New JAMA editor embraces the give-and-take of debate

Taking the helm as 15th editor of JAMA, Catherine D. DeAngelis, MD, says she's confident that mechanisms are in place to ensure the journal's editorial independence.

By Bonnie Booth, amednews staff. Jan. 31, 2000. -

The Journal of the American Medical Association's new editor, Catherine D. DeAngelis, MD, doesn't shy away from controversy -- a character trait that came in handy her first week on the job, when she picked up her phone and found an angry family physician on the other end.

The physician was calling to complain about a study published in the Jan. 5 JAMA that found patients treated by nurse practitioners for some conditions fared just as well as those treated by physicians. The two discussed the study and, in the end, agreed to disagree. She also received one e-mail about the article. But even if she had received hundreds of phone calls on the subject, it is likely she would have taken every one and been unruffled by the uproar.

"I think it was a good study; it was limited, but it was a substantial contribution to research," said Dr. DeAngelis, a former nurse who, while serving as a professor at Columbia University's College of Physicians and Surgeons and School of Public Health, started its first nurse practitioner program in 1973. "How do you deliver the most cost-effective care to patients? You don't get all hot and bothered because a study says one of your colleagues can do certain things. That article didn't say that nurse practitioners are as good as doctors. But for certain areas they do a very nice job."

Dr. DeAngelis said she hoped that study would encourage others to do more extensive research with a wider geographic range, over a larger period of time and with a more diverse population.

Engendering debate is, after all, the purpose of editing a journal.

"Agreeing to disagree is what the whole process of research and editorial and academic freedom is all about," Dr. DeAngelis said. "Good articles will stimulate debate. Especially articles that might alter a current trend or a current practice. Medicine is unfortunately an imprecise science for the most part. Therefore, the art has a lot to do with it, and people see art different ways. My job is to present as clear and accurate a picture as I can."

Dr. DeAngelis is the 15th editor in the journal's 116-year-old history and its first female editor. She takes the helm at a time when the AMA faces continued financial difficulties and when academics and other defenders of editorial freedom are likely to be watching closely for any evidence that the Association is trying to control the content of the publication.

But she doesn't shy away from those challenges, either.

When the January 1999 firing of former Editor George D. Lundberg, MD, called the journal's editorial independence into question, Dr. DeAngelis acknowledged she was one of the "most adamantly vociferous individuals" questioning the AMA's stewardship of the publication. But she feels comfortable with the governance agreement that created a Journal Oversight Committee to serve as a buffer between the editor and the AMA's executive vice president on editorial matters.

"These are stellar individuals who have reputations for integrity and excellence and certainly have experience with academic and editorial freedom," she said.

She added that so far she's received nothing but full cooperation from various delegates, trustees and AMA Executive Vice President E. Ratcliffe Anderson Jr., MD.

For his part, Dr. Anderson said that he is "ecstatic" about Dr. DeAngelis.

"She brings an air of freshness and a new look," he said. "She is very quickly assimilating into the fabric of AMA operations. She told me she's having a great time. That's music to my ears."

Dr. DeAngelis said that worries that the quality and quantity of research submitted to JAMA would decrease in the wake of Dr. Lundberg's firing were unfounded. She said the journal continued to receive about 4,000 submissions last year, a number on par with previous years. "The articles I've seen in the last year and the ones I am involved in now are spectacular," she said.

Dr. DeAngelis also said she thought the AMA's recent belt-tightening was healthy.

"I think they are looking to do what I'm accustomed to doing from academic medical centers and what any good business does," she said. "The first thing you do is cut expenses. You've got to be careful that what you cut is not anything that is part of your core mission, which means you have to have a core mission and a strategic plan of how to accomplish it.

"I think that's what Dr. Anderson is trying to do right now -- get everybody on board to plan that sort of thing," she said.

The AMA's scientific publications continue to operate in the black; and, while that doesn't necessarily make them untouchable during budget cutting, it does give them some cushion.

"I don't think it would be very smart planning to start cutting revenue-generating components," Dr. DeAngelis said.

"On the other hand, I don't think it would be fair to just say spend whatever you want just because you happen to come out in the black every year, either. I'm going to plan a budget that is reasonable so that we can continue to advance the quality of the scientific publications and do it in a cost-effective way. And as long as I don't have to cut things that will hinder my ability to have outstanding publications, I don't have a problem."

Bridging the cultural divide

Dr. DeAngelis said the opportunity to edit JAMA was too good to pass up for two reasons: the publication and its editor serve as a bridge between academic physicians and clinical practitioners; and she gets to sit "in the best bully pulpit in America."

The rift between physicians in clinical practice and academics is long-standing, but if anybody can bridge the gap, it just may be Dr. DeAngelis. As former vice dean of academic affairs and faculty at Johns Hopkins University School of Medicine in Baltimore, she is an accomplished academic. Yet as she sits in an office intentionally void of her myriad diplomas and certificates, she seems infinitely approachable. Plants and fresh flowers are scattered about an office decorated with posters and pictures of children. It could as easily be the office of a practicing pediatrician.

"I don't think the current dichotomy that exists between the AMA and the academics can continue if we are really going to do what has to be done to bring medicine back to the people," she said. "The enemy is not each other. We've got a problem with business people having too much say over what happens to our patients. The only way we are going to recapture our ability to say that we determine what's right for patients is for all physicians to join together.

"JAMA publishes articles that will ultimately result in better patient care," she said. "The research is done primarily by academicians -- not totally, but primarily: That's what they do. The education of physicians is also part of what is addressed by and in JAMA. And while academicians may not belong to the AMA as part of the membership, they do read and contribute to JAMA."

The state of health care is one of the topics Dr. DeAngelis will likely address from her bully pulpit. Her next editorial will be about the plight of academic health centers as a prototype for the plight of medicine in America.

"If we are not careful we are going to destroy academic medicine," she said. "Health centers will be trade schools. You'll go to trade school and learn how to crank out patients at a rate of nine minutes per patient.

"The role of JAMA is to use data-based information to show people what we have done, where we are and where we need to go."

ADDITIONAL INFORMATION:

JAMA review group named

A newly appointed Journal Oversight Committee will determine the criteria that should be used to evaluate the performance of the JAMA editor and then review the editor annually.

The first group of committee members was chosen by AMA leaders from a list submitted by the JAMA editor search committee. New JAMA Editor Catherine D. DeAngelis, MD, also reviewed the list. The members are:

Christine K. Cassel, MD, Mount Sinai School of Medicine, New York.
David A. Kessler, MD, Yale University School of Medicine, New Haven, Conn.
Joshua Lederberg, PhD, Rockefeller University, New York.
William M. Passano Jr., a former publisher of medical textbooks, Baltimore.
Roy M. Pitkin, MD, Obstetrics & Gynecology, Los Angeles.
Kenneth I. Shine, MD, Institute of Medicine, Washington, D.C.
Robert A. Musacchio, PhD, AMA senior vice president, publishing and business services, Chicago.