The Future of MJA

The MJA has served for 100 years as the major means of formal communication between the Australian Medical Association and its membership. It has done this by reporting research and providing guidance that is grounded in science for clinical practice and the formation of health policy. This was enunciated as its purpose and this is what it has done.

In line with its original purpose, the current editorial team, endorsed in this action by the AMPCo board, have begun to revise and reformat the MJA in the light of informed comment from its Editorial Advisory Committee and a formal inquiry into readers opinions and attitudes, likes and dislikes, conducted in 2014. A project planning process has been established and six teams have been formed to explore, discuss and decide on revised format, document processing, etc.

Because the MJA was fractured and traumatised by the events surrounding the dismissal of the previous editor in chief, I have invested energy in seeking to restore respect and good humour among the group. This has taken me 18 months. I have deliberated brought all members of the editorial team into the review project in part to use their considerable intelligence, qualification, dedication and experience, and in part as an expression of my desire to rebuild a team. There is no distinction made in this process among staff: ideas and critique is judged on its value, not who produced it. For example, many staff members contributed to the new cover design, the format of the revised table of contents and the decision and detail about moving research papers from print onto online save for a one-page summary for each paper. In other words, the production and editorial staff have worked in an interdependent mode in pursuit of optimal revision. 

This may seem odd, but there is nothing inconsistent here with the way that I have worked in previous settings as a cursory glance at my academic or business CVs would show. I favour using all talent available to me and I dislike distinctions and layering within the workplace, especially when working in relatively small teams - which the MJA team is.

If we are to preserve the MJA as a journal responsive both to the expectations of the AMA, to the Australian medical research community and health policy makers it will be important to maintain our capacity to change and to move relatively quickly. In the 18 months that I have worked with the MJA I have seen how much effort is required to maintain an active communication network with readers, authors, reviewers and policy makers. To produce a journal that responds in a timely and reflective approach - to the G20 and climate change and the Martin Place siege to name two - to current events requires coordination and integration of editorial and production actions at a high level.

I do not believe that it is easy to separate the medical judgement, editorial processes and production of an association-based journal for the reasons just given. The Canadian, American and British Medical Associations believe similarly and have retained integrated in-house editorial and production functions. So has the Massachusetts Medical Society that produces the New England Journal of Medicine.

Journals that have outsourced their production are very different in style to Association- Based journals. Specialty journals tend to have small voluntary editorial teams. They manage largely research-related content that is easily reviewed and then sent for publication. Many are now wholly on line and meet the comparatively narrow needs of specialties, not general medical audiences. It is easy to see how common templates can be constructed to serve the needs of many of these journals because they are variations on a theme. Those served in this way by Elsevier report high levels of satisfaction, as does the editorial staff at the Lancet, a prestigious journal by any reckoning essentially owned by Elsevier.

The Lancet, unlike the MJA, is a premier research journal but with excellent entrepreneurial flare and public profile as well. It is unique. The resources it commands, both financial and intellectual, enable it to achieve excellence. I gather that Elsevier, as one might expect, participate in the selection of the editor-in-chief, and the symbiosis between Elsevier and the Lancet is generally strong and mutually beneficial. It is possible that if the production of the MJA were outsourced to Elsevier a similar relationship could develop with time.

In brief, prominent international medical association journals that serve the needs of the entire medical profession and not specialties, that provide informed commentary and critique as well as research, are produced in an integrated way in-house. The advantages of interaction of the production team with the editorial side of the team, as we have seen in our redesign process, are substantial.

Now, my comments about the cost of outsourcing the MJA. The dismissal of the production team, most of whom hold university degrees and many of whom have years of experience (a few have been with the MJA for 20 years), would be a big wrench. The transaction costs of moving to a new and unfamiliar production team, located off site and often overseas, would be substantial. It is good to hears said that Scholar 1, our document management system would be able to 'shake hands' with the Elsevier system - an image of US and Russian Soyuz spacecraft docking in orbit comes to mind) but my belief is that it would be a managerial nightmare. Maybe I'm wrong.

As part of the economy of scale that underpins the Elsevier bid, it is likely that the format of the MJA would change to fit the templates that Elsevier applies to its other journals. Whether readers would appreciate a move toward such uniformity I do not know. Many may not care or notice, but some might and wonder whether 'their' journal had been sold off to an international agency as yet another manifestation of economic fundamentalism. These are not idle thoughts: professional associations such as the AMA (and to my certain knowledge the RACP) face major challenges in retaining the loyalty and interest of the foot-soldiers at the same time as moving more in the direction of corporatisation. What do AMA members think about outsourcing? It would be wise (for the sake of the AMA as well as the MJA) to find out.

If the production of the MJA were outsourced, then there would be no point, and no capacity, in pursuing the program of reform that we are half way through. The distraction of negotiating redundancies and the massive amount of transactional activity required to switch systems would soak up everyone's time and energy. I don't want anyone telling me that I don't know this: having overseen the transition from one medical curriculum to another when dean at the University of Sydney I have serious relevant experience.

I fully understand the desire of the AMPCo board to save money, especially with declining revenue from advertising and data bases that have degraded and need urgent repair. The enthusiasm for DoctorPortal will require resources. I am aware that the operation of the MJA is not optimally efficient. I can see ways in which we can effect savings. Once the review process is complete I have in mind to work with the whole team to determine where we can make savings and then, over the next two years, make them. This will be done firmly, humanely and visibly.

The responsiveness of the MJA to member needs could be improved by better communication with the AMA. This needs rehabilitation: we need to get into discussion with the AMA State Branches as well as Federal AMA.

In summary, I freely accept that the board has a choice to make. If the journal production is outsourced then much of its distinctive flavour may suffer and there will be a complex and expensive period of transition. Savings may accrue in two or three years. If the decision is taken to retain production in-house then we will pursue our program of reform and then go in search of efficiency savings. This is NOT unfamiliar territory to me - I have managed effective budgetary savings in several other organisations in which I have worked while being true to humane values and honouring the purpose of the entity.

 

A nail in the heart of the MJA

Efforts to cut the cost of producing the Medical Journal of Australia have driven a nail into its heart.  

An obsession with the bottom line, a failure to understand how the journal is produced, a failure to comprehend its content, nature and purpose, an ignorance of the immense social network of people of goodwill who have supported the Journal by providing articles and reviews over its 101 years, a predominant financially-dominated management approach, an absence of clarity regarding future managerial (as opposed to editorial) direction, have caused this calamity.  

I have received hundreds of emails, text messages and phone calls from doctors, research workers, managers and readers of every stripe, aghast at what is happening with the Journal. 

As the old adage goes, if all you have is a hammer, everything looks like a nail.  Financial challenge for every newspaper, magazine and journal is not in dispute.  Economies are needed.  But these must be carefully tailored to publication in question, not bought off the shelf.

Here is an analogy for what has happened at the MJA. 
Suppose a health service board took the view that the cardiac surgery unit was costing too much and, without telling the surgeon, asked for bids from cheaper, external providers of dubious repute and questionable practices to provide the by-pass pump service.  This false economy would catastrophically mistake the nature of the integrated surgical team.  Quality would be threatened. A Mid Staffordshire Hospital-style catastrophe, http://qualitysafety.bmj.com/content/23/9/706.extract. where the board did not regard clinicians as colleagues, never ventured into the wards and had no idea of what was going on, would be in the making.

Take an economic fundamentalist approach if you wish, and say that voluntarism is out of date, but the MJA has always run and depended on a community – yes, a community – of scholars.  

More than 900 research workers, scientists, clinicians and other scholars provide peer assessment of research papers,  write critical reviews, editorials, perspectives, eulogies, letters (and even the occasional poem) at no charge.  

The unpaid Editorial Advisory Committee helps guide decisions about the form, content and style of the Journal. They do so because of their love of Medicine, the value they attach to collegiality, the value they attach to science, to evidence, to education and to understanding in research, clinical practice, public health and health policy, the pleasure they get from communication, the rewards that come from seeing their ideas, critically refined by review, appear in print.  

You will never understand how the MJA or any other respected scientific journal works by staring at its bottom line, however long you look.

Now acknowledging the true nature of the MJA community affects how you view its economy.  The view that I have provided does not prevent careful quest for efficiency and indeed encourages the search for new outlets and revenue lines.

It encourages the exploration of new media and new communication platforms, and it does not entrench antiquated, paper-based production.  

It takes account of the editorial team in its entirety – the medical editors, the associate editors, the members of the production team – and does not categorise them as those who do the thinking and the others who just ‘move words around on the page’ as the AMA president put it recently, ‘and make the Journal look pretty’. 

What I call the MJA community can be the dynamo for genuine innovation and reform that has a better chance of sustainability than simply outsourcing part of the operation – the equivalent to the pump team – to an outside agency, especially one that causes academics, librarians, students and research managers to express horror at the prospect, based on their experience.

Professor Leeder is former editor of the MJA and emeritus professor at the Menzies Centre for Health Policy at the University of Sydney.

Published in Australian Doctor 8 May 2015.  http://bit.ly/1L5wCPb