“Get something out on social?” urged a colleague in response to UK Chancellor George Osborne’s sugar tax announcement in his Budget speech last week.  “I think you can claim that as a ‘win’ for The BMJ” added another after we reminded him of the many articles we have published on the sugar tax.

We quickly got tweeting, and updated our website homepage with links to some  of the articles we have published about sugar taxes over the years. This includes a call from our editor in January 2016 to listen to the evidence in response to a study we published about Mexico’s tax on sugar sweetened drinks. 

So was it The BMJ wot won it, (to steal a famous headline from UK tabloid The Sun after it claimed credit for the Conservative Party surprise win in the 1992 election)? Did politicians read our content, and did it influence their decision?  We routinely ask readers in our annual reader survey if the journal has helped them make better decisions. Maybe we should ask politicians too.

Osborne’s new tax on drinks containing sugar is expected to raise £520m (€658m; $744m) a year when it comes into force in 2018. The revenue will be used in part to double the amount primary schools spend on sport, to £320m a year.

Junior doctor Rachel Remnant reacted with cynicism to the news in a response posted over the weekend: “I am cynical that the added expense itself of sugar-sweetened soft drinks will have the same effect, she wrote. “My primary concern with these new proposals is not the efficacy however but the restriction of freedom of choice…There are few areas in public health where I believe we are entitled to use the stick rather than the carrot. In this case, we are merely discriminating according to wealth and the ability to pay this tax.”

A sugar tax in the US

The journal has covered the debate extensively over the years. As far back as 2010 our US columnist Doug Kamerow was describing the food industry’s response to a proposed tax on sugar sweetened beverages (SSBa) in America.

“In cities and states where SSB taxes have been proposed, industry financed ‘grassroots’ organisations sprang up out of nowhere with names like ‘New Yorkers against Unfair Taxes’ and ‘NoDCBevTax.com,’ ” Kamerow wrote.

Mexico’s experience

In January 2016 the aforementioned study investigated the effect on purchases of beverages from stores in Mexico one year after implementation of an excise tax on sugar sweetened beverages. The excise tax of 1 peso per litre on sugar sweetened beverages was introduced on 1 January 2014.

The researchers found the tax was associated with an overall 12% reduction in sales and a 4% increase in purchases of untaxed beverages, but emphasised that because it is observational study, no definitive conclusions can be drawn about cause and effect.

They also point to some study weaknesses, such as incomplete data on dairy beverages and their focus on Mexican cities.

Nevertheless, they conclude that this short term change “is moderate but important” and they say continued monitoring is needed “to understand purchases longer term, potential substitutions, and health implications.”

Franco Sassi, head of the Organisation for Economic Co-operation and Development (OECD) said in a linked editorial that the study did not explore whether a 1 peso per litre tax is large enough to achieve meaningful health benefits. To assess this, population models are needed.

Sassi added: “Taxes do have a place in a broader strategy in countries that are facing disproportionate harms from unhealthy diets, but having to make people pay for their potentially unhealthy consumption choices is not a success for public health.”

Could a sugar tax help combat obesity?

In July 2015 the journal published a head to head article asking if a sugar tax could help combat obesity?

In Finland, a sugar tax working group concluded: “A combination of excise duty for key sources of sugar with tax adjusted based on sugar content would optimally promote health – and product reformulation.”

Sirpa Sarlio-Lähteenkorva, adviser at the ministry of social affairs and health in Finland, argued that taxes on specific food categories that are common constituents of poor diets “are practicable because they are simple to administer, adding; “Increasing evidence suggests that taxes on soft drinks, sugar, and snacks can change diets and improve health, especially in lower socioeconomic groups.”

But Jack Winkler, emeritus professor of nutrition policy at London Metropolitan University, argued at the time that such taxes are politically unacceptable and economically ineffective.  Conservative politicians had promised not to introduce any new food taxes, he said.  They have now.

We asked readers what they thought via an online poll. Of the 553 votes, 63% (349 votes), said yes. We also ran a poll asking if a sugar tax should be imposed on food and drink sold in hospitals. Of the 1139 votes cast, 67% (767) said yes.

A cautionary note

Sometimes, of course, politicians do use data from The BMJ, most recently when editor in chief raised concerns that England’s health secretary Jeremy Hunt had misused data in an article relating to the deaths of patients admitted to hospitals at weekends.

But that’s another story.

More sugar tax articles from The BMJ

• Headline writers find sweet spot with sugar tax
• Taxing unhealthy food and drinks to improve health
• The case of the sugar sweetened beverage tax
• Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study
• Taxing sugar

David Payne is digital editor and readers’ editor, The BMJ

The post The sugar tax: “Was it The BMJ wot won it?” appeared first on The BMJ.

Spare a thought for the comedian asked to host a professional awards ceremony within a week of the UK general election.

Oliver Reed lookalike Rufus Hound (pictured) showed all the signs of having his comic wings clipped as he took to the podium at London’s Savoy Hotel last week to present the Nursing Standard Nurse Awards.

This was not a night of hellraising. Instead Hound ploughed a politics-free furrow in a compering gig that was interspersed with references to the vital work carried out by nurses, midwives, and health visitors.  At times, in fact, he almost sounded like a politician.

There was, however, some gentle ribbing. Student nurse winner Mark Collins was affectionately mocked for taking a wrong turn when he went back to his seat. And nursing professor Neil Brimblecombe was hailed for having the best surname in  the packed hall.

Why was I there? Three reasons:

• A spare ticket came my way, and I admire Nursing Standard’s chutzpah in selecting a “grand prix” Nurse of The Year from its finalists (more on that later)
• It’s been years since I attended a nursing awards ceremony, and I was keen to find out more about the winning entries.
• The BMJ Awards are tomorrow night. My DJ needed an airing, and I’m not sure I’ll be lucky enough to blag a ticket to our event in these austerity-driven times.

One thing I really like about The BMJ Awards is its multidisciplinary nature. Most years I’ve ended up on a table with consultants, nurses, and patient representatives, and the Nursing Standard event was similar. For instance, clinical nurse specialist Dorcas Gwata took a social work colleague onto the stage with her when she won the Mental Health Award for her work with young people and families affected by gang crime.

I was lucky enough to be on the table of a winner – Tanya Strange. Tanya, who took the Enhancing the Experience of Care Award,  uses retired nurses and other healthcare professionals to find out how care home residents’ lives can be improved.

Unlike The BMJ Awards which shortlists many finalists, most of Nursing Standard’s 15 categories had just two finalists, so my heart went out to Maddie Groves, whose Medically Fit for Discharge ward team was pipped to the post by Tanya.

But what of the winner’s winner? The 2015 Nurse of The Year award went to Stoke nurse Amanda Burston in recognition of the domestic violence service she launched, which so far has helped more than 400 abuse victims.

You won’t read about Tanya and Amanda in the print pages of The BMJ, of course, because the journal doesn’t tend to cover nursing.  There is more than enough UK and international medical news, views, education and research to keep us busy.  And nurses, midwives and health visitors are ably served by two weekly magazines, and its more specialist practitioners have a range of journals to choose from, including BMJ’s own Evidence Based Nursing.

Are our readers interested in nursing? Yes, if you consider the online success of Chris Mahony’s interview with Royal College of Nursing general secretary Peter Carter in the wake of the Mid Staffordshire scandal, and Tony Delamothe’s column We need to talk about nursing. But perhaps not enough to read a more detailed account of the Nursing Standard awards. Here’s a link to the Nursing Standard’s excellent coverage if you want to find out more.

David Payne is digital editor, The BMJ, and readers’ editor.

The post David Payne: Top nurses with a tamed Hound appeared first on The BMJ.

Wednesday December 10.

8.30am: I’m on the bus into work and checking Twitter when I see an exchange between @garyschwitzer and @bengoldacre about some embargoed papers we press released last night, (including Ben’s editorial and a linked research paper about the association between exaggeration in health related science news and academic press releases), not showing on thebmj.com.

It’s now 4.5 hours after @bmj_latest embargo passed, and the links they invited journos to use still don’t work. London, you have a problem

— Gary Schwitzer (@garyschwitzer) December 10, 2014

I apologise to @garyschwitzer and explain why I think they aren’t working.

9.20am: When I get into work my web team colleagues Kelly Brendel and Tinuke Bernard are investigating why the papers, sent the day before to our web hosts HighWire in California (where it’s now the middle of the night), aren’t there. We take failures like this very seriously. The press released articles also include an investigation by The BMJ’s news reporter Gareth Iacobucci, into private contracts in the NHS. The articles are soon showing.

9.30am: My colleagues in BMJ Learning invite me to their monthly breakfast team meeting to talk about The BMJ‘s website redesign and rebrand, (which went live in June 2014), and our plans for 2015.

We work closely with BMJ Learning because lots of our educational content has CME/CPD links to their website. Last week a reader contacted me because he was suddenly getting a login page when he clicked on the link, whereas previously he went straight to the module. We talk about this problem at the meeting, but more generally about how a single sign-on, both for The BMJ and BMJ Learning, would help. I’m being asked to develop a digital strategy for 2015. I will include this idea on the strategic “wish list.”

11am: I’m back at my desk and Duncan Jarvies, multimedia editor, shows me this year’s Christmas BMJ video, which is due to go live next week alongside a paper. It’s very entertaining. I also look at the latest infographic being developed by our newest team member, Will Stahl-Timmins. It’s great to see articles being brought to life in this way. How can we develop this in 2015? How can we stay authoritative and accurate, but also be more entertaining, engaging, and interactive (and fun, when appropriate)? Another one for the digital strategy, I guess.

Noon: It’s our weekly planning meeting and we talk of an initiative launching in 2015 to capture the views of NHS clinicians. We are very proud of article based “rapid responses” at the The BMJ, and our growing army of bloggers and podcast and “round table” interviewees. As an increasingly international journal, we need to ensure that the views of clinicians get represented in the journal—that we don’t just focus on those in leadership positions.

3pm: With a bellyful of turkey (today was our team’s Christmas lunch in the canteen) I meet with colleagues in BMJ Technology to discuss some items on The BMJ’s backlog. One of them is a request to have more social media links as readers scroll down articles online. Many of our articles contain images, tables, infographics, video, and audio files. We’re very proud of the bmj_latest’s £151k Twitter followers and our 35 815 Facebook “likes.” What can do we do engage with them more? Another one for the strategy, I guess.

4pm: My web team colleague Birte Twisselmann gives me some great feedback about some revamped FAQs about The BMJ‘s iPad app, which we’re making some changes to in 2015. Our app has been live for a few years now and is in need of a revamp. We launched a responsively designed version of The BMJ website in June 2014, and wondered at the time if we would see online traffic migrate from our weekly iPad app to the website, which now fits tablet and smartphone devices better. Another issue for the strategy.

6.30pm: On the bus home after a quick visit to the gym, I remember we are doing a technical release that evening (or at least our hosting partners at HighWire Press are). This will include a more prominent link to audio files on articles, and links to the latest UK and international jobs from BMJ Careers. We can be guilty of silo working at BMJ, but between November 2011 and June 2014 The BMJ website, as the flagship product, had lots of links to sister products (BMJ Learning, Student BMJ, BMJ Careers, BMJ specialty journals, BMJ Masterclasses etc). We stripped most of these out as part of a major de-cluttering of the site, but were keen to reinstate the links to the latest jobs. We hope readers like this change, and wonder if we should add more? Another one for the strategy, but let us know what you think.

• This blog formed the basis of a five minute presentation from me at a BMJ Editorial strategy day meeting, held in London on 11 December 2014. Editor in chief Fiona Godlee suggested I turn it into a blog.

David Payne is digital editor and reader’ editor, The BMJ.

The post David Payne: Digital dilemmas—a day in my life at The BMJ appeared first on The BMJ.

If you shake the current print issue of The BMJ, a cluster of inserts fall to the ground, among them a wine club promotion, an online menswear retailer, and a charity appeal from the Refugee Council.

Sometimes readers do challenge the accuracy of information in these inserts, or question our decision to accept money from organisations whose views they do not agree with.

Last year, for example, a reader complained about an insert from the organisation Campaign for Dignity in Dying, which wants to legalise assisted dying in the UK, subject to certain safeguards.

We told the reader who contacted us to complain that a different issue of the journal had carried a leaflet for Care Not Killing, which campaigns for more and better palliative care, and to ensure that existing laws against euthanasia and assisted suicide are not weakened or repealed.

In our response, we told the complainant: A ‘battle of the leaflets’ may not be readers’ idea of a balanced debate, but in the case of this particular issue we have run a range of articles arguing both sides of the debate.”

Inserts are subject to the same rules which we apply to print and online display advertising. In other words, they must be “legal, decent, and truthful, and comply with the relevant laws, regulations, and industry codes for the geographic area in which they appear.” You can find out more at this link on The BMJ website.

Before an insert is accepted we ensure that its content complies with the conditions outlined above. In July last year, for example, we asked an agency to substantiate claims made in a leaflet for the charity Medical Aid for Palestinians before we agreed to accept it.

Inserts serve the same purpose as advertising and sponsorship. They provide revenue to pay salaries and other overheads, and support initiatives such as open access. In addition, they provide a way for advertisers to reach our audience without filling the journal itself with advertising.

We now have a section on The BMJ website which will offer the digital equivalent of print inserts. Our Hosted content  section explains more.

David Payne is digital editor, The BMJ, and readers’ editor.

The post Readers’ editor: Inserts in the print issue appeared first on The BMJ.

A calcaneal fracture can mean a two year recovery, with a stiff, painful, deformed foot that will not fit into a normal shoe.

How does operative and non-operative treatment for intra-articular fractures compare?

A research team led by Damian Griffin, professor of trauma and orthopaedic surgery at Warwick University Medical School, conclude in their randomised controlled trial that operative treatment by open reduction and internal fixation is not recommended.

The paper “seriously challenges current orthopaedic practice, at least in the United Kingdom” says editorialist Brigitte Scammell, professor of orthopaedic sciences, at Queens Medical Centre, Nottingham.

One in five men and one in four women between the ages of 65 and 74 has some degree of chronic kidney disease, but has the condition been over-diagnosed?

In the past 12 years there has been a considerable amount of research, and an update by the National Institute for Health and Care Excellence (NICE) of its 2008 guidance will limit the number of people in England and Wales who are diagnosed with the condition. Find out more from this summary of its latest recommendations.

Population screening for dementia lacks evidence of benefit, says UK dementia czar, Alistair Burns. Instead the NHS asks GPs to use “case finding” among groups of patients thought to be at higher risk.

Glasgow GP Margaret McCartney dismisses the NHS’s current use of case finding as a “fudge” that won’t protect the public against false positives and negatives—or society from the injustice of more resources directed towards the least unwell.

On 17 July the HIV/AIDS researcher Joep Lange boarded a plane in Amsterdam to travel as a delegate to the 20th International AIDS Conference in Melbourne.

The plane crashed in Ukraine after apparently being shot down. All 283 passengers and 15 crew members died.

In his obituary Agnes van Ardenne, former Dutch minister for development cooperation, describes him as “a towering example of humanity” who was on a “quest to establish the right to healthcare for everyone . . . everywhere.”

David Payne is digital editor, The BMJ, and readers’ editor.

The post The BMJ Today: Feet and fudge appeared first on The BMJ.

By the end of next month rural India could have an extra 5.2m toilets as part of a pre-election pledge by Narendra Modi, now prime minister, to build “toilets first and temples later.”

Readers of The BMJ will no doubt be heartened by the Indian government’s announcement, coming seven years after sanitation topped a reader poll as the greatest “medical milestone” in the past 166 years 

Rebecca Coombes revisited the issue in 2010 ahead of a meeting in New York to discuss progress reachine the millenium development goals, and community led total sanitation was one subject in our Medical Innovations video series The Indian government’s announcement has been greeted with sceptcism by some commentators, who say that many toilets constructed after the 2004 tsunami were converted into storage or prayer rooms because indoor facilities are sometimes perceived as unhygienic.

Abhishek Bhartia, a healthcare administrator based in New Delhi, shares that scepticism. In a response posted at the weekend, he says: “Good to see the focus on providing toilet facilities but worried that such a short deadline will sacrifice focus on effective implementation. It’ll be a tragedy to have funds wasted because of undue haste in trying to solve a longstanding problem.”

On the subject of responses, some regular eagle-eyed responders have contacted us because not all of their previous posts are being returned in search results. One email over the weekend asked if the missing content was because of “sabotage by a competitor!”

The problem started after The BMJ’s new website went live on June 30 and we are continuing to investigate the problem.

But the good news is that last week we did our first post-launch technical release, which addressed many of the glitches reported by you in the first few days after the new site went live. This blog explains more. Thanks again to everybody who has taken the time and trouble to let us know what they think of the new website, and to report any problems. We are very grateful.

David Payne is digital editor, The BMJ, and readers’ editor.

The post The BMJ Today: Talking shit again appeared first on The BMJ.

We like it when readers take the time and trouble to give us feedback. We’ve been particularly appreciative in the last two weeks as The BMJ’s new website beds down following its launch on 30 June. Some readers responded to the editorial published to mark the new website and the journal’s new name and logo.  Eighty readers replied to an email we sent out about the new site. Others used our customer service feedback form, and contacted us directly via email. Last week we did our first technical release since the new site went live, and we used it to tweak the design (based on your feedback), implement some changes we couldn’t squeeze in before launch, and fix some bugs.

Search

Some readers struggled with the magnifying glass search icon: “I hope the definitive, ALPHA, version will not have the same compressed header bar that currently loses the search function and the old link to advanced search,” was a typical response. We have now replaced the icon with the term “Search” on the top navigation bar for desktops. We have also removed the “beta” badge.

We also discovered that the search simple and advanced search wasn’t working properly. We are continuing to refine this, but the problem we were having with results displaying 1970 publication dates for recently published articles is now resolved. If you find any, please let us know.

PDFs and printing

We’ve made it easier to download pdfs, and to print articles after clicking the “Print” button. This was broken when we launched. A couple of readers fed back about not being able to print articles in their “print” section. These are now back, and link from the print table of contents. Here, for instance, is the pdf of  the latest four “pico” research articles that appear in our current print issue.

“Empty” pages

Sometimes we don’t need to wait for readers to alert us to a problem. Shortly after the new site launched, Google’s Webmaster tool indicated that around 800 of the site’s 2m pages were not displaying any content. We identified three fixes to this problem, all of which were deployed. We hope this is now fixed, but do let us know if you find any more.

Here are some other changes that went live at the end of last week:

• A new logo for CME/CPD to mirror the one now used in print.
• A new section, Hosted content, linking to online resources produced by external organisations
• Adding a “view more” button to the homepage blogs widget. This takes users to The BMJ’s blogs site, rather than to individual posts.
• Increased page speed on mobiles devices by 10%. Visitors from mobiles are now spending 14.5% more time on the new “responsively designed” site than they were on the previous site.
• Fixed a bug that stopped some images embedded in articles from showing.

Many readers got in touch simply to tell us that they like the new site. Narayan Bahadur Basnet, a consultant paediatrician from Nepal, said in a response to the launch editorial: “Thanks to the editor and all who have been involved in making the journal faster and easier to read.”

Neeru Gupta, a scientist based in New Delhi, described the website as “like old wine in [a] new, fancy bottle. The contents are as good as before with an attractive outer packing.”

But my favourite, albeit critical response, arrived via email from a US librarian who noticed the print section pdfs were missing.  He says: “The old format with columns and dividers put similar items together for contrast and comparison. The new is all oatmeal with no specifics to catch my attention. Slip some currants, gooseberries, blueberries, strawberries for visual color coding and meaningful groupings.”

We don’t ignore any feedback, and we will be implementing two further technical releases over the next month to address comments that arrived more recently.  Please keep your comments coming.

David Payne is digital editor, The BMJ, and readers’ editor.

The post Readers’ editor: A website needing more soft fruit appeared first on The BMJ.

Writers of this daily update about new stuff published by The BMJ usually face an embarrassment of riches—more than 100 articles go online each week, along with dozens of rapid responses, video abstracts, and audio interviews. But yesterday hardly anything got published because we needed to clear the decks for a new website, which heralds the journal’s new name (The BMJ), new homepage address (thebmj.com), and logo (a dark blue “lozenge” in a lower case font). All this happened after 4pm British Summer Time.

One thing we did manage to publish was an Editorial about all of the above changes, and some updated FAQS to help readers navigate their way around thebmj.com. The site’s old homepage (bmj.com) is now the company’s corporate homepage. We have added lots of links to the online journal to help readers get accustomed to the change.

The big switchover was preceded by a last minute migration of the last few rapid response “likes.” These launched in November 2011, and since then we have amassed almost one million of them.

As we were checking these we realised that some rapid responses were not showing either. All sites launch with some technical glitches, and these two are being worked on as I write. We also noticed that some search results have 1970 as their publication date.

Feedback so far has been mostly good. One reader noticed that we no longer display an article in its “print section.” It is true that we are no longer flagging this at article level, but the “section pdf” will display with the print table of contents when we fix a bug.

Our videos now sit on a new platform, and we need to embed files in the article to which they refer manually. Because so many articles now have a related video, we have had to prioritise which ones get migrated when, based on their popularity and/or recency.

Do let us know what you think, either by responding to this blog, or the Editorial, or via this feedback form.

David Payne is digital editor, and readers’ editor, The BMJ

The post The BMJ Today: New name, new logo, new website, some bugs appeared first on The BMJ.

The two updated Cochrane reviews on the benefits and harms in influenza of the neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) attracted lots of attention after The BMJ published them earlier this month. This is my third blog about the feedback. The first blog focussed on rapid responses to the two research articles, and the second looked at how they were covered in the blogosphere. This final one examines the media coverage.

Debora Mckenzie, New Scientist’s correspondent on infectious diseases, agrees that RCTs are the gold standard method for drug assessment.

But, she argues that, while people with “relatively mild winter flu… can be randomly given the drug or a placebo without raising ethical dilemmas… pandemic stockpiles are intended mainly for people with severe flu.”

Moreover, she argues that the Cochrane reviewers should not have discarded the trials’ data on “reported pneumonia”, and quotes researchers Jonathan Van-Tam (the lead author of the recent systematic review of observational studies and Alison McGeer of the University of Toronto, who say the pneumonia would have been diagnosed by doctors [and hence was valid].

She also cites Marc Lipsitch of the Harvard School of Public Health in Boston, who has reviewed Roche’s Tamiflu data, and agrees that, although observational studies are never as good as RCTs for testing interventions, “It would be unethical to give severely ill people placebo because there is too much evidence Tamiflu saves lives.” Given all this, and the forthcoming meta-analysis of individual patient data from Roche’s trials by the Multiparty Group for Advice on Science (MUGAS, which is part funded by Roche) [link], stockpiling of neuraminidase inhibitors is still justified, Mckenzie concludes.

Richard Van Noorden’s news piece for Nature reports the press briefing at the Science Media Centre by The BMJ and the Cochrane Collaboration, and adds comments from sceptics.  He quotes van Tam and Lipsitch again, along with Peter Openshaw, director of the Centre for Respiratory Infection at Imperial College London, who says: “We should demand better-designed clinical trials and greater transparency, but we should not put lives at risk by ignoring the overwhelming body of evidence accumulated over the past five years that supports the use of antivirals.”

Declan Butler’s follow up story for Nature quotes Peter Openshaw again, along with another flu researcher. It goes on “Jody Lanard and Peter Sandman, independent risk-communication experts in New York, say that the press release on the review omits findings that in their opinion are key. For example, it rounds down Tamiflu’s reported 17-hour reduction in symptom duration in adults to “just half a day”, and describes the reduction as “small”. It also does not report the 29-hour reduction in children. Lanard and Sandman claim that there has been “cherry-picking of the results to make them look worse for antivirals”.” Butler sent The BMJ and the Cochrane reviewers a long list of questions about this, but – ironically – he picked only a couple of our answers to report in his article. Anyway, here’s The BMJ’s press release.

The European Medicines Agency (EMA), reports Van Noorden, stands by its risk–benefit assessments and considers that the updated Cochrane reviews add nothing new.

Over in The Pharmaceutical Journal a news article reports Stephen Whitehead, the Association of the British Pharmaceutical Industry’s (ABPI) chief executive, as saying that “there was no reason for the “game of cat and mouse” that went on between Roche and the Cochrane reviewers.” Mr Whitehead told PJ Online that ABPI guidance instructs its members to comply with any “reasonable request” [and] “the Cochrane request was reasonable.” Roche left the ABPI in 2009, but the association says it is still bound by the industry’s code of practice. In contrast, GlaxoSmithKline, an ABPI member, gave the Cochrane reviewers the data on Relenza (zanamivir) without a fight.

Mr Whitehead questioned why Roche could not have behaved similarly and told PJ Online “It doesn’t help the image of the industry.” Speaking at the ABPI’s annual conference on 10 April, Mr Whitehead also said “there could now be a question mark over whether Tamiflu remains on the World Health Organization’s list of essential medicines.”

Competing interests: I chaired the research manuscript committee meeting where we accepted the updated Cochrane reviews on oseltamivir and zanamivir. Last year I observed and blogged about a key meeting of the Multiparty Group for Advice on Science (MUGAS). On behalf of The BMJ I am an active participant in the AllTrials campaign and the Ottawa Group’s IMPACT study, have contributed to several working groups that led to revision of the EU Clinical Trials Directive, and regularly act as an advocate for and give talks on data sharing and particularly on increasing transparency in the reporting of clinical trials.

Trish Groves is deputy editor and head of research, The BMJ

The post Trish Groves: Media reaction to the updated Cochrane reviews on Tamiflu and Relenza appeared first on The BMJ.

My earlier blog outlined BMJ reader feedback to the two updated Cochrane reviews on the benefits and harms in influenza of the neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza). But the two research articles also attracted a great deal of attention in the blogosphere.

Jon Brassey of clinical search engine Trip is increasingly worried about the accuracy of systematic reviews. He muses on the Cochrane reviewers’ approach – meta-analysing only the data from the trials’ Clinical Study Reports (CSRs), and discarding the published trials as incompletely reported. “…What does the evidence say about relying on published trials?” he asks. “It is [now] evident that systematic reviews [most of which analyse only published studies] cannot be relied upon for an accurate assessment of an average effect size for an intervention…all I can conclude is that a systematic review gives a ball-park figure for the actual effect size…We use systematic reviews as a heuristic for accuracy. I have used myself and heard many others say something along the lines of ‘There’s a recent Cochrane systematic review, so no need to look any further’… [But] can we really say any more than ‘This is likely to effective and the effect size is likely to be in the range of…’? …Systematic reviews producers probably don’t say that they produce accurate results, it’s assumed. But, they probably don’t do enough to highlight the shortcomings either. Accuracy sells, ballpark doesn’t.”

Sociologist Robert Dingwall pulls no punches in his much-tweeted blog entitled Tamiflu and the Ethics of the British Medical Journal.  He also discusses his competing interests up front as “a member of ethical advisory panels to both the UK Department of Health (2006 onwards) and Roche Pharmaceuticals (2007-10), the manufacturers of Tamiflu”. Dingwall says “The BMJ is talking nonsense when it suggests that national governments were victims of a confidence trick by a wicked drug company. The policy community fully understood the limitations of the evidence and the likelihood that the benefits would be moderate. No insider ever thought it was a wonder drug.”

But he reckons that governments now being damned for stockpiling Tamiflu could well have been damned for not doing so: their job, after all, is to keep countries functioning. And if the clinical trial data were so weak, why didn’t the Cochrane reviewers simply say that and save themselves the bother of a lot of complicated statistical analysis? Dingwall asserts that “This story, however, tells us less about Tamiflu than about the circulation wars between leading medical and scientific journals, about the credulity of some science and medical journalists, about the exaggerated public expectations of modern pharmaceuticals, and about the Talibanization of the Cochrane Collaboration. If public and professional confidence in a moderately helpful drug has been damaged, it would not be a surprise if there are deaths to be laid at the doors of the BMJ and the Cochrane Collaboration.”

Canadian pharmacist and blogger Scott Gavura, in a long and detailed critique, agrees that, despite the weak trial evidence and the very uncertain cost-benefit equation, stockpiling was probably inevitable because governments, public health agencies, and the public were so fearful of a major pandemic. He’s unimpressed by the updated reviews on oseltamivir and zanamivir and makes it personal, attacking the track record of two of the Cochrane reviewers. “Tom Jefferson is a vocal critic of the influenza vaccine and his strict approach to data been criticized as ‘methodolatry’ by some epidemiologists,” he says, and “Peter Doshi.. is so stridently anti-vaccine he makes Tom Jefferson look pro-vaccine. Doshi believes that influenza itself is an example of “selling sickness,” and questions the morbidity and mortality estimates of the disease.”

Another long blog post that did the rounds via Twitter is by anonymous microbiologist Rectofossa. This covers much of the same ground as the two blogs above, but in a much more gung-ho style with phrases such as “Predicting history is easy,” and “Quite simply, these people [the Cochrane reviewers and The BMJ] all have a dog in the fight.” And the writer doesn’t much like systematic reviews: ” these sorts of analyses can be of use when you understand how they work and what the limitations are.

A big limitation is that unless you also take into account basic plausibility – which the Cochrane Collaboration doesn’t – you get Tooth Fairy Science. And they are notoriously wishy-washy; were the Cochrane Collaboration to investigate a murder scene they would insist equal weight be given to the idea that the victim backed onto the knife a dozen times themselves.”

I’m sure the Cochrane reviewers would be happy to reply to substantive criticisms and comments made through The BMJ’s rapid responses. In the meantime, they have posted this response ”It took us four years to obtain the full set of reports. The story relating to the acquisition has been documented at The BMJ’s open data campaign. If you disagree with our findings, or if you want to carry out your own analysis or just want to see what around 150,000 pages of data look like, they are one click away.”

Competing interests: I chaired the research manuscript committee meeting where we accepted the updated Cochrane reviews on oseltamivir and zanamivir. Last year I observed and blogged about a key meeting of the Multiparty Group for Advice on Science (MUGAS). On behalf of The BMJ I am an active participant in the AllTrials campaign and the Ottawa Group’s IMPACT study, have contributed to several working groups that led to revision of the EU Clinical Trials Directive, and regularly act as an advocate for and give talks on data sharing and particularly on increasing transparency in the reporting of clinical trials.

Trish Groves is deputy editor and head of research, The BMJ

The post Trish Groves: How bloggers responded to the updated Cochrane reviews on Tamiflu and Relenza appeared first on The BMJ.

It’s nearly two weeks since The BMJ published two updated Cochrane reviews on the benefits and harms in influenza of the neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza). These research articles were accompanied by The BMJ’s peer review comments and other supplementary files and appendices and several commissioned articles.

It’s good to see some post publication review of these articles via rapid responses. Peter J Flegg, a consultant physician in Blackpool, is worried about throwing out the baby with the bathwater. “I am concerned that The BMJ is conflating the Tamiflu RCT data with its admirable aim of supporting open access to all trials data. The potential benefits of early treatment of influenza have become the first casualty in this ‘political’ war, and I am afraid that patients who are eligible for treatment will wrongly be denied treatment with neuraminidase inhibitors as a result, to their significant potential detriment.” He agrees with the US Centers for Disease Control (CDC) which, despite the updated Cochrane reviews, is continuing to recommend these drugs for reducing mortality in severe influenza.

Jake Dunning, an infectious diseases clinician and influenza researcher from Imperial College London, writes from personal experience  of managing more than 150 patients with severe flu since pandemic H1N1 influenza (pH1N1) emerged in 2009. “Despite the great number of hospitalisations and deaths from influenza, antivirals were prescribed infrequently prior to admission (<3%) in contrast to generous prescription of antibacterial drugs (25% in our series),” he reports.

The latest Cochrane review of neuraminidase inhibitors for influenza was an impressive undertaking, writes Dr Dunning, “but unfortunately addressed the wrong question. It is unable to provide the answers we need…Those responsible for pandemic planning and response had to rely on seasonal flu RCT data to make decisions on stockpiling and licensing.”

He cites the recent systematic review of 78 observational studies which reported significant reductions in mortality in adults “most notably a 50% reduction with early treatment.” He concludes “We will serve patients best by looking at – and scrutinising – all available data, while understanding and accepting the limitations of different methodologies.”

Patrick J Saunders and John Middleton, public health doctors from the University of Staffordshire, bemoan the “rearguard argument that the Cochrane analysis relates to trials undertaken on seasonal flu, not pandemic flu” and argue that this is “a bizarre reinterpretation of history given it was precisely the evidence about seasonal flu trials which was used to determine national policy for pandemic stockpiling.”

They report what it was like in UK public health services during the 2009 pandemic, with “the wanton abandonment of first principles such as isolation, basic control of infection measures and clinical assessment in favour of the stubborn insistence on managing ‘England as a single epidemiological unit’; the irrational maintenance of the ‘containment’ phase which led directly to perverse and damaging interventions and over-reliance on antivirals in mass prophylaxis exercises particularly in schools.” And they warn that “It would be irresponsible for these lessons not to underpin current planning for pandemics and any subsequent responses.”

Peter M English, also from public health in England, was seconded to work in a flu response centre early in the 2009 pandemic. He reminds us that early in the “containment phase,” the health secretary promised that everybody with flu-like symptoms would be given antivirals. But, he explains, “most people, while I was involved, were delivered the antivirals a week after the onset of symptoms. We were unable to prioritise high-risk patients.”

He thinks that the reduction in viral shedding that may plausibly have been a consequence of antiviral treatment slowed the spread of the pandemic, but “there is no reason to believe that antivirals given more than 48 hours after the onset of symptoms had any other benefit.”

Having said that, he says “respiratory physicians tell me they believe it may have had some benefit in the most seriously ill patients.”

Motoi Suzuki and colleagues from Nagasaki University sent us a response from Japan, “the leading NI-consuming country [which] has prescribed 75% of all oseltamivir worldwide.”

Prompted by the Cochrane reviewers’ comments that “laninamivir and peramivir may be more potent as NIs, because their bioavailability is far higher than zanamivir and may affect the host’s endogenous neuraminidase”, these Japanese readers provided a table of published and unpublished clinical trials of laninamivir and peramivir for seasonal influenza in healthy adults in Japan and other East Asian countries. None of these trials showed superiority of the newer NIs over oseltamivir and there were no differences in the risks of complications.

David A Cameron, an oncologist in Edinburgh, admonished us for presenting only the BMJ Pico one page summaries of the Cochrane reviews in our print journal, finding it “rather bizarre that this very important, and rather controversial, topic has more pages of comment than research data in the printed version of The BMJ. We have a 1 page summary of the important paper from the Cochrane review, but 4 pages of editorial/news, and 5 pages of further comment under “open data”.” Should we have “let the intelligent reader make their own judgement on the hard data by publishing the full article in the paper version to be read and considered at length?” They would, however, have taken up all or nearly all of that week’s print journal.

Competing interests: I chaired the research manuscript committee meeting where we accepted the updated Cochrane reviews on oseltamivir and zanamivir. Last year I observed and blogged about a key meeting of the Multiparty Group for Advice on Science (MUGAS). On behalf of The BMJ I am an active participant in the AllTrials campaign and the Ottawa Group’s IMPACT study, have contributed to several working groups that led to revision of the EU Clinical Trials Directive, and regularly act as an advocate for and give talks on data sharing and particularly on increasing transparency in the reporting of clinical trials.

Trish Groves is deputy editor and head of research, The BMJ

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Last month the journal launched the first in a series of in-depth reviews written by international experts—State of the Art—to highlight important areas of clinical medicine and academic inquiry.

So far we have published two. The first article examined the mechanisms and clinical implications of neuropathic pain and, according to Google Analytics, has been viewed 21,930 times since its publication on 5 February. It is the 10th most viewed page on bmj.com, and we hope it and subsequent articles steer “an effective course between oversimplification and over-complication,” to quote one reviewer. The second article looked at drug treatments for epilepsy in adults. It went online on 28 February, and so far has 11,418 views, our 19th most popular page.

Early indications are that readers recognise their potential to generate debate and discussion. In their response to the article, for example, Laxmaiah Manchikanti  and colleagues warn that multiple diagnostic tests with a lack of demonstrated accuracy, could lead to increased estimations of prevalence that will lead to “an explosion of expensive drug therapy.”

But how do readers feel about the series’ name State of the Art? A terrible cliché, says retired anaesthetist Neville  Goodman in his response to deputy editor Trish Groves’ article launching the series. The term was first coined in the medical literature in 1959, he says, but by 1975 was used in 18.  How could The BMJ’s team of technical editors have let this through, he asks.

Do you agree with Neville? We did discuss alternative series titles before the articles went live (Specialist Review is one that springs to mind), but none of them, we felt, captured our hopes for the series, which, in the words of Trish Groves, are to “cover a breadth of topics relevant to all BMJ readers, with enough depth and novelty for specialists, academic clinicians, and researchers.”

Another cause for readers’ concerns is the departure of regular columnist Des Spence later this month. Consultant oncologist Santhanam Sundar asked in a response published yesterday: “Can we have more Spence please? Des Spence’s articles, over the years, quite often challenged the status quo and the uncertain evidence base of many medical treatments and procedures. He certainly has upset many with his views.”

Dr Sundary is not alone. GP Ted Wills says: “Des Spence is the only reason I look forward to The BMJ. He is deliberately provocative, but he always makes sense. We need to read more from him and others like him, not less. So please BMJ and Des—think again! And thank you for many interesting and entertaining articles.”

Des’s departure prompted a discussion here about whether we recruit another regular columnist, particularly for UK print readers. Some felt that we should choose a top blog or personal view each week to fill Des’s shoes, or rather his half-page. We decided that yes, we do need a successor, and we will be making an announcement soon.

Des will, of course, be a hard act to follow, but anaesthetist Kai Rabenstein is more resigned to his departure, telling him in a response. “I…wish Des a much-deserved retirement. You will be missed, mate.”

David Payne is digital editor and readers’ editor, The BMJ

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At The BMJ we often talk about the “Chinese wall,” a clear demarcation between the advertising sales and editorial teams. This safeguard helps to avoid conflicts of interest, and means advertisers have no prior knowledge of an article that may mention their product, either positively or negatively. But is the term racist?We pondered this question at our last management team meeting. The conversation was triggered in part by a similar exchange, this time via email, about the term “balkanization.”

Let’s start with Chinese walls, and our concern that its use, particularly at events where we are describing the aforementioned policy, might cause offence.

In 1988 a Californian judge objected to the phrase on the grounds that it “has an ethnic focus which many would consider a subtle form of linguistic discrimination.”

He added: “Certainly, the continued use of the term would be insensitive to the ethnic identity of the many persons of Chinese descent. Modern courts should not perpetuate the biases which creep into language from outmoded, and more primitive, ways of thought.”

Legal ethicist David Hricik, a professor at Mercer University Law School, Georgia. disagrees. He posted his point view on a legal ethics forum, and online debate it triggered concluded with the recommendation that the term “ethical wall” or “ethical screen” be used instead.

Personally I struggle to see how the term could be racist. Most of the lawyers who took part in the legal forum debate agreed. They also discussed whether or not the term itself refers to China’s impenetrable Great Wall, or to flimsy decorative room dividers.

For the record, the actual wall separating The BMJ’s editors and sales colleagues is in fact a floor. We share a cramped second floor office with BMJ specialty journals and marketing teams. The sales team have an airy refurbished office downstairs. Not that we’re jealous, of course.

This leads me to the term balkanization, which is used, according to its dictionary definition, “to describe the process of fragmentation or division of a region or state into smaller regions or states that are often hostile or non-cooperative with one another.” 

The subeditor copied into the email exchange about its potentially pejorative use said it would be clearer and more in line with BMJ style to use other, simpler terms where possible. Interestingly, it had merely been mentioned in a team discussion about an article. The term itself was not in the article.

The colleague who said it rather neatly closed down the email exchange with these words: “This term isn’t racist : it refers to a political situation where big countries are divided into ‘small quarrelsome states’ (says the dictionary) – quite an apt phrase for our editorial team now I think of it!’ ”

David Payne is editor, bmj.com, and readers’ editor.

The post Readers’ editor: Is the term “Chinese wall” racist? appeared first on The BMJ.

Last week we published a cluster of papers on airport noise and cardiovascular disease. One US based study found a statistically significant association between exposure to aircraft noise and risk of hospitalisation for cardiovascular diseases among older people living near airports, and another found that high levels of aircraft noise were associated with increased risks of stroke, coronary heart disease, and cardiovascular disease for both hospital admissions and mortality in areas near Heathrow airport in London.

The articles received widespread media coverage and generated considerable debate, both on bmj.com and elsewhere. Jagdeep Singh Gandhi, consultant ophthalmic surgeon at Worcestershire Royal Hospital reminded us that the “sage of the suburbs” JG Ballard lived his adult life in the shadow of Heathrow. He adds: “Besides sound-proofing, a concurrent task is to assess the sources of engine noise, and this facet is being increasingly studied by the sharpest minds in aerospace . . . Some motors are reputed to have an operation of such quietude that displacement of air is the main source of noise from the flying airframe.”

All the major UK newspapers picked up on the story–online comments expressed the usual jaded lack of surprise at the results combined with healthy scrutiny of the research methods.

Simon Calder saw the research contributing to the debate on the expansion of our airports. The last paragraph of his blog on the Independent’s website read, “But 48 hours ago a correlation between airport proximity and the risk of heart attacks or strokes was not in the public domain. Now that it is, the spectrum of harm from airports has extended from nuisance to a serious public health threat.”

The research also attracted global media coverage. The Times of India, South China Morning Post, French Tribune, and Irish Independent (among others) reported the findings. Airports (or aviation hubs) are often a symptom of a nation’s ambitions and it seems that emerging markets in India, central and south America, Brazil, and China will mean new or expanding airports. The Indian government recently announced plans to build 17 new airports during the next five years, while it is thought that China will build as many as 70 by 2015. These plans are dwarfed by Brazil’s plans for 800 new regional airports—the president reportedly wanting all 194 million of the country’s citizens to have access to air travel.

Our editorialist Stephen Stansfeld advised planners to take the research into account when expanding airports in heavily populated areas or planning new airports.

Here are some of the UK and global titles that picked up the papers:

• Times of India
• South China Morning Post
• Huffington Post
• Independent
• Independent blog

Jett Aislabie is the digital production editor, BMJ.

The post Jett Aislabie: Airport noise and cardiovascular disease appeared first on The BMJ.

In March 2005 Ali Tonks wrote her first weekly Short Cuts column, a summary of nine papers published in the world’s other main general medical journals. The following year we published the first of Richard Lehman’s weekly journal review blogs.

Earlier this year Ali asked if there was too much overlap between her column (which we renamed Research News in 2012), and Richard’s blog. We felt Ali had a point, and wondered if a better use of her time and talents might be writing more clinical features for us.

This isn’t the end of news about research in the journal. The news team now has responsibility for commissioning news about research papers, and they are tagged as Research News for online publication. There’s a feed of the latest ones published on the research and news channels. There is also a research news section in our online table of contents, which shows all those published in seven day period.

In print, news about research will appear in the main news section. We hope at some point to introduce a section in our iPad edition.

Why am I telling you this now? Well, some readers have noticed that the section has disappeared from the weekly print table of contents listed online, and we realise we could have communicated this better.

Last month Mike Nielson from USR Medical Library told us that each week he sends Research News to 150 colleagues, but has noticed it is no longer there.

I suggested to Mike that from now on he emails the link to Richard’s blog to his collegues after it goes online each Monday. Richard’s blog includes summaries of papers from The Lancet, JAMA, NEJM, Annals of Internal Medicine, and The BMJ. He also uses it to indulge his love of gardening by finishing his blog most weeks with details of a favourite plant.

If, like Mike, you routinely send this content to colleagues, here’s the full link to Richard’s blog: https://blogs.bmj.com/bmj/category/richard-lehmans-weekly-review-of-medical-journals/

Richard is currently taking a well earned break, his first in years, but he’ll be back later this month.

David Payne is digital editor and readers’ editor, The BMJ.

The post Readers’ editor: Where has all the research news gone? appeared first on The BMJ.

Advertising and sponsorship are generally seen as necessary evils by us here at The BMJ. While we are positively fizzing with ideas for new content, we know that bringing it to you, and as wide an audience as possible, is much more likely with the support of sponsors.

Having said that we would like to know what your thoughts are. Is all sponsorship equal? Would you feel comfortable with, say, an non-governmental organisation sponsoring a roundtable discussion? How about a government department sending an expert for a webinar, or a private healthcare provider? Would you be happy with “big pharma” suggesting the topic for an article? How about choosing its author?

We need to know where you would like us to draw the line and, if possible, why you want it drawn there.

Our diabetes specialty portal is currently sponsored by MSD. I like this example for the bluntness of its assertion that the company has had no influence on the editorial. “This portal is supported by an unrestricted grant from MSD, who have had no influence on the editorial content displayed,” it says, unambiguously, in big bold type.

Over at Nature there are a few examples of what future sponsorship could look like for us at The BMJ. Their asthma focus is—like our diabetes portal—sponsored by a pharmaceutical company. The company’s logo shows on the table of contents page (in a side bar rather than the middle) where there is also a link to the sponsorship page. I can’t see, however, any declaration of independence. We’d like to know if this is important too—is it crucial to declare the level of influence sponsorship has bought the company? Our current thinking is that we would always publish a full disclosure about not only who the sponsor is, but also the role they have played in generating the information we then provide.

What about co-productions or co-branding? There is a rather wonderful example, again from Nature, of a poster produced with Merck Serono about lipid signalling. MS have a corner of the poster to promote themselves and their products—but they have been wonderfully chivalrous in omitting their own drugs from the compounds list while very fairly mentioning their competitors. Does this make you suspicious? Should sponsorship be taken at face value?

If we published an article by a pharmaceutical company on a clinical topic in a specialty area relevant to one of its products would you read it? Providing there was a clear disclosure I can imagine it would be of significant interest to many readers—pharmaceutical companies are usually the engines of new development and research.  Or is it, perhaps, the thin edge of the wedge?

Click here to give us your views.

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In December 2012 Doug Kamerow asked in his regular BMJ column if gay marriage improves health.

Eight months later the article attracted its first response. Gregory Gardner, a GP in the West Midlands, wanted to know why Kamerow had not mentioned the impact of same sex marriage on the health and wellbeing of children. Dr Gardner’s response cited the 2012 findings from the New Family Structures Study in the Elsevier journal Social Science Research by Mark Regnerus, associate professor of sociology at the University of Austin, Texas.

Four days later John Chilton responded to Gardner. Regnerus’ study, he said, had been “thoroughly discredited.” Mr Chilton, an economist from Virginia,  also emailed Kamerow about the BMJ’s screening process for rapid responses.

I contacted Chilton to explain that we screen for profanities, breaches of patient confidentiality, and defamation, and also choose not to publish if we feel a response does not add to the debate and the same point has been made already.

Were we right to publish Dr Gardner’s response? If we’d said no, would we have been censoring him or stifling debate? On this occasion the decision to publish was ultimately taken by editor in chief Fiona Godlee, who alerted two gay colleagues (myself included) of her decision to do so.

Dr Gardner contacted her when we suggested some amendments to an earlier version of his response.

She told him publishing the response meant we would be letting the BMJ’s community of readers decide what to think.

Now the article has attracted a third response, from former Student BMJ editor Balaji Ravichandran, who accuses the journal of “shameful homophobia” in choosing to publish the first response.

He says: “I suspect the editors indulged in those two fallacious platitudes, ‘freedom of speech’ and ‘editorial balance,’ when they decided to publish the response. But, when they did so, I wonder if they had asked themselves whether a rapid response which purported to argue the ‘Bell Curve Theory’ of racial intelligence, or one that suggested ‘intelligent design’ as the grounds for withholding palliative care, might have been published on the same grounds.”

Rapid responses are post publication peer review, and Chilton’s response was, in essence, a review of Dr Gardner’s response (so was Ravichandran’s). Regnerus’s NFFS study claims to “clearly reveal” that “children appear most apt to succeed well as adults—on multiple counts and across a variety of domains—when they spend their entire childhood with their married mother and father, and especially when the parents remain married to the present day.”

Andrew Ferguson’s feature in the Weekly Standard article, The perils of politically incorrect academic research, published in July 2012, describes Regnerus as a “bull in the china shop of mainstream sociology.” His study was funded by the socially conservative Witherspoon Institute to the tune of $700,000. Liberal groups were asked to contribute also, to “guard against charges of ideological trimming,” but in vain. Regnerus told Ferguson that the Witherspoon Institute had nothing to do with the study’s design or implementation, or how the findings were interpreted.

The alleged flaws in Regnerus’ study are well documented in Ferguson’s article and elsewhere. Of the original pool of 15,000 rsepondents, only two young adults reported living with their gay parents for their entire childhood. Respondents were not asked to give their parents’ sexual orientation. Instead they were asked if they knew their parents had at any point engaged in homsexual activity. Nor were they asked if their parents identified themselves as gay.

But Ferguson says Regnerus’ critics (including three colleagues in his sociology department and more than 200 co-signatories to a letter to the editor of Social Science Research) ignore the study’s “unique strengths,” including the size and randomness of its sample, and a pledge to make all his data, “which straddles the full ethnic, socioeconomic, and geographic range of gay America,” digitally available.

Kamerow didn’t ask in his column if same sex marriage was good for the health of the children of gay parents. He pointed to evidence that extending the “conjugal condition” to same sex couples might confer benefits – better healthcare insurance, decreased healthcare visits and costs, and better mental health among mid-life and older gay male couples.

Finally, Chilton’s email to Kamerow linked to a blog by Dr Gardner on the Anglican Mainstream website. Gardner was described as being from the BMJ, presumably because his blog was an extract of his unsolicited response which we had chosen to publish. I contacted the site and suggested an alernative wording. This has now been amended.

See also:

• Suspect ‘Science’
• Controversial gay-parenting study is severely flawed, journal’s audit finds
• Q & A with Mark Regnerus about the background of his new study
• Back in the Gay: Does a new study indict gay parenthood or make a case for gay marriage?

David Payne is editor, bmj.com, and readers’ editor

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Columnist Charles Moore asked in The Spectator magazine last week if the Liverpool Care Pathway might have inspired more confidence if it had been called, say, the Oxford Care Pathway.

Was Moore referring to Oxford as an ancient seat of learning and innovation, or lazily perpetuating the myth that Liverpool is synonomous with riots, poverty, and crime and therefore incapable of either developing or inspiring confidence in a tool to deliver end of life care? (It was the city’s Marie Curie Hospice that collaborated on an end of life care pathway for use in hospitals in the late 1990s, BMJ clinical fellow Krishna Chinthapalli reminds us in his blog).

David Mowat, Conservative MP for Warrington South, suspects Moore, who lives in Sussex, might be displaying southern snobbery towards the great northern cities of England. Those of your readers who live north of Birmingham are keen for him to share his insight,” he says in a letter published in the current print issue.

The Spectator is not alone in devoting online and print space to the pathway and a debate about its merits and shortcomings. The BMJ and Daily Mail seem to have turned it into a cause célèbre, but from very different standpoints (although both seem to have ignored Moore’s suspicion that the pathway’s brand was damaged because of its association with the home of Cilla Black and the Beatles).

A search of BMJ rapid responses about the pathway returns 105 results. A similar search of articles returns 65, dating back to 2003, a few years after the pathway was first developed.

The most recent flurry of coverage was triggered by Glasgow GP Margaret McCartney’s Medicine and the Media examination of the Mail’s campaign against the “controversial guidelines on ‘hastening death.’” Margaret’s article had nine responses, all of them from the UK.

Our assumption at the BMJ was that the pathway was widely recognised internationally and so is of interest to readers outside the UK (we make a similar assumption about latest NICE guidance and certain NHS-related topics, particularly rationing and system failures).

Was this assumption wrong? Maybe. We press released McCartney’s spirited defence of it  but my colleagues in the press office say it was largely ignored outside the UK.

A good indication of international interest in the Liverpool Care Pathway is the extent to which it gets covered in other general medical titles. But neither NEJM nor JAMA covered it, at least if you believe their search engines. The Lancet, based in the UK, returns just one article from November 2012 announcing the Association of Palliative Medicine’s review.

Last week we decided to dedicate our weekly online poll to the pathway, asking if the UK government was right to scrap it. The poll closed today, and of the 703 votes cast from 44 countries, 76.55% (538) said the government was wrong. Predictably, most votes came from the UK (595) and 458 of them (76.97%) voted no. In other words, the 108 international votes did not influence the result. Interest from outside the UK was neglible. The second highest number of votes came from Australia (18). New Zealand came third (14).

The above figures do not include readers in India and the US, where we can run separate polls. In India we decided to ask the same question, but to collate the results separately. It received just four votes in seven days. We hope our new India poll, Is bariatric surgery the answer to India’s growing obesity and diabetes problems?—will excite Indian readers more.

In the US we changed the poll question after two days (and ten votes) because we posted an article about payment models and the Affordable Care Act and we felt (rightly as it turned out) that this would be of more interest to US readers.

David Payne is readers’ editor and editor, bmj.com.

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Joginder Anand, a longstanding reader of the BMJ, wants to know how we can encourage authors to respond. In a recent email he asks: “Should the BMJ not make it mandatory for the leading authors of all articles to respond to criticisms or requests for clarifications?

My question back to him is how? What would be the penalty?

Dr Anand suggests banning further publication in the journal.

Would that work? I don’t think so. Many of our authors are busy clinicians or researchers. Often they intend to respond, but finding the time to do so is a challenge. We are delighted when they do, but acknowledge it isn’t always feasible.

All corresponding authors get alerted when a response is posted to an article they have written, and are encouraged to respond. We don’t specify a time limit before posting. Many choose to wait for days or even weeks, or perhaps until their article has generated a few responses, before addressing the points raised in a single response back. Occasionally we contact authors and ask them to respond.

There are other ways of engaging authors. All articles include the email addresses of the corresponding authors. Readers often contact them directly if they have questions or comments. Also, many authors are active on Twitter and Facebook, and use these channels to field feedback when they have written an article.

But Dr Anand makes an important point, and I discussed his email at the recent BMJ hack day two weeks ago when I outlined some of the challenges facing the scholarly publishing industry to the web developers who took part.

I reminded them that post publication discussion is seldom confined to the actual article these days, and asked for their views on how a journal can easily capture all the “noise” an article generates—an at-a-glance dashboard that pulls in metrics, citations, page ranks, social media, press coverage.

Or how can the discussion drill down into the very article itself, generating discussion threads around particular sentences, paragraphs, or graphs? How can such feedback be sorted so, for example, a cardiologist can focus on the feedback provided by other cardiologists.

This was the challenge. And of the 13 hack presentations on the Sunday, four addressed the need to revolutionise scholarly publishing.

One tool, the Evolving Journal hack, stands out. Devised by Jonathan Asiedu, Jeremy Chui, Ben Heubi, James Lethem, and Harry Tanner, their platform “adds value over time by considering the inputs, outputs, questions, and criticism by the medical community of multidisciplinary professionals after the peer review process.

“Effectively, we enrich the journal by providing further context to the document through conservation, semantic linking, and open data access,” they claim.

The team took a BMJ paper published in 2004 about benzodiazepine use and risk of dementia. As you can see from the image above, it lists views, comments, and citations on the left, along with a clear way of navigating the paper. The article is on the right, using colour-coded links to cluster different professional groups.

The team’s accompanying YouTube video pitch explains more.

The project doesn’t directly address Dr Anand’s concerns, but it makes it easier for both authors and readers to easily assess a paper’s impact at both a “macro” level (citations and page views), and at a “micro” level (paragraph three of the conclusions seems to have generated a great deal of debate, for example).

And if an author’s “badge” was colour-coded as well as his or her professional background, readers could more easily see how often he or she had engaged with an article’s community of readers.

David Payne is editor, bmj.com and readers’ editor.

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The BMJ’s impact and influence should be measured by more than just established metrics such as impact factor.

But the new figures, released two weeks ago, are very welcome. The journal’s impact factor rose more than 20% to 17.215. My first thought on discovering this was that a strategic aim to increase the impact of the BMJ’s scholarly content is starting to pay off.

The new figure makes the BMJ the most highly cited open access general medical journal in the world, now higher than PLoS Medicine and puts it in the top four general medical journals, above the Annals of Internal Medicine. This is due in part to a conscious drive to publish research that will be highly cited as well as widely read by clinicians around the world.

But authors also value media coverage alongside measures such as impact factor, and articles in the BMJ get namechecked regularly in UK and international newspapers, magazines, blogs, and broadcast channels. This blog aims to illustrate the ripple effect caused by media coverage and the debate it can engender, both in the BMJ and beyond.

Mostly these are triggered by an article being referenced in a press release, but not always. Each week the BMJ press team sends an update of the most recent media mentions.

Let’s start with nickel allergy. Last week’s included a BBC Health Check online feature about nickel allergy and new coins which cites a letter published in the BMJ.

The letter, published in April 2012, was about the UK Treasury’s plans to introduce Royal Mint nickel-plated coins. The authors, from St John’s Institute of Dermatology and the Royal Hallamshire Hospital in Sheffield, said there has been no assessment of the new coinage which is being brought in to save costs. Letters aren’t routinely press released by the BMJ press team, but this one was.

Secondly, neither Treasury officials nor the Royal Mint had considered the potential costs to health in terms of skin disease, financial implications to the NHS, or other costs to the taxpayer. Sweden, in contrast, had concluded that nickel-plated coins pose unacceptable risks to health. It will stop producing any nickel-containing coins from 2015.

The BBC story was pegged to a new study published in the Wiley journal Contact Dermatitis. The study compares the performance and allergy risk of the new nickel-plated coins (five and ten pence) with those of the cupro-nickel coins being replaced. The study was also covered in the Dail Mail and by WebMD on the Boots website.

A Royal Mint spokeswoman told the BBC it was satisfied that there was no increased risk of people developing nickel allergy by handling the coins. Not so, say the authors of the Wiley study.

A second story published in the mainstream press last week was a call to ban junk food and fizzy drinks in hospitals. The topic was debated at the British Medical Association’s annual representive meeting in Edinburgh, covered in the BMJ, and national news outlets including the Daily Mail and Mirror.  The story was also covered on Sky News, BBC News online and in The Guardian, Huffington Post, The Scotsman, Medical News Today, Top News USA and Health Service Journal.

The calls were led by Aseem Malhotra, interventional cardiology specialist registrar, Royal Free Hospital, London, who had written a BMJ Observations column to support his argument.

Retired GP Francois Fouin described the high rate of obese NHS staff as a “national disgrace” in his online response to Dr Malhotra’s column. Those of us who are old enough will remember our years in hospital enthralled by the nursing profession when prestigious hospitals only recruited the smartest in mind and body.” he added.

In a separate response, psychiatry core trainee Thomas Burden said: “There is evidence that dietary interventions and a healthy diet may help to treat or prevent antipsychotic-induced weight gain. Despite this, most psychiatric hospitals continue to serve patients calorifically-dense meals of poor nutritional value. I believe that this needs to addressed urgently.”

Thirdly, a BMJ research paper published last week investigated the association between intake of fish and n-3 polyunsaturated fatty acids (n-3 PUFA) and the risk of breast cancer.

The accompanying press release, “Fatty acids found in fish linked to lower risk of breast cancer,” helped to ensure the story got widespread coverage across the globe (Daily Telegraph, The Mirror, Hong Kong Standard, The New Age, iAfrica, Business Standard, Daily Mail, and Bangkok Post).

Finally, Glasgow GP Margaret McCartney’s argued in a recent Medicine and the Media that the NHS and some UK royal colleges profit by selling commercial advertisers access to pregnant women through promotions such as Bounty bags.

The article sparked a lively debate on the BMJ website but also led to a blog from Finnish Medical Journal medical editor in chief Päivi Hietanen and news editor Jaana Ahlblad about the cardboard baby boxes distributed there.

The box doubles as a cot and was commended in a BBC News Magazine article. An image of the box and its contents was also chosen as our print picture of the week last week. Margaret’s column was picked up by “househusband” blogger Daniel Owen as well as dozens of national news  media titles , culminating in a letter from health minister Dan Poulter to NHS chief executives in England urging them to review their systems for allowing sales people to have access to new mothers.

David Payne is readers’ editor and editor of bmj.com

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The BMJ wants its research papers to help doctors make better decisions, which is why they are open access and free to view.

But to deliver on the pledge our research also needs to be scientifically valid, clinically relevant, widely read and cited, and appeal to international readers. Each year we get more than 3000 submissions, but we usually only accept 2 to 5%.

Sara Schroter has run the BMJ’s in-house research programme since 2001. Her latest report is an audit of papers submitted and published between 2004 and 2012. It tracks a range of indicators. These help us to see if our published research is being accessed on bmj.com and cited, and what proportion is getting picked up by secondary sources like Evidence Updates, Journal Watch, Evidence Based Medicine Journal, etc.

Sara’s report compares study designs, turnaround times, total number of online accesses in the first three months of publication, and rapid responses. She also looks at which papers get picked up by secondary sources, and the impact of a paper when its findings get included in a press release.

It also contains a location analysis, based on the country of the corresponding author listed on the paper. But because many research papers have numerous authors and often from several countries, it’s hard to draw firm conclusions.

On average, our research papers published in 2012 were accessed over 7000 times in the first three months of publication.  The number of accesses refer to the total number of accesses on bmj.com to the PDF, full text, or abstract.  In 2012, over 30% of our research papers were picked up in Evidence Updates and Journal Watch General Medicine, further increasing their visibility on other platforms.

The table below shows the top accessed BMJ papers over a nine year period. The number of citations relate to the year of publication, and in the subsequent two years.

With the exception of 2007, when we published a high proportion of papers from the UK, the percentage of papers published from the UK is on a downward trend (just under 40% in 2012) with increasing proportions from elsewhere in Europe and North America. In 2012, we published almost as many papers from mainland Europe as the UK.

When a paper gets press released, on average it gets more citations, and more accesses on bmj.com, than those that were not press released.  However, this may be a function of the type of papers that get press released!

We have been working on improving our processing time and in 2012 our median interval in days between provisional acceptance and online publication was just 44 days (LQ 33, /UQ 66) without stopping the clock when authors were handling proofs and final revisions.

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In January this year a hospital pharmacist contacted us after a colleague had questioned a prescription for amlodipine 10 mg four times a day for migraine.  She contacted the prescriber, who said he had got the dose from this clinical review  about pharmacological prevention of migraine published in The BMJ.

The article had specified amlodipine 5-10 mg QD in a table, with an explanation at the bottom of the table which clarified the abbreviation QD to mean once daily.

Our policy in such circumstances is to issue a correction and attach it to the article, which we promptly did. Because of the potential patient safety risk, we also amended the table and republished the article. The correction reminded readers not to confuse QD with QDS, which means four times a day.

The journal’s managing editor then reminded the editorial team to avoid dosing abbreviations such as QD. On this occasion it was used to save space, and, although its meaning was clearly defined in the footnote, it nearly led a busy clinician to prescribe four times the correct dose.

An added complication is that acronyms are not used consistently between the UK and US, and as an international journal we need to be mindful of this. Lastly, she urged the team to always ask authors to clarify what they mean, and that our policy is to minimise the use of abbreviations.

The incident recounted above was in my mind this week at a meeting to discuss a company-wide project to establish some policies and principles for protecting patient safety. We tend not to think of The BMJ as a point-of-care resource, unlike some of our other products such as Best Practice, but our education content (clinical reviews and practice articles), frequently contain dosage information, and they have to be unambiguous.

The project team has suggested a range of principles about empowering us all to raise patient safety concerns and issues, and including the issue in our induction programme when we join the company, and in our training.

Readers also need to be aware of the channels they can use to raise patient safety concerns. The issue described above was flagged via our complaints inbox (complaints@bmj.com). Readers can also contact our customer services team (support@bmjgroup.com), and respond to a specific article if they feel it contains misleading information. Responses are monitored seven days a week. You can find out more about our complaints inbox at this link

It goes without saying that we are extremely grateful to the pharmacist for alerting us to this problem, and to all readers who contact us with patient safety concerns related to articles in The BMJ.

David Payne is editor, bmj.com, and readers’ editor

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Last week’s print BMJ included a 14 page supplement about BMJ Awards, held a week earlier in London. If you didn’t see it, here’s a link. The BMJ Awards website lists all the winners, along with pictures from the night.

The BMJ Awards are now five years old. The event goes from strength to strength. Next year we are launching BMJ Awards India in Mumbai.

I’ve attended all of the UK events and inevitably compare the BMJ event with the dozens of others I’ve been to over the last 20 years for healthcare professionals, digital developments, and journalism.

This year I sat with a great bunch of people from the Itchy Sneezy Wheezy team. Part of Imperial College Healthcare NHS Trust, they were nominated for Child Health Team of the Year, but sadly didn’t win.

Itchy Sneezy Wheezy were genuinely pleased for the winning team (Cardiff Child Protection Systematic Review Group), clapping enthusiastically when comedian Dara O’Briain (pictured left), our awards host this year, gave them their trophy. Such magnanimity is not unusual at the BMJ Awards, unlike many others I’ve attended, where unsuccessful teams switch off and talk loudly after their category has been announced. Healthcare professionals seem to be genuinely pleased when colleagues get recognition for their work. Itchy Sneezy Wheezy thought it was great that the vital work done by child protection teams was being acknowledged.

A colleague described this year’s ceremony as a “coming of age.” I’ve enjoyed every event so far, but this year’s felt slicker somehow, and despite there being more categories, finished half an hour earlier than in 2012, allowing extra time for guests to circulate get to know each other.

Each year the format gets reviewed. This year we introduced a winnner’s winner category. At one staged we discussed whether this grand prix awards should be called “doctor of the year,” but it didn’t feel true to the spirit of the awards, which is to celebrate team achievements (my Itchy Sneezy Wheezy friends included doctors, nurses, a project manager, and a former history teacher). This year’s BMJ Medical Team of the Year award went to the British Nepal Otology Service (BRINOS, pictured below), winners of the Karen Woo Surgical Team of the Year earlier in the evening. You can find out more about BRINOS in this BMJ podcast.

I “championed” two awards categories this year. I attended the judging day and saw first hand how entries are scrutinised and evaluated. There were some lively debates as we broke into groups before returning to feed back on our decisions to the full panel.

I fulfilled a similar role when I worked at Nursing Times in the late 1990s. This involved accompanying two judges on site visits to interview shortlisted teams, who took time out from their busy working day to tell us about their projects.

Asking busy teams to allocate time and resource to accommodate a site visit feels like a big ask these days. Instead we allow for some follow-up queries if judges need to check things. An indication of how busy our entrants are is the fact that many I spoke to on the night had jumped on trains after finishing clinics (some of them arriving just as ceremony was about to start), and were booked on very late trains home to run clinics the following morning.

I mentioned Dara earlier. He was a superb compère and deserves credit for maintaining the pace of the evening without making it feel rushed.

We’ve been lucky with our hosts and celebrity guests over the years.  They include Hugh Grant, who paid a moving and funny tribute to the late Ann McPherson in 2011 after she won Health Communicator of the Year.  Last year Tony Blair’s former communications director Alastair Campbell spoke on behalf of mental health charity MIND, describing his own mental illness at the same time. This year paediatrician Ranj Singh (pictured) who presents Get Well Soon for CBeebies, joined us as a judge for the child health team of the year.

Dara gently ribbed Northwick Park Hospital fast-facing stroke team, winners of the clinical leadership team of the year, for taking longer than others to organise themselves for the photographer.

My two most memorable quips came from Sandi Toksvig, who hosted our first event five years ago. After being introduced by BMJ editor-in-chief Fiona Godlee, she guessed that Fi and Stella Dutton, our chief exective at the time, had both been stalwarts of the school netball team, before alluding to a BMJ research paper about tea drinking habits and oesophageal cancer in northern Iran: “That’s the last time I drink tea in Iran!”

David Payne is readers’ editor and editor, bmj.com

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I spent yesterday at St George’s Hospital in Tooting, south London, talking to readers of the BMJ. The medical school library had organised an open day and a sales colleague had organised a BMJ stand, so I joined him to discuss our plans for the BMJ website with both qualified doctors and medical students.

We’ve set ourselves a very tight deadline to have a responsively designed version of the website live by late summer (one that work as well on laptops and tablets as it does on smartphones), so we’re seizing any opportunity to show our evolving designs to readers so we can ensure we end up with something that makes sense to them.

I was particularly keen to test the new site’s top navigation. Reader feedback since the 2011 redesign is that the site is cluttered, so we’ve dispensed with some of the “channels” and merged others.

Our most popular channels are research and education. We wonder if education is the right name. Some of these articles include Cleveland Clinic CME questions. Would CME or CPD be a more accurate name for this channel? Certainly it’s our longer term aim to include CME questions for more educational content, so our ultimate aim is to rename this channel, but perhaps not by September. The term CME meant very little to the medical students and doctors we spoke to today. Perhaps we should have different names in different countries?

We plan to merge our news and comment channels (which are less popular) into a new “news and views” section to include editorials, analysis, features, opinion pieces, news, and obituaries.

Currently we have a multimedia channel showing our latest videos and podcasts. We’ve decided to add this to our archive channel, as we’re increasingly embedding audio and video in articles, and we think there are smarter ways of signposting this kind of content (including YouTube and iTunes). We plan to replace the Careers channel with a simple “jobs” section linking to BMJ Careers.

There are also some new channels. One of our most popular sections is our advice for authors wanting to get published in the BMJ, so we’ve added a new “For authors” channel offering advice on the kind of research the BMJ is likely to publish. Many others journals have this section. It proved popular when we showed it to doctors at St George’s yesterday.

Another new channel is one we are calling Campaigns. Since the 2011 redesign we’ve launched two high profile campaigns in the wake of some of our investigations – one on overtreatment (too much medicine), and another on open data (calling for negative drug trial results to be in the public domain). We felt these campaigns are a bit buried on the current site, and we want to given them the prominence we feel they merit.

Today’s “testing” followed a simple format. The BMJ stand had free pens, memory sticks, and marker pens alongside leaflets for our various products. Every time a doctor or student asked for one, I asked if they had a free five minutes to look over our designs. All of them said yes.

We gave them various scenarios. The first was to suggest where a summary of the latest NICE gudiance would go. Another was to locate a cohort study published in the BMJ and mentioned on the radio that morning. We also asked them to locate an obituary, access latest article responses, and describe how they find out if the BMJ was the right journal to publish their paper. We were also after general feedback about the designs.

The feedback was fantastic.  Interestingly, some doctors answered “news and views” to the above questions. including the ones about NICE and the cohort study.  We don’t routinely cover new NICE guidance in news (perhaps we should?). Instead we publish summaries as an education article. Neither do we write news stories about our own research.  Again, should we?  These aren’t design questions, but they are great at helping us to establish how we could cover issues differently.

David Payne is editor, bmj.com, and readers’ editor.

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Readers of the Radio Times can visit locations used in the filming of Sir David Attenborough’s Africa on a tailor made tour offered by the 90 year old UK listings magazine. The Africa trip is one of dozens of destinations listed on RT Travel page and the latest example of how publishers are increasingly thinking like retailers to offer their readers everything from holidays to horticulture.
The Radio Times sells 900 000 print copies a week. Its Christmas issue sells 2.2m, and the magazine’s website has 3m unique users. Its readership is ageing, but 60% are in social grade ABC1, with spare cash to spend on leisure pursuits such as travel and gardening.

Tom Bureau, CEO of Immediate Media Company, which has published the title since 2011, told the Professional Publishers Association (PPA) annual conference in London last week how Radio Times markets these “curated travel offers” to both print and web readers using an e-commerce platform and close collaboration between the editorial and brand teams.

Publishers aren’t just becoming retailers either. They are also joining the education sector. Susie Forbes, former deputy editor of British Vogue, is now the principal of Condé Nast College of Fashion and Design, which opened a month ago and currently offers a 10 week course, leading to a Vogue Fashion Certificate, aimed at helping aspiring fashionistas enter the hugely competitive industry. From October, it will offer a one year Vogue Fashion Diploma. The college is also thinking about offering two year undergraduate degrees and partnering with a university to offer a Masters Degree programme.

When the college opened, there were 180 applicants for 45 places, many of them graduates in other disciplines rather than school leavers. She told the meeting: “We needed to refect the quality and excellence of magazine brands. If our students are engaged, brilliant, and highly employable, we will have been successful.”

The company needed to learn about compliance and accreditation before the college opened its doors. Students are taught by visiting designers, journalists, and stylists, including some Condé Nast staffers. How do they feel about taking time out from their Devil wears Prada day job to teach? Forbes joked that editorial colleagues run the other way when they see her coming since she took on her new role, but tutors are mainly drawn from the wider fashion industry.

Both Radio Times and the Condé Nast titles are unashamedly consumer titles. How are business publications diversifying? William Drew edits Restaurant. In 2002 the catering title ran a feature about the world’s 50 best restaurants. That feature has since spawned an industry sponsored three day annual event in London, an accompanying book launches listing the top 50 restaurants (as voted by 900 experts), and accompanying food festivals.

When the Danish restaurant Noma was named No 1 last year, it received 100 000 reservation requests in 24 hours. The website announcing the winners had 500 000 visits in the three days after the announcement of the 2012 winners.

Drew told the conference that the 50 Best Restaurants event was successful because it had strict voting criteria, was industry led but relevant to consumers, and a mix of print, digital, and face-to-face events. There are now offshoots covering Asia and Latin America.

What has any of this to do with the BMJ, I hear you ask. More than you’d think. The journal has extended its brand (horrible phrase!) in recent years.

The day after learning about the 50 Best Restaurants initiative I was in a packed London hotel ballroom watching comedian Dara Ó Briain present BMJ Awards to 14 winners. Categories in the sponsored event—the fifth to be held—include research paper of the year and team awards covering primary care, mental health, cancer, child health, diabetes, patient safety, renal medicine, technology, and cardiovascular medicine, among others. For the first time in the event’s five year history we awarded a “grand prix” medical team award to BRINOS, set up in 1988 to treat ear disease among patients living outside the reach of hospitals in the Nepalese capital Kathmandu. As I mentioned in a previous blog, next year our first BMJ Awards for India will be held.

We don’t have a college like Condé Nast, but we do run a successful learning product offering online modules and Masterclasses. Also, instead of running paid courses about medical publishing we award £1200 grants to medical students who come each year for the eight week Clegg Scholarship placement. It’s very hands on and there is no formal training. Editorial colleagues also regularly get invited to run writing for publication workshops in the UK and overseas.

Would any of Radio Times‘s initiatives work on the BMJ? I’ve struggled to think of how a BMJ Travel division would work (disease hotspots of the world?!), but I do recall a colleague suggesting some years ago that print BMJ readers might like a wine club of the kind run by Laithwaites for The Sunday Times.

Can brand and product extensions of the kind described above damage your core product? This gets taken very seriously at the BMJ. We have a brand integrity group, led by editor in chief Fiona Godlee and Luisa Dillner, head of research and development. The group meets regularly to discuss sponsorship guidelines and other potential synergies (and conflicts) between our commercial and editorial outputs.

So all ideas for wine clubs, travel agencies, or gardening offers (perhaps tied in to the BMJ blogger Richard Lehman’s Plant of the week?) would probably face the brand integrity team’s scrutiny.

David Payne is editor, bmj.com, and readers’ editor.

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Each year the BMJ runs an online reader survey. The survey is mainly multiple choice but there is also a free text question where we ask readers: “What single improvement to bmj.com would make the most difference to you?” Every year the most popular response is “Make it free.” There are other recurring responses to the survey. In 2012 there were lots of requests for a simpler navigation and less clutter, a better search engine, and clearer access to article pdfs.

Let’s start with the “free” question. Like all other publications, the BMJ incurs costs. There are salaries to pay and the journal needs to develop, so removing the paywall is unfortunately not currently an option (although there is a lot of free content on the site, including open access research, blogs, podcasts, and articles we decide to make free for a fixed period, including ones linked to press releases.)

This very valuable reader feedback is very much in our minds just now as we embark on the next stage of the website’s development. The site needs to work better on mobile devices. Of the 1.5m visits to bmj.com in the last 30 days more than 250,000 were from mobile devices, including tablet computers. The number is rising all the time.

Later this year we hope to launch a “responsively designed” BMJ website with pages that adapt to desktop, laptop, and mobile computer screens, including smart phones and tablets. This provides an opportunity to remove some of the aforementioned clutter—maybe some house ads advertising BMJ events, some content feeds that aren’t getting many clicks etc. We removed some in December 2012. We can and will do more with a responsively designed site.

Our designer is currently mocking up some pages. It’s early days yet, but they look good so far—article pages in particular look very clean and simple, which is a challenge with a full text research article with tables and supplements to signpost.

Our last redesign was not that long ago—in November 2011. The BMJ website is the most visited of all the company’s websites, so colleagues on sister products value having a space on our pages to promote their content or services. Currently we have feeds from doc2doc, research from our specialty journals, links to learning modules and masterclasses, and to BMJ portfolio, where doctors track and record CME/CPD credits.

We have just added a tool called crazyegg, which generates a “heat map” showing where site visitors have clicked. We realise that many of these links to sister products get very few clicks, so we will be using these heatmaps to prioritise what gets displayed where, if at all.

The brighter colours on the two images below show the homepage hotspots. The first, for example, shows that the research, education, and careers sections generate the most heat. The search box also fares well, as do some of the top links to sister products (journals and jobs). The second image demonstrates how our eye gravitates to the centre of the screen, clearly at the expense of the section immediately below, which contains a feed of latest Endgames articles and forum discussions on doc2doc.

Finally, another important change to communicate is the company’s name change. Two weeks ago we stopped being BMJ Group and simply became BMJ. The flagship journal becomes The BMJ. We will need a new url as the company website will have bmj.com as is its web address. We are still working out what this will be, but the company site bmj.com will feature the journal in a prominent slot. We also hope readers will bookmark the journal website with its new url when it goes live.

David Payne is editor, bmj.com, and readers’ editor.

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Cuba’s population witnessed huge economic change after losing the former Soviet Union as a trading partner in 1989. Food shortages caused by the downturn led to obesity rates falling from 12% to 7% in six years, an average weight loss of between 4-5kg across the whole population.

The country also introduced new green policies, including the creation of neighbourhood gardens and the arrival of 1.5m imported bikes from China.

Can developed countries currently affected by the economic downturn learn from Cuba’s experience? Can it be used to prevent cardiovascular disease and diabetes in say, Spain, the UK, and US? How important is a country’s transport policies in helping to reduce obesity and diabetes incidence?

All of the above information was gleaned not from the full text or abstract of a BMJ research paper, but from the video abstract  published to accompany it when it went online last week.

Manual Franco, associate professor in the social and cardiovascular epidemiology research group at Alcalá University Medical School, Madrid, was the lead author. His paper investigates population-wide weight loss and subsequent weight gain in relation to diabetes burden and cardiovascular mortality in Cuba between 1980 and 2010.

Video abstracts are a first for the BMJ. The seven minute clip, narrated by Professor Franco , describes how the research team analysed Cuba’s mortality data, cardiovascular health data, plus primary care chronic disease registries, to reach their conclusions.

The abstract was one of three published, all of them available on the BMJ website’s multimedia page, as embedded files in the actual papers, and on our YouTube channel. The second abstract accompanies a cohort study that assesses the association between obstetricians’ years of experience after training, and the maternal complications of their patients during their first 40 years of post-residency practice.

Co-author David Asch, an associate professor at the University of Pennsylvania, asks in the four-minute film: “This study tethers clinical outcomes with medical education. The more we can evaluate how good our training program is with how good the care is, the better able we are to develop good training programs that suit the nation’s needs. Are our training programs producing the kind of doctors? ”

The third video abstract accompanies a systematic review and meta-analysis of observational studies and investigates the association of coronary artery calcium score with all cause mortality and cardiovascular events in people with type 2 diabetes. Caroline Kramer, endocrinology research fellow at Mount Sinai Hospital’s centre for diabetes in Toronto, says in the film: “Our results suggest the need for further investigation, particularly oweing to the implications that a negative screening test may hold for the clinical certifcation in this patient population.”

Video abstracts were first discussed more than a year ago at a meeting between the BMJ and Institute of Physics. The IOP introduced video abstracts to its New Journal of Physics in 2009 and describes them as a way of enabling authors to “go beyond the constraints of the written article to convey their research.”

The journal provides a page of author feedback about video abstracts. This one from Mark Fromhold, a physics professor at the University of Nottingham, is typical

He writes: “Video abstracts convey the core of a paper quickly and directly by combining authors’ commentary with animations. This format makes the paper more visible and accessible to the scientific community and is also ideal for outreach—which increases the value of the publication.”

From now on we will routinely contact the authors of accepted papers and ask them to consider submitting a short film. We hope the three uploaded so far, each of them very different, will inspire others to follow suit. In time we will publish guidance on bmj.com, after we have had some feedback from readers, so we can advise which approach is the most popular.

Video abstracts don’t have to be slick films with high production values. Most will be a simple piece to camera from an author explaining what a paper set out to investigate, what approach was taken and why, and a summary of the results and conclusion.

Professor Franco hits the nail on the head when he describes his Cuban paper: “This is more than a story about statistics. It is also a story about people.”

For more information about video abstracts, contact BMJ multimedia editor Duncan Jarvies at djarvies@bmj.com

David Payne is editor, bmj.com, and BMJ readers’ editor.

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In the early 1990s I spent the weekend at the home of a friend’s parents, both of them GPs. I’d recently started work as a political news reporter on the GP magazine Pulse. “Never read it,” said my friend’s dad. “I’m a BMJ man through and though.”

He’s now retired, but whenever I visit a well-thumbed copy of the latest print journal sits on his desk. At the time I did not ask how he defined a “BMJ man,” but now realise he likes the journal’s general readability, and its mix of peer reviewed research and educational articles, editorials, and obituaries. At the time he had little interest in medicopolitical news which the BMJ’s competitor titles for UK family doctors (Pulse, GP, and Doctor) covered comprehensively.

I thought of my friend’s father two weeks ago at the annual meeting of the BMJ’s editorial board, a group of internationally renowned and active clinicians, clinical academics, and health policy experts. A large part of the meeting was spent discussing what the BMJ should be covering in the year ahead, but there was also a long discussion about what distinguishes the journal from the world’s other general medical titles (Lancet, NEJM, JAMA, PLoS etc).

What, in other words, is the journal’s unique selling point? What is it that its readers like and value? Is its “Britishness” a strength or weakness, particularly to international readers? How can it appeal to both primary care doctors and secondary care doctors? Does the voice of patients have a place in the journal, and if so, how? What about other health professionals? Should it cater for them too?

When my friend’s father was working as a GP in Herefordshire the BMJ was a very different beast. It carried less news, there was no website, blogs, podcasts, videos, or iPad edition, there were no arresting cover images (the blue cover doubled as a table of contents). Nowadays the journal employs both doctors and journalists, it runs campaigns and investigations, offers Cleveland Clinic CME points, carries both UK and international news, and uses email alerts and social media to let readers know when new articles appear online each day.

In a typical week we now publish almost 100 articles online (excluding blogs and multimedia). This forces readers to filter in some way. How can we make that easier? One board member suggested badging our international offering BMJ World, as the BBC does. Another proposed that we recruit a UK editor to commission and curate articles most relevant to UK readers (although arguably we do this already when we decide what goes in print each week, and which articles to promote on our designated homepage for the UK). We explained a recent decision to scale back on medical humanities content (no more reviews, for example) because they fared poorly in reader panel surveys and in online hits. This was felt to be a shame. There was a similar call to commission more articles on ethics.

Most board members weren’t aware of these recent changes. At lunch one said the journal’s readability was doubtless because of the journalists on the staff. Another responded to an update from us about recent campaigns and investigations (transparency, research ethics etc) by describing us as “an objective haven for tough issues.”

We also talked about influence and impact, particularly internationally. One board member suggested partnering more formally with newspapers like the New York Times, which not only covers many of the articles we press release but also highlighted the annual “dose of fun” in our Christmas issue. We do partner with other publications and channels UK organisations (the Daily Telegraph and Channel 4 Dispatches for many of our investigations.

There were comparisons with other international titles. The NEJM website was commended for the way it clusters articles online. The board liked PLOS commentaries that accompany research papers and are written by someone at the journal.  Authors appreciate being able to ask pre-submission queries and like to see their articles covered in mainstream media (the BMJ’s press office, incidentally, works hard to ensure press released articles get covered by national and international media, and we have a PR agency in New York with excellent access to medical correspondents).

Some of this feels a world away from the needs of a Herefordshire GP, and it is a challenge to balance the (sometimes conflcting) information needs of UK readers working in primary and secondary care alongside those of international researchers, and doctors in developing countries. Perhaps there is no such thing as a BMJ man or woman anymore?

David Payne is editor, bmj.com, and readers’ editor

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In 2011 research physician Tristan Barber responded to an editor’s choice on conflicts of interest, saying: “Reading the current BMJ and noting several letters regarding conflicts of interest, it was particularly distracting to have the front cover being a fold-out advertisement for a pharmaceutical product.

“As a consequence I was very aware of all of the pharmaceutical advertising throughout the current edition. This may have been commented on before, but whilst considering industry impact on researchers and authors, has there been much consideration of the impact of advertising within a journal on the opinion of readers on its editorial policy or contents?”

Dr Barber’s concerns sprang to mind last week when the BMJ’s editorial advisory board assembled in London for its annual meeting. The board consists of internationally renowned and active clinicians, clinical academics, and health policy experts.

As part of the meeting we discussed the journal’s Too Much Medicine campaign, which aims to highlight the threat to human health posed by overdiagnosis and the waste of resources on unnecessary care.

One board member asked how we square campaigns about overdiagnosis and overtreatment with a business model that relies on pharma advertising for new drugs. More specifically, if there was evidence that a drug fell into the category of too much medicine, would we still publish it? Does anybody at the BMJ vet them to ensure that a drug’s benefits aren’t over-stated?

Editor-in-chief Fiona Godlee compared the BMJ campaign and its advertising policies with The Guardian newspaper, which has a long-standing interest in highlighting climate change, but still publishes hefty travel supplements with advertisements for long haul travel.

BMJ Group believes that the sale of display advertising space is a legitimate source of revenue to support the publication of its journals in print and online. The BMJ’s advertising policy asks that ads are “legal, decent, and honest” and comply with the laws of the country in which they are to be seen.

Advertisers shoulder this responsibility, working within the regulatory codes of practice devised by bodies such as the ABPI  At the BMJ we often talk of the “Chinese wall,” a clear demarcation between the advertising sales and editorial teams. This safeguard helps to avoid conflicts of interest, and means advertisers have no prior knowledge of an article that may mention their product, either positively or negatively. You can read our advertising policy on the BMJ Group website  It’s quite complex and is currently being restructured to make it easier to navigate.

The policy has separate sections for some products, such as tobacco and food. Two years ago the BMJ was accused of running an ad that lent credence to a marketing campaign sponsored by bottled water manufacturer Danone on the Hydration for Health website.

Glasgow GP Margaret McCartney  led the charge on her blog before writing a follow-up BMJ feature  about the evidence to support the idea that we don’t drink enough water. The journal decided the ad had breached BMJ Group’s advertising policy about foodstuffs, which states: “Advertisement for foodstuffs, food supplements, vitamins, and minerals should conform to the guidelines of the British Code of Advertising and Sales Promotion and should be submitted with full substantiation of all claims.

“All claims must be referenced to full length research papers published in peer reviewed scientific journals. (Abstracts won’t do.)The BMJ editor must approve all advertisements before publication.”

If readers dislike an ad, they can follow McCartney’s example and complain to the journal, usually by submitting a response. The advertiser is then shown the response and asked to comment.

Why does any of this matter? Perhaps this is best explained not by the BMJ but by self-styled “grumpy scientist” Dr Aust, who responded to McCartney’s blog post about Hydration for Health’s ad on bmj.com: “Honestly, if the BMJ are going to let this kind of sh*te run on their site, what hope is there for the rest of us trying to counteract all the “Hydration balls” in the mainstream press etc?”

David Payne is editor, bmj.com, and readers’ editor.

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At the beginning of 2013 bmj.com’s most accessed article in India typically received between 100 and 200 views. In three months the figure has more than doubled.

In the first full week of January there were 9,784 visits to bmj.com from India. The figure has been rising since. Last week there were 12,121.

In November 2012 we ran our first online poll for readers in India. Should the UK withdraw aid to India, we asked. The poll was live for two weeks, and it received just 64 votes, with 40 saying no. Our latest India poll, “Should AYUSH doctors be allowed to prescribe allopathic drugs?” received 217 votes over two weeks. Of that figure, 114 readers (52.5%) said no.

There have been other modest gains. We now have more bloggers from India,  including neurosurgeon and telemedicine guru Krishnan Ganapathy, and Soumyadeep Bhaumik, a medical researcher and freelance writer who also wrote the recent BMJ practice article on snakebite. Soumyadeep also writes regular news items for us.

What changed? Last month the BMJ’s online edition for India was formally launched with events in four cities—starting at the British High Commission in Delhi, and then moving to Kolkata, Mumbai, and Chennai. Hundreds of people attended the receptions, many of whom had travelled for hours to join us. The events were hosted by editor in chief Fiona Godlee and BMJ India editor Anita Jain, a graduate of Seth GS Medical College and KEM Hospital in Mumbai.

What do readers make of BMJ India? In the very near future we will be running an online survey (we just surveyed our US readers, and received more than 1,000 responses in less than two weeks), but responses to the editorial we published last month to mark its formal launch encapsulate the pros and cons of “editionalising,” either online, or in print.

Prashant Sharma, a haematopathologist at the Postgraduate Institute of Medical Education and Research in Chandigarh and a BMJ reader since medical school. said of BMJ India: “I’d be interested in its choice of perspectives and opinion… I browse the British edition for its very distinctive cultural insights and takes on the goings-on in the world and the UK (its one of the 2-3 international journals I choose to do that).

“I’m a bit ambiguous about whether the local edition will be able to offer me any extra juice worth my time in that regard. After all, there are many Indian journals and eNewsletters I can refer to about medicine in India…But mostly, its very flattering to note that readers like me figure on your list of priorities! All the best!”

I told Dr Sharma in my response that the aim of BMJ India was to showcase Indian content but at the same time include articles from elsewhere of interest to our readership. Visitors from India see the India homepage automatically, but readers can flip between our other online editions (UK, US, and international), to see what else is being published. I assured him that we will always include articles of global relevance on all our editions. And our online table of contents lists all articles published in the previous seven days. You can access it at this link.

B M Hegde, editor in chief of the J Science of Healing Outcomes, Mangalore, welcomed the new edition, but detected a hidden agenda—better business for the journal. “The Indian economy is looking up and people have more money in their pockets. They are likely to subscribe more and more, more so because of the BMJ’s reputation. Sheer numbers make good business sense,” he said.

Dr Hegde is right. Journals do need to make money through subscriptions, sponsorship, and advertising, but I don’t think the BMJ conceals its need to make money. The income we raise helps to pay salaries and offset the costs of providing free content such as open access research. A video produced to mark the launch describes other free content available on the site.

Price

The journal’s current price did get raised at the launch events in Delhi, Kolkata, Chennai, and Mumbai. We are currently working on a new pricing structure. Details will be unveiled soon, and any price change (both for international and personal subscriptions) will ultimately be decided by BMJ colleagues based in India. We hope eventually to set our price for India in rupees so that isn’t subject to the vagaries of international exchange rates.

Print

Ranjan Kumar Singh, a physician at Khagaria District Hospital, said: “It would be better to have Indian edition of the journal in print too. A few years back BMJ had a South Asia edition in print form, which was edited locally.” Dr Singh is referring to the 2004 theme issue, which was very popular at the time and is still widely discussed by readers in India.

Technology has since moved on, so we have no current plans to publish a one-off issue in print. We are confident that our India offering is an improvement on this—regular news, comment, research and education of interest to readers in India, showcased in an online edition for India.  We also plan at some point to produce an special issue for iPad and Android devices, similar to the one we published last week about the Mid Staffs inquiry report. Perhaps even an app focused on Indian content, similar to the current one based on the print edition. Tell us what you think, what issues we should be covering, your thoughts on pricing, and what formats would work best.

Awards

A second exciting development in India is the announcement of the first BMJ Group Awards for India, taking place in 2014.  The first BMJ Awards are currently held in London each year. The first took place in 2009. Since then some of its winners have come from India.

“We hope to make it the “Oscars” of Indian medicine,” said Tim Brooks, CEO of BMJ Group.

David Payne is editor, bmj.com, and readers’ editor.

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Last year a colleague phoned a patient named in a BMJ practice article. The patient had consented to her story being published (it was about to go live), but had wrongly thought her account was destined for publication in an obscure medical journal that would gather dust on library shelves.

My colleague was concerned that the patient might not realise that because bmj.com is well optimised for search engines, her name and details might appear high up in a list of Google results for years to come. It would also be seen by the BMJ’s 120 000 print subscribers, and those with access to the journal’s iPad app. Instead the woman opted to have her first person account anonymised, so she could not be identified.

This incident, described at a refresher course on patient consent for BMJ staff last week, illustrates how seriously the journal takes patient consent. Do doctors worry about getting a patient’s consent if they mention him/her in an article? Many do, of course, but the BMJ’s experience is that some need reminding of its importance, particularly since it could result in censure by the General Medical Council (GMC) and other medical regulatory bodies.

According to human rights and data protection legislation, patients have a right to confidentiality. Even if they are not named, they could still be identified. The fair thing to do is ask for consent.

The BMJ’s 1991 guidance was published at the same time as similar advice from the International Committee of Medical Journal Editors (ICMJE). Our experience since then has been that most patients grant consent, but if an author cannot get it (perhaps because a patient has moved away), their details can be anonymised (describing a 50 year old as middle aged, for example) by applying the following test: “whether a reader, knowing the underlying facts, would reasonably be able to identify the person being discussed.”

On some occasions we have anonymised an author’s details to protect patients further, usually when the issue being discussed is so overwhelmingly in the public interest that it merits wider discusssion. One example is a personal view article, published in November 2012, describes how it feels to withdraw feeding from newborn babies. The article was by a doctor practising outside the UK, but the location was not disclosed to protect the families involved.

Can doctors discuss a dead patient’s medical history? The 1988 Data Protection Act applies to the deceased, but the GMC says a doctor’s duty of confdentiality continues. Will writing about them distress family members? Does their medical history justify disclosure? Are relatives available to contact? We try to take all these into account before publication.

What about children? If the child is deemed old enough, they should be asked. If not, ask their parent or guardian. How about if a patient lacks capacity? As with children, the person acting for them has to consider their charge’s best interest. The chart below illustrates the process used by the BMJ to get consent, and what happens when it is refused or cannot be obtained. You can open it as a pdf at this link.

Consent also applies when images are used to illustrate an article.  If the ones chosen could potentially identify the patient, an author should get consent.  In 2001 a reader challenged the BMJ’s policy after we published an image in a news story of a nine year old boy with attention deficit hyperactivity disorder. What did the picture add to the article?  Should different standards apply to journalism? BMJ news editor Annabel Ferriman said in response to complaints that the boy’s story, including quotes from his mother and photographs of him, appeared widely in the US media. In effect the photograph was already in the public domain, she argued.

Richard Smith, then editor of the journal, described how news photographers usually do obtain consent, apologised if the picture caused offence, and said he would ask the journal’s ethics committee to review the BMJ’s policy. The image had been used in the mainstream media. Should the BMJ apply a higher standard?

The BMJ refresher course mentioned above was attended by both the journal’s medically trained staff and its journalists. Names make news, we are told at journalism school – we like to know addresses, ages, how many children, all of which add colour, detail, and, well, emotion to a story.  If we breached a patient’s confidentiality, we would not face the GMC, but the BMJ might be reported to the Press Complaints Commission.

Would we use that image today, given that it was already in the public domain?

David Payne is editor bmj.com, and readers’ editor.

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Yesterday morning the BMJ’s press officer needed to locate a rapid response about Tamiflu from Peter Doshi, a postdoctoral fellow at Johns Hopkins University, Baltimore. Doshi’s response accuses the drug’s manufacturer Roche of “all talk and no action” following its promise to share full clinical study reports (CSRs) for 10 treatment trials.

Our Tamiflu open data campaign page was a logical starting point. It wasn’t there. Doshi had in fact responded to this news story, posted last week: Roche says it will not relinquish control over access to clinical trial data.

Our press officer’s problem was doubtless one experienced by many bmj.com readers. How do you find a response’s online location? Arguably we make it harder for readers by often commissioning three or four articles on a similar topic. Head to head articles are a classic example. Our last two head to head articles asked, “Should the NHS work at weekends as it does in the week?” Yes, argued NHS medical director Bruce Keogh. Paul Flynn, chair of the BMA’s consultants committee, disagreed.

Keogh’s article received 42 responses. Flynn’s received three. Surely it would be better to have a single response stream, sparing readers the inconvenience of accessing both articles to read what people are saying?

We can turn off commenting on specific articles, but don’t tend to, unlike other publications, such as The Guardian, according to Tom Happold, its former head of multimedia, whom I met last week. Should we disable responses on some articles, so the debate is concentrated in one place?

The head to head issue could be easily solved by posting these as a single article. We have considered this in the past. But it might be tricker for more complex bundles of articles. The BMJ investigation into sports drinks, for example, published last July, included six features and an editor’s choice. The main feature attracted 19 responses, another attracted five, and the remaining four one each. The editor’s choice also attracted one.

The wisdom of the crowd suggests that readers are logically drawn to a main article. Supplementary articles seem to raise legitimate questions, and so it would be wrong to deny readers the opportunity to respond. And responses are searchable. But does this serve our readers, many of whom might prefer to read a single thread of comments rather than having to switch between articles?

David Payne is editor, bmj.com, and readers’ editor

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Sir David Nicholson, head of the NHS in England and chief executive of the NHS Commissioning Board, has faced repeated calls for his resignation after publication of the Francis Report inquiry into failing at Mid Staffordshire Foundation NHS Trust. Nicholson was chief executive of the strategic health authority overseeing the trust for a period when death rates were found to be high.

Last week the BMJ’s weekly online poll asked UK readers if he should resign. Of the 736 votes cast, 88.4% (651 votes) said he should. Because the subject was very NHS focused, we ran separate polls for our India and US online editions.

Polls usually run for a week, and the subject/wording gets decided at the editorial team’s Tuesday morning meeting for inclusion in that week’s print issue. The issue goes to press on Tuesday evening and reaches UK readers on a Friday or Saturday. We also promote polls on our Facebook and Twitter feeds.

On Friday evening a Department of Health press officer left a voicemail for BMJ editor in chief Fiona Godlee. He wanted to discuss the poll. The BMJ press officer left a message with the DH press office, but so far they have not got back to us.

A poll’s wording tends to generate lots of internal discussion. This one was no different. When we first proposed it one colleague suggested that we amend it to “Are calls for Sir David Nicholson’s resignation reasonable?” We thought this was too lily-livered.

Another colleague wondered if we should wait for a future BMJ article calling for his resignation. We usually link to a relevant article online, but as there was no article in the pipeline, we felt the delay would sacrifice topicality.

There was a further concern that the poll wording was too ad hominem, but we felt we had to be specific and name the person.

It isn’t possible to comment on BMJ polls, and although we haven’t run any articles explicitly calling for Nicholson’s resignation, we did have this response to an editor’s choice article about the Francis report. He said: “No. Dismiss. Deny further employment. Deprive pension. Gag him. Blow his whistle.”

Should the BMJ have run this poll?

David Payne is editor, bmj.com, and readers’ editor

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This blog is the first in a series about you, our readers. Fiona Godlee, the BMJ’s editor in chief, suggested I write a regular blog explaining some of our policies and procedures. Many of them have been in place for decades, but our readership of practising physicians and academic researchers may not be aware of many of them. I’ll aim to choose topics based on recent questions from readers around the world who see the journal in print, online, and on the iPad.

But firstly, why me? I edit bmj.com, and over the last five years I’ve written a number of articles about digital developments and future priorities at the BMJ. Secondly, a big part of that role is fielding reader queries. I and my colleagues in the web team get asked all sorts of questions.

Yesterday, for instance, a US sports physician from Concord, North Carolina, wanted to know how to cite a BMJ article about first rib fractures, published in 1869. Readers like him were on our minds last week, when we held a BMJ editorial strategy session in Baltimore. I and some of my colleagues discussed what the hot issues are in US healthcare and how we should cover them in the journal.

The BMJ is the first international medical journal to launch an online US edition. We now have 20 US employees, including a US news and features editor based in New York, and two research editors (one based in Washington, the other in Boston), plus a growing stable of freelance journalists and columnists working across the US.

One of the issues we considered in advance of the launch was how to accommodate US spelling and punctuation into BMJ house style. We resolved this by deciding that house style is to reflect the reader, not the author. This means that articles about the US that display online in the US edition should be in US English.

Laboratory values may be expressed using either conventional or Système international d’unités (SI) units, depending on what the author uses, with conversion factor expressed secondarily (in parentheses) only at the first mention.

Articles that contain numerous conversion factors may list them together in a box. In tables and figures, conversion factors may be presented in the footnote or legend. The metric system is preferred for the expression of length, area, mass, and volume. Conversion factors can be obtained via the Units of Measure table in the the AMA manual of style.

Our US edition launched in September 2012, so we now have some analytics data to help us decide what kind of articles are popular. This helps us to decide our editorial priorities for the coming year. Unsurprisingly, US readers have similar tastes to readers elsewhere. Investigations, research, and education articles get lots of traffic, along with Christmas BMJ articles .

But surprisingly, the most read article in the US in 2012 (34,231 US page views and counting) was a Finnish cohort study published on November 30. It explores the extent to which muscular strength in adolescence is associated with all cause and cause specific premature mortality.

So far the study has not been cited and has only had two responses, but it did attract lots of US press coverage, 1000 Facebook likes, and 128 tweets. The top five most read include Brian Deer’s January 2011 series on Andrew Wakefield and the impact of his 1997 Lancet paper false linking the MMR vaccine with autism. Here’s the top five articles read in the US in full.

• Muscular strength in male adolescents and premature death: cohort study of one million participants
• The truth about sports drinks
• Why Rudolph’s nose is red: observational study (Christmas paper)
• Low carbohydrate-high protein diet and incidence of cardiovascular diseases in Swedish women: prospective cohort study
• The difference in blood pressure readings between arms and survival: primary care cohort study

One response to the editorial published to make the launch of our US edition said: “I am attracted by the journal’s good writing, honesty, and relative absence of Marxist enthusiasm. This is in comparison to the NEJM and JAMA. Please remember that this American is interested in the mother country’s side of things.”

A second US reader who regularly responds to articles, told me: “I read the BMJ because it’s more than merely informative. It’s also appealing, personal, friendly, and diverse. In contrast, I find most US medical journals impersonal, pedantic, pretentious, and exclusive. But beneath these cosmetic differences, both BMJ and US medical journals share a subservience to Big Pharma, which limits medical progress.”

A third US reader told us: “The BMJ is more trustworthy than American journals, which rely on conflicted peer reviewers and depend on ads and supplements bought by pharma.

“American medicine is calculated so as to “not rock the boat.” In contrast, commentary on BMJ articles is much more intellectually-provocative with a more literate and livelier writing style. The BMJ provides maximum connection to cited materials. It is a pleasure to hunt down sources to assess accuracy of authors’ and commentators’ interpretations.

“The BMJ also provides many more open access reports than most American medical journals. [BMJ editor] Fiona Godlee is doing a first rate job. A world leader who displays great courage in addressing controversial issues that have domestic and international implications.

“Maybe “British” in ‘BMJ’ reflects the outlook of the former British empire. We Americans, in contrast, are so insular in our views! Dr. Godlee’s stance and the new BMJ policy relating to access to data underlying published research reports will profoundly affect the policies of medical journals everywhere. The mark of any great journal is its influence. The BMJ stands “heads and shoulders” above its peers.”

David Payne is editor, bmj.com

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