The BMJ – the periodical formerly known as the British Medical Journal – is a most ingenious paradox.
* It’s a paid-for weekly that sends a free copy every week to its 150,000 core readers
* It continues to thrive as a classic, subscription-based peer-reviewed research journal – even though all of its research, dating back to 1840, is available for free on its website; and its fastest-growing extension is its open access offspring, BMJ Open
* It’s a pillar of the medical establishment that regularly and coolly takes a hatchet to that establishment’s most sacred shibboleths.
I’ve been blessed with an endlessly varied and rewarding career in publishing, but I can honestly say that it is a particular privilege to look after The BMJ, and correspondingly was a real kick to shamelessly piggy-back the team’s moment of glory at this year PPA Awards (as the team knows full well, I don’t actually do anything: just count the dosh and take the credit).
The BMJ is a unique institution. Here, in order, are the ingredients that go to make it so successful and distinctive.
1. Benign ownership
The BMJ has had one careful owner since its foundation in 1840: the British Medical Association. Exhibiting sagacity and courage rarely seen in any professional association, the BMA took the decision, some eleven years ago, to spin out The BMJ, and all our associated businesses (now some 60 journals, online learning, clinical decision support tools in multiple languages) into an arm’s length business, bidding us to go forth and multiply – which we have done very successfully. They’d enshrined editorial independence in the journal long before that. The BMA’s abiding concern is that we produce a journal that continues every year to be rated very highly as a benefit by its members (those 150,000+ recipients of the free copy); and does nothing to discredit the Association. Being perhaps a little old-fashioned, they take the view that telling the truth is a core function of the journal, irrespective of whom we upset (the Department of Health; NHS England; the pharmaceutical industry; NICE; numerous eminent doctors and academics; the Indian Medical Association; the BMA itself – it’s a long and distinguished list). Let’s also acknowledge that the truth is a contingent, emergent and elusive matter at any time. It’s the rigorous, determined, and open-minded pursuit that counts. The best journalists are those who do this; and the calibre of our team is partly at least due to their recognition that we encourage this kind of work, even when it can lead to a carpeting of the CEO in the very grand offices of the chief medical officer of one of the world’s biggest pharma companies.
The continuity of ownership is also important; it creates a stable platform for our more adventurous sallies. While The BMJ has been very open to change – the first general medical journal to go online, for example, twenty years ago; an early pioneer of open access publishing – it has been operating from the same address for nearly 90 years, and three of our six most senior editors have been with us for more than 25 years.
2. Genuine expertise
A fellow PPA member boasted to me recently that her business employed five people with professional qualifications relevant to the company’s target market. More than one in ten of our 480 staff are fully-qualified healthcare professionals, and The BMJ alone employs a dozen doctors on the editorial team – that is nearly one in three. The journal is pitched at working doctors, and our editors understand them, how they work, what they think, what they need to know. A remarkably successful scheme is that of editorial registrar – where a newly-qualified doctor spends a year on the editorial team before going into practice. Or at least that’s the theory; at last count, we have five on the payroll, including our editor-in-chief, who have never escaped the journal’s spell.
The prevalence of doctors is not without its frustrations: sometimes, views on the importance or treatment of a story can vary quite sharply between our medics and our journalists (some of whom are award-winning in their own right). But like all the best bands, those musical differences are never terminal, and generally result in a compelling final mix.
3. Outstanding editorial leadership
Dr Fiona Godlee is a magnificent editor – don’t take my word for it, she won the PPA Editor of the Year award last year, after all. You might think self-interest would have dictated I place this item at number one in my list. But Fi knows better than I that it is the two conditions above that enable our editors to flourish. Although she – technically at least – reports to the CEO, in fact, the editor is a BMA Council appointment, and can only be removed by a vote of Council. The churn is reassuringly low: Fi is only the seventh editor since Victoria was on the throne. (You can check this fact by visiting one of the BMA’s meeting rooms, where the editors are listed in gold leaf on an oak panel – like the vicars in an old parish church.)
4. Independence from advertising
That aforementioned pharma nabob was enraged by our campaign for the release of all clinical trials data. The BMJ has been a leader in this campaign for some years, and there are encouraging signs that the rest of the world is coming round to this view (the Wellcome Trust, for instance, the UK’s biggest private-sector funder of medical research, now insists that all trials it funds must be published in full). It’s based on the simple observation that half of all trials are never published, and those that are, are twice as likely to be ‘positive’ (generally, endorsing the efficacy of a drug) as the unpublished ones. The pharma man’s position was that we clearly did not understand the issues, or we would be supporting the pharma industry’s opposition to publication. Knowing that we could afford to lose all of his company’s ad budgets and still thrive, certainly made that meeting less stressful. The ad base of The BMJ is highly diversified, and includes pretty much all the medical employers in the UK, who use our jobs pages whenever the free NHS Jobs website can’t fulfil their recruitment requirements. The sheer diversity of the revenue base is a further source of strength. From individual subscriptions to overseas licensing – local editions are published in markets as diverse as Turkey, Nigeria and China - the journal has built a number of distinct and substantial revenue streams.
Fiona this year celebrated ten years in post (and 25 with the company), but her appetite for innovation is as keen as ever. This year, she introduced a soberly smart monthly academic edition, for those many subscribers outside the UK who value the journal for the peer-reviewed research, who still want print – most libraries do - yet do not want the weekly, with its trove of news about the NHS. This tactful separation of the overseas academic readership from the BMA UK membership, frees the way for a complete renewal of the weekly print, debuting with the issue of October 24th. It’s a suitably bold move for the editor who in 2007 abandoned the impermeable sobriety of the traditional, text-only, research-oriented covers, for the image-driven covers readers were used to in the rest of their reading lives; closing her ears and stiffening her upper lip to the inevitable accusations of ‘dumbing down’. From her own point of view – with all respect to the PPA – it is probably true to say that the most important public acknowledgement in the past year has been the award of the ‘Patients Included’ kitemark: The BMJ is the first publication in the world to earn it.
A word from our lawyers
It was Henry Kissinger who said that academic arguments are so vicious, because the stakes are so low. That is not, of course, the case in medicine: often the stakes could not be higher. One of our best moments of the past year was receiving a letter from our lawyer in Dallas, Marc Fuller, telling us that Andrew Wakefield had finally exhausted the appeals procedures in the Texan legal system – he’d run out of ways to threaten us. A disgraced former doctor (it was The BMJ’s unflinching reporting that resulted in his being stripped of the right to practice), Wakefield had been trying to sue us ever since The BMJ exposed as fraudulent his ‘findings’ on the links between vaccination and autism. The Texan ruling came, coincidentally, during the measles epidemic in California that claimed a number of children’s lives.
Fuller – a libel expert - wrote: “It has been a real honour to have represented The BMJ in this case. This series of articles and editorials was the best reporting I have ever defended. And it is easily the most important. In the States, the anti-vaccine crowd is sizeable and vocal enough that this “issue” remains on the radar of parents with young kids. With a few notable exceptions, the mainstream media does a good job of reminding everyone what frauds Wakefield and his crew are. But their reporting is almost always based on this series. They and the public are in your debt.”