Harvard Public Health Review
Summer Fall 2006

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Declaration of Independence

Championing editorial freedom at JAMA, medicine's most widely circulated journal

In early 1999, the trustees of the American Medical Association (AMA) faced a messy situation. They had abruptly fired George Lundberg, the longtime editor of the prestigious Journal of the American Medical Association (JAMA), over a survey of U.S. students that posed a provocative question: "Is oral sex really sex?" Because Lundberg published their responses--60 percent said "no"--at the same time President Bill Clinton was arguing likewise during his impeachment trial, the trustees accused Lundberg of improperly using JAMA to influence a political debate.

Lundberg's sacking not only left JAMA leaderless, but also sparked criticism of the AMA for obstructing editorial freedom. Who would step into the hot seat as his successor now?

A search committee, meeting with the editors of 10 AMA-published Archives journals, raised doubts that the trustees would agree to a hands-off policy. At that point, Catherine DeAngelis, editor of the Archives of Pediatrics and Adolescent Medicine, raised her hand. "I moved that if the trustees wouldn't agree, we'd resign--all 10 editors!" she recalls. "Within 24 hours, they did sign off--and a day or two later, they offered me the editor's position."

It was yet another unexpected career twist for DeAngelis, a pediatrician, editor, author, and 1973 masters of public health graduate of the Harvard School of Public Health (HSPH). From her childhood in a Pennsylvania coal-mining town to her position as JAMA's editor-in-chief, she has followed a winding path through academic medicine marked by unconventional moves and an independent streak. Her selection as JAMA's first woman editor surprised her as much as anyone, given her uncompromising stance.

"Editorial freedom is essential," DeAngelis declared at the press conference announcing her appointment in 2000. "It is the absolute byword by which I will operate. If I had any doubts, I wouldn't be standing here."

CONFLICTS OF INTEREST
Since then, she has flourished in what she calls "the best job in the world." DeAngelis has turned down deanships and medical school presidencies, she says, preferring the reach and influence of JAMA, the world's most widely circulated medical journal (360,000 copies in print). Responsibility and constant pressure are just part of the deal.

Take, for example, the challenge of holding the line against advertisers' influence while allowing appropriate associations between contributors and drug companies. When one company insisted on placing an ad in an upcoming issue scheduled to print a favorable study of its drug, DeAngelis agreed--then delayed the study's publication so that it and the ad would not coincide.

DeAngelis has come under fire--most recently, in July--when authors have failed to disclose financial ties to a drug company prior to a study's publication, violating JAMA's policies. "We take this very, very seriously," she told the Wall Street Journal, adding that "There has to be a certain level of trust" between a journal and its contributors. The day that trust disappears, she said, "I will hang it up."

In the last year, the journal's "impact factor"--that is, the number of times a journal has been cited in the past two years divided by the number of original research articles it has published in that time--has doubled, to 24.8. Her team has aggressively courted authors who might have published elsewhere.

Jeffrey Drazen, editor of the rival New England Journal of Medicine, which has an impact factor of 44, calls DeAngelis "a good, solid, fair competitor." A professor of environmental health at HSPH and, like DeAngelis, an MPH graduate, he adds that "We both go after papers, and sometimes she gets them and sometimes we do. We have a very healthy respect for each other; she's done a good job there."

Delivering on a promise she made when she became JAMA's editor, the journal has highlighted issues of women's and children's health and medical education, in addition to conflicts of interest in medicine. Publishing the results of the controversial Women's Health Initiative trial of hormone replacement therapy in 2002 was "a real coup," she says, and the journal devoted an entire issue to women's health issues last spring.

DOCTOR OR NUN?
Service to others has always figured into DeAngelis's life plan. Initially unable to afford medical school, she trained as a nurse and, in the early 1960s, seriously considered becoming a Maryknoll nun and devoting her life to work overseas. Instead, she acted on her dream of being a doctor. Working her way through college and medical school, she received her MD from the University of Pittsburgh in 1969.

An interest in children's health steered her into working at a free clinic four hours a week. After completing a pediatric residency at Johns Hopkins Hospital, in Baltimore, Maryland, DeAngelis scrapped her plan to return to Pittsburgh as a pediatric transplant surgeon: "I thought, I love kids, and for every child I can help as a transplant surgeon, there are many more I can help as a pediatrician." She decided to focus on strengthening the links between general outpatient pediatrics and teaching and research.

To be able to run an ambulatory clinic, DeAngelis realized she needed to know something about health economics, insurance, and law. Though Hopkins and nearby Washington, D.C., had plenty to offer, she was drawn to Boston and HSPH by the chance to see patients in a Harvard-affiliated Roxbury community free clinic and by a pair of faculty mentors. One was Rashi Fein, an eminent health economist at Harvard Medical School. The other, at HSPH, was the late William Curran, widely regarded as "the father of legal medicine."

Curran, the School's expert on the overlapping spheres of law and public health, wrote a health law column for the New England Journal of Medicine and was a busy man. But DeAngelis prevailed on him to tutor her for a half-hour at lunchtimes on health law as it pertained to outpatient pediatrics, including the then-new field of patients' rights.

"Bill loved Italian food, and I made him good Italian meals--sausage and peppers, and meatball sandwiches," she recounts. "After awhile, he was giving me an hour and we'd eat lunch together. It was a wonderful mentorship."

Meanwhile, DeAngelis saw pediatric outpatients at the free clinic in Roxbury one day a week. It struck her that these kids were underserved and "that there's a lot of this stuff that nurses could do--well-child care, for example." With her MPH in hand, DeAngelis wrote a book and launched a model master's program at Columbia Presbyterian Medical Center in New York City that brought doctors and nurses together, producing certified pediatric nurse-practitioners. That model has since been replicated elsewhere, she says.

After a brief stint at the University of Wisconsin, DeAngelis returned to Johns Hopkins, becoming a full professor, founding director of the Division of General Pediatrics and Adolescent Medicine, and, from 1990 to 1993, vice dean for academic affairs and faculty. A year later, she accepted a position as editor of the AMA's pediatric Archives journal, unwittingly landing on a path to her current post.

"It was the last thing on my mind," says DeAngelis of her move from academe to the helm of a world-class medical journal. On leave as a professor of pediatrics at Hopkins, she plans to return--but not anytime soon. She has just signed another five-year contract at JAMA, she says, adding: "It's been phenomenal."

Richard Saltus has been a reporter for the Associated Press, the San Francisco Examiner, and the Boston Globe. He writes frequently about science, medicine, and public health

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