Why Bother With Medical Journals and Whether They Are Honest? By Richard Smith, former editor of the BMJ

Sly Saint

Sly Saint

Senior Member (Voting Rights)
Stephen Lock, my predecessor as editor of the BMJ, taught me always to remember that journals would soon ‘be wrapping up next week’s fish and chips’. Something we expected to cause excitement often, he noted, had all the impact of ‘a doughnut in the North Sea’. Journals rarely cause change directly, but I want in this chapter to try and convince you that journals can have profound effects. They might do this through anything they publish, but I’m particularly interested in cases where the journals may have behaved poorly.

Any such debate today tends to begin with the case of the Lancet and the measles, mumps and rubella (German measles) vaccine (MMR) (1). Public health doctors froth at the mouth when telling this story. For them it illustrates the waywardness of journals and their ability to create havoc and cause extensive harm.
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The BMJ did something similar when we ran an exercise on our website to identify ‘non-diseases’ (46). Over a hundred conditions were suggested and we then asked readers to vote for their top non-diseases. This caused outrage among some who argued that it was a cheap publicity stunt that mocked the suffering of many. I responded by arguing that it was primarily an exercise to alert people to the fact that diseases are not ‘out there’ like animal species waiting to be discovered but rather medical, social and even sometimes political constructs. We also wanted to point out that having your problem defined as a disease may not be the best way to deal with it.

One group who were particularly upset by this exercise were sufferers from chronic fatigue syndrome or myalgic encephalomyelitis (ME). (Even the name is disputed. Doctors prefer chronic fatigue syndrome and have produced an operational definition of it. Many patients prefer ME. In a spirit of conciliation I’ll now use ME.) They are an interesting group of patients who have in some sense been ‘at war’ with the medical establishment in general and medical journals in particular. They have entered the discourse that goes on in medical journals in a way that not many other patient groups have done. (Another group are those concerned with Munchausen-by-proxy.) Sufferers from ME think that their condition is not taken seriously by most doctors. In particular, they resent the contention of doctors that the problem has a psychological component and is not simply a physical condition (not that any condition, doctors argue, is ‘simply physical’).

Each year one of the ME organizations gives a prize for ‘the worst medical journal’. Usually it is won by the BMJ, sometimes tying with the Lancet. Some of those interested in ME have made complaints about me to various authorities. They saw the BMJ as pushing the line that the problem is psychological, using only advisers whom they despise (many of them psychiatrists), and publishing only research that supports our line. My line was that we don’t have a line. We took the best research that we could get and asked people who were recognized experts to write and review for us. We didn’t publish research because the results pleased us and we didn’t tell any of the experts what to write. Plus anybody could send us electronic letters and we posted all of those that were not obscene, libellous, incomprehensible, wholly unsubstantial or gave information on patients without their written consent. We posted and published on paper many contributions from people who were very critical of what we published on ME.

I am perhaps being disingenuous here. I can see that one view of ME — we might call it the orthodox view — did dominate in the BMJ and most (perhaps all) other major journals.
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https://www.crossfit.com/health/the-trouble-with-medical-journals-section-2
 
What I want to know is why are we still here:

In particular, they resent the contention of doctors that the problem has a psychological component and is not simply a physical condition (not that any condition, doctors argue, is ‘simply physical’).
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This is the usual misunderstanding of the central issue. And it allows for everything else that is said to seem valid to an outside reader. If all illnesses have a psychological component than our insistence on the purely physical is irrational.

But all of this brief statement needs to be examined further. Pulling out the details of what is meant by psychological component and how that is applied is rather important.

There has never been (as far as I'm aware) any BPS adherent willing to discuss this beyond the vague and misleading; there's a 'psychological component'.

If they were correct about about their supposition regarding what they mean by this there would be no 'war' because we would all be well and grateful for the treatment that gave us back our lives. It's unfortunate that they can't see that it is not some kind of perverse resistance on our part or a psychological need to be right about this being fulfilled. It is simply that we have discovered (to our own surprise often) that the treatment based on their BPS theoretical model has left us more ill than when we began.

That indisputable fact renders all of their various writing on the subject completely ignorant blathering.

ETA: the people who self-identify as adhering to the BSP model for understanding illness continue to ignore real social factors that contribute to getting ill and quality of life after illness onset. Somehow this escapes their notice.

I find that rather peculiar. Although another word for it could be convenient.
 
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It seems that Dr Smith does not keep himself up to date.

We took the best research that we could get and asked people who were recognized experts to write and review for us.

There's never an excuse for an editor letting poor quality stuff through. The editor has a responsibility to know who is a real expert and who is a 'recognised expert'. That last term says it all.
 
If they were interested in clarifying whether ME or any other condition is a disease or not, they would present the two different points of view.

My impression is that "high profile" journals have no interest in such scientific debate but side with the majority view of their subscribers. A large portion of doctors want it to be a non-disease because that means they don't have to care for patients. Whether there are any sensible arguments for it not being a real disease is not something that really interests them. Essentially the medical community has handled the problem of an untreatable disease by agreeing that it is not a disease and therefore not their responsibility. I'm generalizing here and there are exceptions.

That is presumably also the true purpose of the CBT/GET model. It's a justification for what the healthcare system wants to do with us patients, and that's why nobody has a problem with the model making no sense whatsoever on closer examination.
 
My emphasis :
In particular, they resent the contention of doctors that the problem has a psychological component and is not simply a physical condition (not that any condition, doctors argue, is ‘simply physical’)
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I wonder where the psychological aspect is in, for example, suffering from appendicitis? The only place I can imagine psychology getting involved is after surgery and discovering that the diagnosis was wrong, or being diagnosed so late that sepsis sets in. The psychological aspect in both those cases would be in being absolutely furious after the event.
 
Arnie Pye said:
My emphasis :


I wonder where the psychological aspect is in, for example, suffering from appendicitis? The only place I can imagine psychology getting involved is after surgery and discovering that the diagnosis was wrong, or being diagnosed so late that sepsis sets in. The psychological aspect in both those cases would be in being absolutely furious after the event.
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This is where it gets fuzzy. Because when the BPS people talk they use examples that are less acute than this. But if pressed I think the line would be about the psychology around healing from the broken leg or the appendix surgery.

Generally, when these health crises are addressed with medicine psychology doesn't need to be invoked as the moment of discovering the problem and fixing it is generally pretty immediate.

So how the patient got there is often not too relevant. And if healing isn't complicated then also no need for any intervention. But they can nevertheless invoke the general principle of body-mind (where the emphasis is on body) as important without explanation and nobody really challenges what this means to patient care because it's all good--medicine has done it's job. It's as if it's a revealed truth that doesn't need justifying.

But the only reason the BPS can have any legitimacy in the way it advertises it's importance is because of MUS. And here invoking mind-body changes to make mind the concept of primary importance in the illness. There are no quick fixes or answers there. So they swoop into that void. And then they invoke conditions like cancer which is in between the acute care of an appendix and the chronic care of MUS.
 
Jonathan Edwards said:
It seems that Dr Smith does not keep himself up to date.

We took the best research that we could get and asked people who were recognized experts to write and review for us.

There's never an excuse for an editor letting poor quality stuff through. The editor has a responsibility to know who is a real expert and who is a 'recognised expert'. That last term says it all.
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It was first published in 2000.

Still very annoying, but less so than if it had been written for 2020.
 
It's very long. This is the section about ME:

As I described in chapter 2, a similar complaint was made against me. A group of readers and authors complained that the BMJ presented a one-sided view of the condition known as chronic fatigue syndrome or myalgic encephalomyelitis. The BMJ, they alleged, published only material that supported the idea that the condition is psychological, used the same reviewers (most of whom are psychiatrists), and refused to publish studies that show that the condition is a physical condition. The complainants conducted an analysis of what the BMJ had published on the subject, and their anger was increased when we declined to publish the analysis. (One objection to the analysis was that it included information only on papers we published and not those submitted to us — so how could it show bias?)

My response was that the BMJ did not have a position on the nature of chronic fatigue syndrome or myalgic encephalomyelitis. We selected the best research studies submitted to the journal and published them. Often studies contradicted previous studies that we had published. Bias seemed to arise because we were more likely to accept randomized trials of treatments (including a psychological treatment called ‘cognitive behavioural therapy’) than we were studies reporting a small series of patients who had evidence of a previous infection. We thought of this as a bias towards rigorous science, a bias that it was right for us to have.

In addition, we would ask a variety of people to write commentaries for us, selecting those who know about the condition, argued well using evidence and wrote clearly. It did so happen that most of the experts thought that the condition does have a substantial psychological component and that it is highly unlikely to be entirely a physical condition. Indeed, most of them believe that most conditions have a physical and psychological component. They are also distressed by the implication of the complainants that a physical condition is somehow more ‘real’ than a psychological condition. This seems to perpetuate the stigma against those with mental health problems.

When it comes to letters anybody can comment, and the BMJ carries many letters from people who disagree with most of what the BMJ publishes. When I left the BMJ received well over one hundred rapid responses (electronic letters to the editor) each week and we were able to publish fewer than 10% in the paper journal. This arrangement provided a rich test bed for studying editorial bias: what were the characteristics of the fewer than 10% that we selected? We’d like to think that they were more interesting, sound and readable, but no doubt other forms of bias were at work.

This is a question of where editorial judgement ends and misconduct begins. Editors are expected to discriminate, but they should discriminate on grounds of evidence, importance, relevance, quality and clarity rather than on personal foibles. But it is also widely believed to be the job of the editor to give a publication a ‘personality’ — and that’s likely to be related to his or her personality. So some personal selection seems desirable.

The complaints against me alleging misconduct in relation to selecting material on chronic fatigue syndrome — to the British Medical Association (BMA), the owners of the BMJ, and the Press Complaints Commission — were dismissed, but the complainants saw this as an establishment cover up. Perhaps it was.
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The funny thing about bias is that people having it can be totally unaware of this fact. To them it can be the norm.

I don't doubt that the BMJ selected the best papers on CFS. I just think they were neck deep in their own biases when deciding what made these papers the best.

I doubt they would consider unblinded homeopathy clinical trials as "the best". When the treatment is psychotherapy and exercise for ME, then any papers on this are apparently suddenly amazing no matter how flawed.
 
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It's NOT an issue of people with ME devaluing any psychological contribution. This is a false argument.

The BPS cabal position is that after the initial infection any long term symptoms must be viewed as amenable to primarily (or even exclusively) treatable with psychological therapies.

These 'treatments' only work theoretically on paper. In reality people with ME or MUS continue to be either worse off or not recovered -- in it's most useful definition, as pre-illness functioning.

This is all further made fuzzy be the moving target of what they (the cabal) mean when they talk about 'psych contribution' and so many other vague terms that seem to morph into some other meaning as the previous meaning becomes insupportable.

An example would be that first it was just incorrect illness beliefs that needed CBT now it's that our HPA axis is dysfunctional and that too can be treated with CBT.

The one constant in all this is that THEIR therapy is ALWAYS the answer. Period. It will always be so whatever the findings. It will simple morph into a shiny new concept to account for CBT being the solution.
 
It's notable that in the exerpts, particularly the one that @Trish posted, Richard Smith seems to be arguing that medical journals are not purveyors of truth, but rather should simply reflect the standards of medical science orthodoxy at the time.

This perspective arises as one looks back at the prevailing views and scientific standards published in medical journals in the past. We can choose to look back in scorn, or simply accept that scientists and medical doctors had greater ignorance (and poorer funding) than they do now.

They are also distressed by the implication of the complainants that a physical condition is somehow more ‘real’ than a psychological condition. This seems to perpetuate the stigma against those with mental health problems.
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It's amazing how pervasive this myth is. We are not distressed by the implication that our illness may have a psychological component. We are frustrated that all we are offered are psychological therapies that offer little functional benefit.

The claim about perpetuating stigma is more baffling, as no one has that retort when someone states that MS or cancer is not a psychological condition.

As an aside, also note that Richard repeatedly refers to "randomised trials" not "randomised controlled trials", which is somewhat revealing about how he perceives quality and reveals the double standard he has between pharmacological trials and other therapeutic trials.
 
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