Report of the Bellagio Conference: Background
Every year, through both public and private channels, the public invests huge sums of money in health and medical research to address questions about the origins of ill health, and the effects of preventive or therapeutic strategies to protect and improve human health and well-being. Medical journals, of which there are an estimated 20,000 worldwide, are the principal medium for primary communication of the outcome of this massive public investment. It is worth pondering the fact that it is not unusual for a mere half dozen pages in a medical journal to represent the main output from a research project which may have cost several million dollars.
The influential position of medical journals between public investment in research and public access to the fruits of this investment places a heavy responsibility on those who control what is published—medical journal editors. Medical journal editors have a public duty to ensure that reports of research provide valid information, in language and formats that are accessible to the wide variety of different consumers of this information.
Unfortunately, although the quality of medical editing may be improving gradually, a growing body of research has demonstrated that substantial problems exist. Investigations of the quality of reports of health and medical research in medical journals and textbooks, and of the process of medical editing, have revealed a variety of serious deficiencies and distortions, some of which pose indirect threats to the health of individuals and the wider public.
This disturbing state of affairs is beginning to be acknowledged more widely within the community of medical journal editors. There is evidence of growing concern about the patchy standards of medical editing, most explicitly manifested in successive statements by the International Committee of Medical Journal Editors (The Vancouver Group), a small group of general medical journal editors, and in a growing body of research on the quality of medical publishing, particularly that prompted by and reported at two recent international congresses on peer review.
A variety of obstacles confront editors who are committed to trying to improve medical editing. These include lack of formal training for their work, isolation from their peers, lack of ready access to information about how they might improve their practice, lack of the resources that are often required to secure statistical and methodological advice which is so often necessary, and increasing external pressure that could distort their editorial and ethical responsibility to ensure publication of full and honest accounts of research.
Medical journal editors in developing countries and of small journals face additional obstacles. Most editors of such journals edit only part-time and have had little previous experience. Often, high quality manuscripts for their journals are difficult to obtain, partly because competition for such manuscripts comes from large circulation journals, partly because medical science and medical writing may be at earlier stages of development. These editors also face scarce financial resources and have limited access to publishing and printing expertise. Those publishing in languages other than English have difficulty getting the articles in their journals indexed in the world's main medical data bases.
Recognizing their crucial role in ensuring that valid information derived from health and medical research is made publicly accessible, increasing numbers of medical journal editors are agreed that something must be done to improve the standards of their work and that of their colleagues. They understand that to achieve higher standards there is a need to improve the professionalism of medical journal editors. The skills involved in medical journal editing are not obtained during a medical career before entering the publishing field or simply through the process of editing, but are acquired through deliberate attention, study and practice. As with all professions, there is a special body of knowledge that must be expanded and refined through research. Mechanisms are needed for training newcomers to the field. Self-regulating methods must be developed to identify and help editors who perform below reasonable standards and to deal with those who do not improve.
A number of scattered initiatives have been taken to try to help the community of medical editors to raise the standards of their important work. This paper, developed by 22 medical editors and scientists from 13 countries of Western and Eastern Europe, North and South America, Africa and Asia, proposes the creation of a global organization of medical journal editors, The World Association of Medical Editors (WAME). WAME will help to coordinate and give impetus to efforts to improve medical editing worldwide, and, as a result, ensure that public investment in health and medical research yields greater dividends for the public good.
Common Purposes of Medical Journal Editors
The overarching purpose of medical journals (and thus of editors), regardless of language, region of the world or type of journal, should be to promote the science and art of medicine and the betterment of the public health. To achieve this purpose, key elements that editors consider include public health, science, ethics, economics, rigor, balance and breadth. Different journals and editors would have differing mixtures of these objectives and requirements according to their individual circumstances.
Specific critical objectives for medical journals include the following:
- To publish original, important, well-documented, peer-reviewed clinical and basic research articles.
- To provide physicians and other health professionals with continuing education in basic and clinical science to support informed clinical decisions.
- To enable physicians to remain informed in one or multiple areas of medicine.
- To improve public health internationally by elevating the quality of medical care, disease prevention, and medical research.
- To foster responsible and balanced debate on controversial issues and policies that affect medicine and health care.
- To promote peer review as a vehicle for scientific discourse and quality assurance in medicine and to support efforts to improve peer review.
- To achieve the highest level of ethical medical journalism.
- To promote self-audit and scientifically supported improvement in the editing process.
- To produce a publication that is timely, credible, and enjoyable to read.
- To forecast important issues, problems, and trends in medicine and health care.
- To inform readers about nonclinical aspects of medicine and public health, including political, philosophic, ethical, legal, environmental, economic, historical, and cultural issues.
- To recognize that, in addition to these specific objectives, a journal has a social responsibility to improve the total human condition and to promote the integrity of science.
The achievement of the above objectives varies greatly with the type of journal, different regions, culture, and level of socioeconomic development. The extent to which self-criticism of medical science through peer review of published material, the role of continuing medical education, the impact of traditional and alternative systems of local health care delivery, and the financial sustainability of journals may be far more critical issues in some nations and with some journals than with others.
Skills Editors Need
Few persons acting alone possess the diverse set of skills necessary to achieve the above goals and objectives, but certain skills are key.
Scientific and peer review skills. A medical journal editor must first be a medical doctor by training, should have clinical or research experience, and should have a substantial knowledge base in the journal's particular area of medicine. A medical journal editor must have knowledge of the scientific method, research, statistics, and epidemiology, and principles of evidence-based medicine, and how they are applied and evaluated. The editor must understand the science and art of editorial peer review, should promote self-criticism, and be capable of selecting, collecting, using, grading, and discharging peer reviewers from a wide range of fields. The editor must be able to evaluate the quality of the peer review itself and make decisions based on objective as well as intuitive assessment of these reviews. A personal knowledge of every scientific discipline in which one receives papers is not usually possible, even in relatively narrowly focused journals.
Organization and management skills. Editors must cooperate with numerous other individuals to guide their journal toward meeting their objectives. Editors are judged by the way they select, evaluate, motivate, and lead other individuals. In some cases, these individuals may comprise large numbers of editorial staff; in all cases, these individuals will be authors, reviewers, and editorial board members. Success or failure in this complex work will depend on the editor's knowledge of human behavior; ability to choose the right people, delegate effectively and comfortably, and evaluate the work of others; and willingness to value and reward others. A medical journal editor should be a good manager, able to organize people to achieve efficient work flow, and able to hire, supervise, lead, motivate, discipline, and dismiss people as needed. The editor should also have a sound understanding of the business of publishing, including finances, budgeting, production, circulation, and advertising.
Substantial disagreement exists over the extent to which editors should be involved in evaluating the quality and validity of advertising carried in a journal. Some believe that this is an editorial function; many believe it should be managed entirely separately by advertising and publishing staff except in areas of clear error, dishonesty, or gross lack of taste. Editors should be aware of international standards for evaluating advertising.
Communication skills. Editors of medical journals should themselves be effective communicators in the spoken and written language in which they work, possess a keen appreciation for the opinions of others, and maintain a willingness to examine different viewpoints to choose the one or several that are best for readers. A medical editor need not necessarily be an excellent writer but such a skill is helpful. Editing the language and style of manuscripts to improve clarity and readability after acceptance is necessary and must be practiced by someone in the organization. With small journals, the editor may be that person. With larger journals such duties may be delegated to editorial specialists. Editors must have open lines of communication with everyone involved in the journal's production, including copy editors, proofreaders, production operators, and all members of publishing staff (circulation, fulfillment, and promotion), and, particularly, the publisher.
Leadership, professional, and public relations skills. Medical journal editors may be called upon or have opportunity to exert leadership on issues of import to national and international health care. As visible representatives of their fields, medical journal editors may be asked to speak publicly to individuals or to groups, and sometimes to a mass audience by way of radio and television. Thus, experience in public speaking, and the ability to think adroitly and promptly in response to questions are great benefits. A medical editor needs to possess political sensitivity, exercising due judgment. Primary-source medical journals must have editorial independence from the owners of the journal. However, the editor must cultivate a healthy relationship with, and respect for, that owner to achieve successful function. In some cultures, it is of great benefit for an editor to possess enough legal knowledge or sensitivity to prevent the organization from being sued for libel or defamation or, if so sued, to be correct enough to win in a court of law. Other helpful skills include a transcultural appreciation of individuals and groups, familiarity with the medical education and research communities in the country of the journal, understanding of quality control and assurance methods, and knowledge of health economics, health policy issues and governmental politics. Perhaps, above all else, an editor must possess a high level of integrity, vision, and courage, be willing to set the agenda for a discipline or field, and demonstrate great tolerance for conflict.
Belonging to the press. Editors of medical journals should regard themselves as members of the fourth estate. Though most editors of scientific journals look upon themselves as belonging to the scientific community rather than being associated with media, they should also recognize the general principles that allow the press to flourish. Medical journals are no more neutral transmitters of information than newspapers and magazines. We select, alter, present—and sometimes produce—information, just as other media do. We are susceptible to the same kinds of infringements upon, and threats to our liberties. We depend to the same extent on the preservation of our editorial freedom to maintain our credibility among our readers and their trust in us. Medical journal editors must understand these issues to maximize their effectiveness.
Obstacles, Challenges and Needs of Medical Journal Editors
Most of the world's medical editors work with limited support, no training, and inadequate contacts with other editors. In many countries, editors are experienced doctors who are selected on the strength of their clinical and/or research achievements rather than on experience and knowledge about editing. In developing countries, medical journal editors share these same problems, but in addition, they often must work with limited resources and in professional cultures that do not set a high value on researching, writing, and publishing. All medical editors have needs that are not being presently met.
Information. Many medical journal editors work mostly in ignorance of the large body of knowledge and experience of medical editing. Problems arise with peer review systems, medical writing, ethical issues, production, copy editing, marketing, and, indeed, with all aspects of the complicated process of publishing medical journals. Usually medical editors must cope alone; there is no clearly defined organization to help. Some editors seek help from established colleagues of the larger journals. In one week the editor of the BMJ was contacted by an editor asking about getting his journal into Current Contents, another worried by the possibility of a libel action, and another wanted to know what to do about a possibly fraudulent paper. Most editors struggle on alone, doing the best they can. The result of the isolation of editors is that many of the medical journals that serve doctors, and so patients, are of poorer quality than they need be.
Electronic communication. A closely related need of medical editors is for easy access to information. An isolated editor might want advice on a reviewer for a manuscript or insights into electronic publishing. At the moment editors cannot find their way easily to the information that does exist on medical editing. This is especially true if they do not personally know another editor whom they can consult. The available information is scattered and often published in journals that are not read regularly by doctors. A new editor might want to be put in contact with another editor working in similar circumstances, to have a dialogue on common problems. This type of communication could be made available most cheaply and easily through a global electronic network of medical journal editors. Such an approach would be in addition to more traditional methods of communication because many editors will want information in paper form for the foreseeable future.
Editorial freedom. Perhaps the most difficult and important part of an editor's job is the maintenance of independence and integrity. Editors must have full authority to determine the editorial content of their journal. Editorial freedom is, first and foremost, a freedom from a number of threats. Government interference and censorship are relevant even to medical journals. Pressure from owners and publishers has been experienced by many editors. Most medical journals are, at least partly, financed by advertisements. Direct attempts from the advertisers—usually the pharmaceutical industry—to influence the editorial contents of a journal seem to be uncommon, but it would be naive to believe that the industry has no interest in, or impact on, what is published. The medical establishment may threaten the editor's position when new ideas are aired which do not fit in with the conventional wisdom of the medical profession, and which may be regarded as dangerous. Funding agencies and sponsors could influence the editorial process. Threat of lawsuits against journals and editors seems to be an increasingly relevant and chilling factor in some countries. Even authors and readers may, for example through boycotts, influence the contents of a journal in a way that is not consistent with editorial freedom.
Editorial freedom is, however, not only a freedom from a number of potential threats, but freedom to make the best possible, high quality, reliable and readable journal. To achieve this, the editor must have the freedom to define editorial policy, standards for scientific quality, originality, relevance and importance of papers, and must be able to put the interest of the readers before the interest of others. The editor must have the freedom to assure open debate in order to air any opinions of relevance and interest to the readers, and to offer fair treatment to authors by providing space for comments and debate. The editor must also have authority over administrative routines in the editorial office and a decisive role in the appointment and dismissal of editorial staff.
Because of the central importance of editorial freedom to high-quality medical editing and the publication of high-quality medical science, medical editors who are pressured by owners, advertisers or authors need support and advice, and, if necessary, an organization to speak up on their behalf and to publicize the facts in such cases.
Standards. The need for advice on standards and on how to raise them is paramount. Many medical editors, although keen to reach high standards, do not know what those standards are or how to achieve them. Editors, for instance, ask for advice on standards for statistical presentation or on who should be an author on a paper. Some standards have been set for medical editing—for instance, by the International Committee of Medical Journal Editors (the Vancouver Group)—but these have been set by full time editors without reference to the particular problems of isolated medical editors or editors in different parts of the world. The standards of the Vancouver Group, therefore, may have been set too high in some cases. The Vancouver Group has not organized research into many of the issues on which it sets standards, and so those standards have not been evidence based. Editors need standards that are described after wide consultation and that are based on evidence.
Education and training. One of the greatest needs of medical editors is for education and training. While no doctor would contemplate undertaking abdominal surgery without training, most doctors edit journals— and so supervise the flow of information that is vital for health care—without former training. There are many examples of doctors without any experience of editing being appointed as editors by medical societies. Training is needed before medical editors assume responsibility for a journal and while they are doing the job. New editors need courses, apprenticeships with or visits to established journals, and distance learning programs.
Medical journal directory. At the moment no directory exists of medical journals and medical editors. Nobody knows how many medical journals exist, and no mechanism exists to transmit a message to all medical editors. Such a directory could be useful to editors, authors, researchers, funders of research, and organizations like WHO or the World Medical Association. The directory would need to contain much more than the name and address of the journal and the editor. For example, it might include information on target audience, types of material published, peer review systems, frequency of publication, and subscription information.
Research on medical editing. One need that has been identified by some long-standing editors but which may not be felt by new medical editors is the need for research into the processes of publishing scientific material. Although medical editing is at the heart of the scientific process, many of its decisions - for instance, on how many reviewers to use and whether to blind them to the identity of the authors - are made with little or no research evidence. A new organization of medical editors could promote research into medical editing worldwide.
A voice for medical editors. Currently, organizations who want to consult with medical editors must speak to individual editors rather than any organization which can speak for a large number of medical editors. Medical editors need an organization to represent their interests, allow them to speak together on matters of importance to the health of the public and science, and provide a place where international organizations could consult them.
Data-bases. A particular need of editors in the non-English speaking world and the developing world is to have their journals recognized internationally. Currently their journals often are not listed on the otherwise excellent databases kept by organizations in the English speaking developed world. These editors would like regional databases.
Other important needs. Other significant obstacles to achieving an editor's defined goals are lack of financial resources and good manuscripts. These obstacles may be given different priorities in different journals and at different times of development of a journal
Two basic resources are money and manuscripts. Newly established journals and journals in developing countries are economically vulnerable. The advertising market for these journals is mainly restricted to the pharmaceutical industry, and even for a well established journal like Revista Medica de Chile, established in 1872, issues may occasionally be delayed while waiting for advertisements. The African Journal of Medical Practice, which was established from scratch in 1994 without any grant support, has had a very hard time funding the first issues. In new journals, erratic publishing deadlines can lead to the publication of suboptimal papers. Lack of sufficient financial resources not only threatens the technical standards of the journal and the frequency of publication, but may even undermine editorial freedom
Most journals depend on spontaneously submitted manuscripts, and a shortage of good manuscripts will have serious consequences. The competition for high quality manuscripts is especially stiff for medical journals in the developing world, since authors want the maximum exposure for their papers. This means that they tend to submit their best manuscripts to international journals with a high "impact factor", leaving journals publishing in languages other than English, journals with a low circulation and journals not indexed in the main data bases with fewer manuscripts, usually of lower quality.
How much collaboration among editors can help individual editors deal effectively with limited financial resources and the shortage of good manuscripts is an open question. However, in a global organization, editors can exchange information on their experiences and make suggestions to each other.
There are already at least 4 organizations that meet some needs of medical journal editors. The Council of Biology Editors (CBE) is based in North America, has about 1200 members, and runs courses and produces useful publications. The European Association of Science Editors (EASE) has 950 members, most of whom are British, Dutch, or Scandinavian; the Association holds conferences and produces a regular Bulletin. The International Committee of Medical Journal Editors (the Vancouver Group) comprises about a dozen, largely full-time, editors of large general journals. It meets once a year and produces statements on editing practice. The International Federation of Science Editors (IFSE) is directed more to Southern Europe, the Middle East, and Asia and holds a conference every two years.
These organizations have done good work in offering standards, training and educational opportunities, but they cannot meet most of the needs of international medical editors. The biggest problem with CBE and EASE from the point of view of medical editors are that their membership covers editors working across the whole field of science, as well as managing and copy editors. A large part of the agenda of these groups, therefore, only indirectly relates to medical editors. In addition, they are not global. The Vancouver Group is concerned with medical editors but is not global and has few members, a limited aim (primarily to produce statements on important topics in medical editing), and no resources or secretariat to meet the needs of medical editors worldwide. IFSE is an organization that is known to very few medical editors.