Editorials in this study are not difficult to spot. The highly selected participants may well have encountered the intervention (and the popular expectations associated with it) in the media previously. Those given the neutral writing exercise probably guessed they were controls. The “objective” measures of disease severity are open to assessment bias, which may have had an influence if the subjects told the assessor what they had done in the writing task. Finally, the outcomes in the two different diseases should probably have been analysed separately rather than summed. But perhaps my interpretation is biased by my own cultural prejudices. I have an instinctive empathy with Bolton’s approach to writing therapy as an art rather than a science3 and a personal distaste for quick fix interventions that smack of pop psychology and have been marketed to the public through the same channels as Billy Graham and the F Plan diet. If others in the UK share this cynicism our scientific community
is probably the ideal ground to attempt to replicate Smyth et al’s study in an uncontaminated population that has no prior expectations of the intervention. Trisha Greenhalgh Senior lecturer Department of Primary Care and Population Science, Royal Free and University College Medical School, London N19 5NF (
[email protected])
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Smyth JM, Stone AA, Hurewitz A, Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial. JAMA 1999;281:1304-9. Spiegel D. Healing words: emotional expression and disease outcome. JAMA 1999;281:1328-9. Bolton G. The therapeutic potential of creative writing. London: Jessica Kingsley, 1999. Pennebaker JW, Colder M, Sharp LK. Accelerating the coping process. J Pers Soc Psychol 1990;58:528-37. Pennebaker, J. W. “Writing your wrongs.” American Health 1991;10:64-7. Smyth JM. Written emotional expression: effect sizes, outcome types, and moderating variables. J Consult Clin Psychol 1998;66:174-84.
Intensive care medicine comes of age And offers a multidisciplinary model for future emerging specialties
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ord Nuffield is reputed to have said, “Anyone can give an anaesthetic and that is the problem.” This could equally well have been said of intensive care medicine over the past 30 years—a specialty without a home and until recently without a recognised training in the United Kingdom. This summer, however, intensive care medicine was recognised in both the UK and Europe under the European specialist medical qualification regulations. Other countries have established training programmes in intensive care medicine, but the UK’s is unique in that a multidisciplinary group planned the training for a multidisciplinary specialty. The establishment of the specialty thus holds lessons for other emerging multidisciplinary specialties—and it may have wider benefits for the parent specialties. The basis of intensive care medicine is wide, incorporating skills from many disciplines, and several specialties have always had an interest in it. More than 18 countries have established training programmes in intensive care medicine, and this diversity of background has led to there being almost as many different approaches to training as there are programmes. In Spain intensive care medicine is based largely on acute medicine; in the United States at least four specialties have individual training programmes with no single core curriculum; and in six countries the training is only available through the specialty of anaesthesia.1 Even in Australia, which has had a clearly defined programme since 1976, there are still two main pathways for training, through either medicine or anaesthesia. These are significantly different in content, although there are major efforts to unify the approach. In the UK the specialty has been a long time coming, but it has been developed by multidisciplinary collaboration, and the result is that it provides from the outset a final common pathway. This is no mean feat since it has evolved through the endeavours of an intercollegiate board representing no fewer than six royal 31 JULY 1999
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colleges as well as other interested groups such as the Intensive Care Society. The certificate of completion of specialist training is achieved through dual accreditation. It requires a certificate of completion in a base specialty as well as completion of advanced training and another certificate of completion in intensive care medicine. The base specialties include anaesthesia, medicine, and surgery. At present there is an examination open to all intensive care medicine trainees, which is voluntary. This in itself is an interesting initiative for a new specialty. The diploma provides substantive evidence of having undertaken a training programme, and, as with other qualifications, it will probably in time achieve currency in the job market both in the UK and overseas. The examination is also unusual in that it tests breadth and depth of experience and the ability to critically appraise current trends rather than the ability to remember large bodies of knowledge. Recognition for intensive care medicine not only confirms its transition from amateur to professional status but also lays the foundations for proper development of the specialty. But the benefits are even more far reaching. Training in intensive care medicine should influence all its base specialties. The plaintive cries from some specialties that “our trainees don’t look after the sick patients anymore” are now potentially answerable since one role of the new specialty will be to facilitate training in the management of the critically ill. The long term effect may therefore be improved patient care in ordinary wards, a problem highlighted recently.2 Not surprisingly, countries where intensive care medicine has grown from a single specialty are now making serious efforts to produce a final common pathway. The UK example shows that it is possible to plan that pathway as multidisciplinary from the outset and that intercollegiate cooperation is essential in designing and delivering a quality training structure. There are other areas of medicine where new specialties are emerging from several different disciplines, and the 271
Editorials approach developed in intensive care medicine offers a model for realising a similar outcome. Neil Soni consultant anaesthetist Chelsea and Westminster Hospital, London SW10 9NH
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Duncan Wyncoll consultant in intensive care medicine Guy’s and St Thomas’s Hospital Trust, London SE1 9RT
Bion JF, Ramsay G, Roussos C, Burchardi H. Intensive care training and specialty status in Europe: international comparisons. Task Force on Educational issues of the European Society of Intensive Care Medicine. Intensive Care-Med 1998;24:372-7. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316:1853-8.
Another editor bites the dust Trust is needed to balance editorial independence and accountability
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arlier this week the Massachusetts Medical Society, owner of the New England Journal of Medicine, announced that Jerome P Kassirer, the editor, would be leaving. His tenure will end in eight months, but he will start a seven month sabbatical at the beginning of September. The Boston Globe, which broke the story, reported that Kassirer had been fired.1 The society denied this and said his contract was simply not being renewed. His precipitous departure, seven months after the firing of George Lundberg, editor of JAMA,2 is likely to cause another round of soul searching over balancing editorial independence and accountability. Kassirer has fallen out with the Massachusetts Medical Society over the use of the powerful brand name of the journal, a battle also fought by his predecessor. The society wants to expand its publishing, using the brand name of the flagship journal (in the way that we have the BMJ Publishing Group). The editor of the New England Journal of Medicine is not responsible for the other publications spawned by the society and frets that the good name of the journal, built up over generations, will be debased. This central struggle undermines the relationship between the editor and the publisher, with the stereotype being a pure editor concerned with science and quality and a grasping publisher bothered purely with revenue and profit. Doctors will recognise this stereotype. It’s similar to that of the doctor ethically committed to doing the best by an individual patient and the money driven manager trying to keep the hospital in budget (or in the United States increase profits). In a much appreciated editorial Kassirer argued passionately against doctors abandoning their commitment to individual patients.3 Sabin, another Boston based doctor, responded, however, that doctors had to think about both the individual and the population, particularly in relation to healthcare rationing: “Patients and society need clinicians to love both the individual and the collective and need to join them in deliberating about solutions to this painful but ultimately unavoidable conflict of the heart.”4 The reality is that any system—be it a hospital or a publishing group—that makes one set of players think about quality and another about cost will experience unresolvable conflict. A better system is to oblige all players to think about quality and cost, and that is the system in the BMJ Publishing Group, where the editor of the BMJ is also the chief executive of the publishing group. 272
Such an arrangement is not, of course, a panacea, and when the editors of the two leading American general medical journals have left rapidly in one year it’s time to think harder about balancing editorial independence and accountability. Kassirer has written two editorials in the past six months on this subject (itself probably a sign of unrest),5 6 and a new arrangement has been proposed to protect the editor of JAMA7—and criticised by the fired one.8 Some of the deepest thinking has come from Huw Davies, a management academic from Scotland, and Drummond Rennie, the deputy editor of JAMA.9 The key to resolving the inevitable conflicts that will arise between owners, editors, and other stakeholders in a journal (or a publishing group) is, they write, trust. “Trust exists when each party holds certain expectations of the other: expectations of competence, predictablity, and fairness.” But, they continue, a trusting relationship is slow to develop and easily damaged. Davies and Drummond identify nine features that can lead to “robust governance . . . founded on trust.” They include mutual accountability among owners and editors, a shared vision, explicit strategic objectives, a free flow of information for communication rather than judgment, and informal mechanisms for resolving distes. These are wise thoughts. Anything that builds trust is good. Anything that erodes it is bad—in all systems, including journals and hospitals. Both the Massachusetts Medical Society and the American Medical Association are looking for new editors for their prestigious journals, and both need to build systems of governance that encourage trust. If they don’t, they’ll never find good editors—and their journals will fade.
News p 273
Richard Smith editor, BMJ 1 2 3 4 5 6 7 8 9
Tye L. Medical journal’s top editor is fired. Boston Globe 1999;26 Jul. Smith R. The firing of Brother George. BMJ 1999;318:210. Kassirer JP. Managing care: should we adopt a new ethic? N Engl J Med 1998;339:397-8. Sabin JE. Fairness as a problem of love and the heart: a clinician’s perspective on priority setting. BMJ 1998;317:1002-4. Kassirer JP. Editorial independence. N Engl J Med 1999;340:1671-2. Kassirer JP. Should medical journals try to influence political debates? N Engl J Med 1999;340:36-7. Rosenberg RN, Anderson ER, Jr. Editorial governance of the Journal of the American Medical Association: a report. JAMA 1999;281:2239-40. Ferriman A. AMA’s scheme to protect JAMA’s independence has drawbacks. BMJ 1999;318:1645. Davies HTO, Rennie D. Independence, governance, and trust. JAMA 1999;281:2344-6.
We ask all editorial writers to sign a declaration of competing interests (www.bmj.com/guides/confli.shtml#aut). We print the interests only when there are some. When none are shown, the authors have ticked the ‘‘None declared’’ box. BMJ VOLUME 319
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