As I see it

Abstract

This is the last editorial I shall write as Editor-in-Chief of the BJOG, for I am leaving the Journal at the end of this month. I became Editor-in-Chief of the Journal seven years ago when its fortunes were at a low ebb following our publication of two papers which turned out to be fraudulent. After my appointment I spent a sleepless night, realising that I knew very little about editing a medical journal. At that time there were few, if any, courses in medical editing, and so I learned editorship in the traditional fashion, by making mistakes. Thus was I thrust into this position stammeringly, a poor Uncle Claudius, a consultant obstetrician working in an obscure district hospital, with a modest record of clinical research and an amateur's enthusiasm for mathematics and statistics. But I need not have worried. Many people have kindly said to me how much they enjoy reading the Journal and how it is improving all the time. In fact it was not difficult for the Journal to improve, for seven years ago it was held in such opprobrium that it could only become better. After my appointment I learned that the editorial content and management functions of the Journal are quite distinct, and that I was responsible only for its editorial content. I was not interested in negotiations with the publisher, printer or typesetter, and had nothing to do with subscriptions or the finances of the Journal, except when these might interfere with the editorial content of the Journal. It is a foolish Editor-in-Chief who thinks he can influence the decisions of the College in these matters. After my appointment I realised that the success of a medical journal depends not on its Editor-in-Chief, but on his ability to choose his assistant Editors, the members of his Editorial Board, and the persons to review the papers we are sent. I have been fortunate in having a team of assistant Editors who are clinical scientists, who are experts in their field and who are unswervingly loyal to the Journal. Their tasks are huge. They analyse the papers which we could possibly publish, with the reports of referees and statisticians; present these papers at the monthly meetings of the Editors; and if the papers are accepted they edit them before publication. The assistant Editors are well known to you; their names are at the front of each issue of the Journal. I have valued the Editorial Board, not only as a source of reliable referees, but for its advice concerning editorial policy. The Editorial Board has steadfastly supported the philosophy of the Journal, the publication of the highest quality original scientific research in obstetrics, gynaecology and women's health. All the adjectives and nouns in that phrase are important. We publish scientific research, and so we do not publish audit, medical education, College policy documents, guidelines, book reviews, reports of meetings or political tracts. The scientific research we publish has undergone rigorous peer review, and so we hope it is of the highest scientific quality. We tend to reject studies which are not original. And we have expanded the scope of the Journal to include wider issues of women's health, such as violence against women, qualitative research and quantitative studies of women's perceptions of their illness and its treatment. We have expanded the scope of the Journal geographically. Some years ago we changed its name from the British Journal of Obstetrics and Gynaecology to the BJOG: an International Journal of Obstetrics and Gynaecology, a move which was not universally approved. But we were merely carrying on the traditional international perspective of the Journal. The Journal was founded as the Journal of Obstetrics and Gynaecology of the British Empire, changed its name to the Journal of Obstetrics and Gynaecology of the British Commonwealth, then to the British Journal of Obstetrics and Gynaecology, and finally the BJOG: an International Journal of Obstetrics and Gynaecology. The present title states the international nature of the Journal, while acknowledging its British roots. We have therefore always had an international perspective, which now extends far beyond the shores of the former British Empire. More recently we have appointed an International Editorial Advisory Board, the function of which is to give the Journal advice on women's health in the regions of the world. All these editorial practices were discussed and approved by the Editorial Board and the Assistant Editors. If the consensus view of the Editorial Board were otherwise, our editorial practices would be different. It is a foolish Editor-in-Chief who attempts to impose his own views on a journal without seeking the endorsement of the Assistant Editors and the Editorial Board. It is the Assistant Editors, members of the Editorial Board and hard-working referees who guarantee the quality of a scientific journal. I have recruited loyal referees to be members of the Editorial Board, and conscientious members of the Editorial Board to be Assistant Editors. I have tried to achieve a balance on the Editorial Board, of younger researchers who may not yet be consultants, and experienced campaigners who will punch their weight in any argument; of the various subspecialties; of teaching hospitals and district hospitals; and of London and the regions. And so the Journal maintains an organic unity, with an orderly succession, which will maintain the philosophy and scientific integrity of the Journal. The work is arduous, but everyone gives his services willingly, with little or no remuneration, for the sake of the Journal. After my appointment I was amazed to find that the truth was often the opposite of what it seemed. Famous researchers whose work I admired and whose integrity I thought unimpeachable sometimes turned out to be self-seeking and disingenuous. One famous investigator suggested that a Commentary be published in the Journal at the same time as an important study in another Journal. We did publish a Commentary, but by an author of my own choosing. This was followed by such an outpouring of vitriol from the famous investigator, as to leave me staggered. Even the papers that we have published which are beyond scientific reproach have had an influence on clinical practice which is the opposite to what you would expect. We are often told that in terms of the strength of evidence it is the randomised trial which holds sway, and that case series and case reports are so unsound, being full of biases, that they should not even be published. Yet in obstetrics and gynaecology the opposite may be true. About 15% of the papers we publish are reports of randomised trials, but in the past seven years it is difficult to ascertain the influence of these randomised trials on the practice of obstetrics and gynaecology. The trials we have published asked more questions that they answered, and usually ended with the statement that we need more randomised trials. We publish many case reports and uncontrolled case series, which almost certainly have had a major effect on clinical practice. The B-Lynch brace1 and the Rusch balloon2 were described in small uncontrolled case series, and undoubtedly have saved many women from hysterectomy to treat severe post-partum haemorrhage. Probably the most important paper the Journal has ever published was a systematic review, not of randomised trials, but of uncontrolled case series of symphysiotomy in the treatment of obstructed labour3. In this systematic review Kenneth Bjorklund showed that symphysiotomy is a simple operation which is easy to teach and which requires the minimum of equipment, and which can save thousands of women's lives each year from obstructed labour. We are often thought to be a “slow journal”, but if that is the case, I make no apology for it. The fraudulent case report eight years ago was published in undue haste. The Independent Enquiry into this episode made exact recommendations concerning peer review, which we have followed rigorously. If our editorial processes are slow it is because no scientific study is published without this strict peer review. If the scientific content of the journal is good, it is because of this strict peer review. More than once we have been grateful to our referees, not only for the insight they give to a paper from their specialist knowledge, but also for alerting us to papers which they know are fraudulent. If we are a slow journal it is because of the poor English in which they are often written, for we take great pains to render these papers into simple English. Paradoxically, the worst writers of English are obstetric registrars from the United Kingdom, the home of the language; the best writers of English are from Scandinavia. I blame the poor teaching of English in British schools for this. This is why case reports written by obstetric registrars take the longest time to be published, for they are so choked in a Sargasso sea of jargon and abbreviations that it takes great effort to cut through the vegetation to the meaning of the sentences. Often we are criticised for not “fast-tracking” papers, but the concept of fast tracking in a monthly journal is a joke, when one considers the time from submission to acceptance of the paper, which includes peer review and discussion at a meeting of the Editors, and the time from acceptance to publication. If an author considers a paper to be so important that it should be fast tracked, then it is important enough to be submitted to a weekly journal with a large circulation. Fast-tracking will come about, not from any change in our editorial processes, but because of our introduction in the near future of electronic submission and peer review of manuscripts, together with publication of articles in press on the internet before they appear in the paper version of the Journal. Publication of a medical journal is a complicated process involving the Editor-in-Chief, publishers, printers and typesetters, and tensions are bound to arise at several of these points. The journal is going through a difficult time just now, for there is a change of Editor-in-Chief, a change in the editorial processes of the Journal with the introduction of the electronic system, and there are constant negotiations with the publisher. This is such a difficult time for the Journal that some have doubted its survival. But the Journal will survive, and flourish; for where there is the goodwill I have encountered among authors and readers, it will survive, no matter the arrangements made for its publication; where investigators wish to find a home for the paper describing their scientific research, it will flourish; and where women wish to read about their experiences of illness and its treatment, it will thrive. Vivat BJOG!