers, particularly if taxpayers are indirectly contributing to the owners' lobbying efforts for the welfare of their members. "They should be accountable to the public for how they use the profits," said Dr. Michael M. E. Johns, executive vice president for health affairs at Emory University School of Medicine in Atlanta, who is a member of a committee searching for Dr. Lundberg's successor at The Journal of the American Medical Association. "In a not-for-profit medical society, you would think that most of the dollars would go to education" and charity. "It is fine for them to make a profit," he said. "But why is it kept a secret?" By LAWRENCE K. ALTMAN, M.D. Copyright 1999 The New York Times Company <http://www12.nytimes.com/library/national/science/082499hth-doctors.html> janet paterson 52 now / 41 dx / 37 onset po box 171, almonte, ontario, canada, K0A 1A0 a new voice: http://www.geocities.com/SoHo/Village/6263/ [log in to unmask]