Politics and Independence

THE COLLAPSE OF THE CANADIAN MEDICAL ASSOCIATION JOURNAL

On February 20, 2006, when Dr. John Hoey, editor-in-chief of the
Canadian Medical Association Journal, returned to the Ottawa
headquarters of the Canadian Medical Association after a vacation,
his journal was in excellent shape. It ranked as the fifth leading
general medical journal in the world, and it received more than 100
original research papers per month, allowing the editors to be highly
selective in what they published. It had nearly 70,000 subscribers --
representing the more than 85 per cent of Canadian doctors who are
CMA members. Yet Dr. Hoey's decade as editor would end abruptly that
afternoon when the journal's publisher fired him and his senior
deputy editor, Anne Marie Todkill.

The publisher, Graham Morris, said that the firings were his decision
and denied that Dr. Hoey and Ms. Todkill lost their jobs over
specific articles. "I just felt that it was time for a fresh
approach," he said. Dr. Larry Erlick, a CMA board member who chaired
the journal oversight committee until mid-March, gave a different
explanation: "The issue is .. not about editorial independence --
it's about a relationship between parties and their ability to work
together." Yet to many observers, the primary issue seemed to be the
editors' independence. The CMA has been divided over whether it wants
an independent scientific journal with news and commentary or a
political organ for its members.

There were early signs of trouble. In 2001, the journal published an
editorial supporting the medical use of marijuana, contrary to the
CMA's position, and the CMA's general council complained to Dr. Hoey
about it. In 2002, another editorial sparked a firestorm: a man had
arrived at a Quebec emergency room in the midst of a myocardial
infarction, but it had closed at midnight, and he died en route to an
open ER; the CMAJ editorial criticized Quebec doctors for not having
staffed the ER. The case received enormous media attention, and the
province responded with a bill requiring general practitioners to
staff ERs around the clock.Yet "a lot of Quebec physicians were quite
offended and felt undeservedly judged by ... that editorial,"
recalled Eugene Bereza, former chair of the CMA's Committee on
Ethics. CMA leaders considered the editorial irresponsible, said
Larry Patrick, an Ontario physician who was a CMA board member at the
time. The CMA's president called for a retraction, but the CMAJ
editorial board cautioned the association that it was threatening the
journal's editorial independence.

That year, the CMA board set up a journal oversight committee, but
its functions were unclear. Former CMA president Dr. Dana Hanson said
it was to address CMA members' "valid concerns" about CMAJ
editorials; Dr. Erlick, its current chair, said it was to resolve
disputes among the editors, the publisher, and the CMA; and CMAJ
editors wrote that it was to help them maintain "harmonious
relations" with the CMA. Dr. Patrick, the committee's first chairman,
said Dr. Hoey wouldn't work with the committee, but others, including
former New England Journal of Medicine editor Dr. Jerome Kassirer,
found that the committee was unresponsive to the editors and was used
by the CMA as a new means to "complain about CMAJ content considered
politically inconvenient."[1]

Such content remained, and conflicts persisted. Last November, a
dispute arose over a news report on Plan B, the
emergency-contraception pill that had just gained over-the-counter
status in Canada. The reporters asked women throughout the country to
try to purchase the drug and found that they were asked to reveal
personal information to pharmacists. When one of the reporters
interviewed an official at the Canadian Pharmacists Association, the
group objected to the article on the grounds that pharmacists had
been observed unwittingly. The pharmacists' association had a
long-standing relationship with the CMA. The CMA's chief executive
officer, Bill Tholl, sided with the pharmacists and took his
objections to Mr. Morris, the CMAJ publisher.

Mr. Morris had come to the CMA in 2004 after a decade at a large
media conglomerate, but he was new to medical publishing. He told Dr.
Hoey not to run the Plan B article, arguing that the women's
observations could be considered scientific research that had not
received ethics approval. It was the first time Dr. Hoey's bosses had
told him to pull a story. Facing a crisis, the reporters offered to
remove the quotations from the consumers, and the journal published a
revised article. Even so, it was convincing, and after provincial
privacy commissioners expressed concern, pharmacy groups instructed
pharmacists to stop requesting personal information. But the
precedent stood: The CMAJ had changed an article at the request of
its publisher.

Dr. Hoey notified the journal oversight committee afterward, but he'd
lost confidence in it and asked Dr. Kassirer to lead an ad hoc
committee to assess what had happened. The result was duelling
oversight committees, one serving the editor and another apparently
serving the CMA. Dr. Erlick, of the CMA's committee, said the editors
had cut his committee "out of the loop." But three months later, that
committee hadn't responded to the editors. "The issue is still on our
agenda," Dr. Erlick said in early March. Dr. Kassirer's committee
examined documents, interviewed editors, and concluded that editorial
autonomy at the CMAJ was "to an important degree illusory."

Mr. Tholl then became alarmed by another article, an unflattering
profile of Canada's new minister of health, Tony Clement, that was
published on the journal website two weeks before the CMA board was
to meet with Mr. Clement. Mr. Tholl and Paul-Emile Cloutier, the
CMA's communications director, went to the CMAJ offices, and Mr.
Tholl spoke -- loudly, witnesses report -- to Ms. Todkill, the senior
deputy editor, allegedly making a disparaging remark to her as he
left. Ms. Todkill reportedly complained to CMA executives about the
incident, but the CMA will not comment. Mr. Morris ordered Ms.
Todkill to pull the story off the web, and a reporter added some
positive remarks from the CMA president about the health minister
before reposting it. The editors asked Dr. Erlick to call an
emergency meeting of the oversight committee, but he declined. They
contacted members of the Kassirer committee, who added the incident
to their report.

A week later, Dr. Hoey and Ms. Todkill were fired. When asked about
the Plan B and Clement articles, Mr. Morris said, "There was no
connection between those articles and the change of staff." Although
he maintains that he didn't make his decision to fire the editors
suddenly, it was clear that no plans had been made for succession. To
most of Canada's medical community, the firings came as a complete
surprise. The journal had achieved high visibility, and in 2004, CMAJ
news reporters had been nominated for one of Canada's highest
journalism awards.

The remaining editors, including an in-house deputy editor and six
associate editors stationed throughout the country, felt devastated.
Deputy editor Dr. Stephen Choi became acting editor-in-chief and
wrote a proposal to ensure that the publisher and owner could not
make decisions about editorial content; when the CMA did not agree to
the plan, Dr. Choi and the journal's editorial fellow resigned.[2]
With no one to oversee peer review and publication, scientific papers
began piling up at a rate of 25 to 30 per week. Scrambling for a
replacement, the CMA turned to Dr. Bruce Squires, the journal's
former editor-in-chief. The 71-year-old Dr. Squires meant to help,
but under pressure from editors of other journals, he, too, left,
urging the CMA to agree to Dr. Choi's demands.

The editors were unable to speak about the matter publicly, owing to
the CMA's confidentiality policies, so the editorial board contacted
the media. Journalists have characterized the story as a battle over
editorial independence, despite the publisher's claims to the
contrary, and press coverage has been widespread; leading
international scientific and medical journals have run sympathetic
editorials. The sense of a battleground was heightened by frequent
postings on the CMA and CMAJ websites, including several "Messages
from the Publisher" and editorials by CMA officers [3], the Kassirer
committee [1], and the remaining editors.[2] For two weeks, the
95-year-old journal was at a standstill. Anita Palepu, a
Vancouver-based associate editor who resigned in early March over the
CMA's plans for the journal, said of the CMA leadership, "I don't
think they expected how strongly most of the editors would feel about
this. ... I think they underestimated that severely."

On March 7, a resolution appeared to be in sight: The CMA announced
that a former chief justice of Canada's Supreme Court would lead a
panel to examine the journal's management and make recommendations
within 90 days. Until then, the CMA pledged to honour several rules
proposed by Dr. Choi, including granting the editor-in-chief total
responsibility for editorial content and requiring editors to report
to the publisher only with regard to business and financial
operations. As interim editor, the CMA named Dr. Noni MacDonald,
former dean of the medical school at Dalhousie University in Halifax,
and Dr. Squires agreed to serve as editor emeritus.

Yet the CMAJ's future remains uncertain. The CMA president, Dr. Ruth
Collins-Nakai, said that the CMA board doesn't believe there was
editorial interference, but she declined to say more about why the
editors were fired, citing "legal and personnel constraints." Dr.
Kassirer resigned from the editorial board, accusing Dr.
Collins-Nakai of hiding "behind a veil of bureaucratic legalisms" and
of putting "a gag order" on the editors. Other board members said
they also planned to resign, and a professor at the University of
Ottawa called for authors, peer reviewers, and advertisers to boycott
the journal.

The underlying fight within the CMA between those who want control
over "their" journal and those who favour the complete independence
that characterizes major medical journals is likely to continue.
Organized medicine is a political and social entity, and Canada has
emphasized its political functions by doing such things as giving
provincial medical associations the authority to negotiate all fees
for physicians' services under universal health care. So it shouldn't
be surprising that Canada is now the epicentre of the ongoing
struggle over the scope and limits of editorial freedom at
association-owned journals.

Dr. Shuchman is in the department of psychiatry at SUNY-Buffalo. Dr.
Redelmeier is a professor of medicine at the University of Toronto,
Toronto. Dr. Shuchman has written news articles for the CMAJ. Dr.
Redelmeier is a member of the CMA, the CMAJ editorial board, and the
Kassirer Committee on Editorial Autonomy of CMAJ. Both receive
financial services from MD Management, a CMA subsidiary.

[REFERENCES]

1. Kassirer JP, Davidoff F, O'Hara K, Redelmeier DA. Editorial
autonomy of CMAJ. CMAJ (in press). (Accessed March 9, 2006, at
http://www.cmaj.ca/cgi/rapidpdf/cmaj.060290v1 .)

2. Choi S, Flegel K, Kendall C, et al. A catalyst for change. CMAJ (in press). (Accessed March 9, 2006, at http://www.cmaj.ca/cgi/rapidpdf/cmaj.060276v1 .)

3. Erlick LS, Cloutier LMC. Editorial governance plan for CMAJ. CMAJ (in press). (Accessed March 9, 2006, at http://www.cmaj.ca/cgi/rapidpdf/cmaj.060294v2 .)