A medical-publishing tradition

The editor-in-chief of the 205-year-old New England Journal of Medicine was in Israel to attend the “Summit” of the Rambam Medical Center in Haifa.

Prof. Rafael Beyar and Prof. Jeffrey Drazen (photo credit: Courtesy)
Prof. Rafael Beyar and Prof. Jeffrey Drazen
(photo credit: Courtesy)
In June 1812, a bloody war was fought between the US and the United Kingdom over the issue of a naval blockade and maritime trade. Just five months earlier, a journal now known as the New England Journal of Medicine (NEJM) appeared that has since become one of the world’s most reputable publications in general medicine and the oldest one to be continuously published.
Producing a prestigious magazine (originally quarterly and then weekly) for 205 years is an impressive achievement, all the more so a journal that attempts to report to professionals the latest and most accurate information in the constantly changing field of medicine.
The New England Journal of Medicine, published by the Massachusetts Medical Society, was launched in September 1811 when a Boston doctor named John Collins Warren and James Jackson, submitted a formal prospectus to establish the New England Journal of Medicine and Surgery and Collateral Branches of Science as a magazine on medicine and philosophy. In January, the first issue was published.
In 1823, the Boston Medical Intelligencer appeared, but when four years later it accumulated debts, the editors of the New England Journal of Medicine and Surgery and the Collateral Branches of Medical Science bought in it and merged it in February 1828 to form the weekly Boston Medical and Surgical Journal.
The Massachusetts Medical Society purchased it in 1921 and renamed it seven years later as the New England Journal of Medicine. The journal’s logo includes the Rod of Asclepius – the snake-entwined rod carried by the Greek god Asclepius connected to healing – and the dates corresponding to the different stages in the journal’s publication.
The weight of history bears down on the shoulders of NEJM editor-inchief Prof. Jeffrey M. Drazen, who has just made a visit to Israel. He was here to participate in the Rambam Medical Center’s annual “Rambam Summit” along with Prof. Richard Horton, editor-in-chief of the prestigious British medical journal The Lancet. Both received awards from Rambam director-general Prof.
Rafael Beyar along with former US diplomat ambassador Dennis Ross for his influencial presence in the quest for peace and Harvey and Gloria Kaylie from New York for their philantropy and support of Jewish communty needs in Israel and the Diaspora and for their support of kidney health research.
The five award recipients were also greeted by Prof. Karl Skorecki, the director of medical and research development at the Haifa medical center and a world-class expert in population genetics and nephrology.
Only last month, Horton – who had previously been considered anti-Israeli and allowed the publication in The Lancet of letters highly critical of Israel – launched a series of articles in The Lancet on various aspects of Israeli medicine.
It was Skorecki with the blessing of Beyar who invited Horton for his first visit to Rambam after the British editor and physician had previously frequently visited the regions neighboring Israel. Skorecki was even a student of Drazen.
Horton said at the conference that the medical world has the ability to affect much more than the treatment of diseases. He described his “vision of medicine” as a tool that serves far beyond the care of human beings – extending individual health to global and even planetary health.
The Rambam Summit has been held annually since 2010 and focuses each time on a specific medical specialty. This time, the packed event specialized on nephrology and genetics (prevention and treatment of kidney disease and innovations in the field. Dr. Suheir Assady, director of Rambam’s nephrology department and a leading researcher in the field, lectured on innovations in kidney disease treatment.
Assady, together with Dr. Daniela Magen, head of pediatric nehrology and Dr. Hagit Baris, head of the genetics department, coordinated sessions featuring internationally renowned researchers on kidney diseases and genetics in children.
In previous years, the summit dealt with trauma, medical technologies, pediatrics, cardiology and digital medicine, among others.
“In light of the cooperation we have developed in recent years with leading research and development organizations in Israel and around the world, Rambam – the largest hospital in the north – is becoming a significant factor in the field of digital medicine and medical innovation,” Beyar said.
The Rambam director-general, who is a leading interventional cardiologist in his own right, noted that in 1965, the hospital was the first in Israel – and the Middle East – to perform a successful kidney transplant from a deceased donor.
Since then, many hundreds of kidneys have been transplanted there into adults and children.
IN AN exclusive interview with The Jerusalem Post, the NEJM editor-inchief said that he had never been to Rambam before but has visited the country several times, especially for professional conferences and meetings.
But there are also Jewish reasons.
His brother, he said, is a Conservative rabbi, and when Drazen was 10 years old, his grandmother – from a hassidic family – came on aliya and settled in Bnei Brak.
He also visits Muslim countries, as “medicine knows no boundaries.”
As a journal editor, writer and researcher, he identified himself “primarily as a physician with a specialty in lung diseases. I still see outpatients with asthma and other pulmonary diseases and inpatients in my hospital’s intensive care unit.” It is very rare for medical journal editors, who are almost always physicians, to remain in their white coats.
Seeing patients, he continued, “is a motivating factor, my passion. I look for ways to help people and make their lives better. So much can be done in the field of medicine, but while we may make disease go away, we can’t always get their lives back to where the want it to be.”
When he was offered the job of NEJM editor, he told executives that he wanted to spend 25% to 30% of his time away from the journal and at the patient’s beside. He also teaches respiratory physiology to first-year students at Harvard Medical School.
“A medical journal editor has to stay current. Perhaps my predecessors made a mistake by not also working as physicians,” he suggested.
Since 2000, Drazen continued, so much in medicine has changed.
If my memory of medicine had stopped seven years ago, I couldn’t write about it or understand it anymore.”
He regularly reads The Lancet, The BMJ (British Medical Journal) and other leading general medical journals, which have extended their their interest over many years to include many political and societal issues affecting medicine and health. But when asked to compare them, Drazen said: “I focus all my energy on our journal, to discuss things that are new and useful for the medical profession. I won’t criticize other journals. My guiding principle is to provide reliable information. We occasionally get into political issues such as women’s reproductive health, but not the war in Gaza. When we have to take a political stance, it is to improve our ability for doctors to get medical information.”
An exclusive group of general medical journal editors called the International Committee of Medical Journal Editors is comprised of 13 to 15 editors-in-chief, including Drazen. “We have regular meetings in various places around the world; the last time was in Copenhagen.
“The number of medical journals, including specialized ones, has increased dramatically,” he noted.
“There are many new online ones that promote open access [no paid subscriptions], but some have no peer review. In some journals, the author pays for the privilege of being published. In the NEJM, the author doesn’t pay. We make money from subscriptions to individuals, libraries and medical institutions.”
Medical journals “shouldn’t try to communicate on science with the layman public; that’s the job of journalists like you,” he added.
NEJM employs 10 full-time professional editors and executive editors, plus seven deputy editors. Of the 10 professional editors, nine also work as physicians, while the other has a doctorate. There are four statisticians and nine associate editors.
The number of peer reviewers – consultants and specialists who read submitted articles in advance to point our errors and other problems – totals 25,000. “I can’t say how many are Israeli, but there are many.” The level of Israeli medicine and research in general is very high, Drazen said. “It is world class in many fields. For a country of eight million, Israel is very productive and innovative.”
He added that his journal looks for peer reviewers who have a reputation for high-quality medical research. The best reviewers are people involved in research themselves in their mid-to-late career.
We have a database of them.”
When his journal’s first article appeared under the byline of John Warren in 1812, his clinical description of angina pectoris (chest pains) “was perfect, but we would not accept today his understanding of the cause. We look at medicine 100 years ago, and it seems crazy. But in another 100 years, medical knowledge will seem crazy.”
The NEJM has moved with the times. The BMJ was the first to hesitantly publish an online journal in 1994, worried that it would harm print sales to doctors and other medical professionals. A few months later, NEJM followed by putting itself online. In 2000, we had a circulation of 200,000 print journals and 20,000 online subscriptions.
Today, we sell 150,000 paper copies a week and have 2.5 million online users.”
Asked which NEJM articles he regarded as most important over the years, the editor-in-chief said: We had a contest for readers on our 200th anniversary, and most people thought it was the one that appeared on November 16, 1848 on the first successful use of ether as general anesthesia. Others thought it was the first identification in December 1981 of the AIDS virus [HIV], but the journal has had many important “firsts”. During Drazen’s editorship, he believes that reports on the SARS and Ebola viruses were most important.
NEJM has been exposed to some criticism in recent years by various forums such as the Propublica, an independent, non-profit newsroom that produces investigative journalism in the public interest. Its articles have discussed what critics perceived as the journal’s “resistance to becoming more transparent about the research it publishes.” Propublica wrote that “a group of British scientists faulted the journal, as well as some of its peers, for failing to disclose that the questions being answered in certain studies were not the same as those in the researchers’ original protocols.” Changes are normal and sometimes to be expected, but they need to be disclosed, the group argued. Drazen countered that in recent years, the journal began posting the protocols and statistical analysis plan for all clinical trials it publishes.
A rare, infamous case involving NEJM was the publication of an article which purported to demonstrate the clinical utility of the selective nonsteroidal anti-inflammatory drug produced by Merck & Co. and was named rofecoxib (Vioxx). Approved by the US Food and Drug Administration, it was prescribed to treat osteoarthritis, acute pain conditions and menstrual problems. But after being widely marketed, the drug was shown in 2000 that patients who were prescribed rofecoxib had four times as many heart attacks myocardial infarctions as those who were given other drugs. The pharmaceutical company’s aggressive marketing was blamed for the drugs’ faults being overlooked.
Vioxx was withdrawn by Merck in 2004 from the market after disclosures that “it withheld information about rofecoxib’s risks from doctors and patients for over five years, resulting in between 88,000 and 140,000 cases of serious heart disease.”
Both the FDA and the Journal of the American Medical Association criticized the validity of the data interpretation that had been published in NEJM; the journal finally said it regretted the original publication and that Merck “had trained its representatives to identify speakers for educational events who were ‘opinion leaders’ who could provide ‘favorable’ views of the company’s products to other doctors.”
Drazen told the Post that “physicians and patients are smart. The Vioxx matter won’t happen again, for various reasons, among them the fact that our international committee of journal editors decided that articles have to specify primary and secondary outcomes and put them in public database so the outcomes can’t be changed.”
As for the Trump Administration’s efforts to cancel the Affordable Care Act (Obamacare) to provide medical care to all Americans, Drazen said it “won’t be easy to cancel it. Republicans realize that many people who had health insurance under Obama – even though they were unemployed and stand to lose it because health insurance in the US is linked to one’s workplace [or retirement or poverty] – will be unhappy to lose it.”
He concluded that Israel’s national health insurance system is enviable, but unlikely to be adopted in the US, even though Massachusetts, where he lives, has state-required healthcare.