Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA. E-mail: firstname.lastname@example.org.
First published October 1, 2014 - More info
Arnold Relman, one of the foremost public policy thinkers in American medicine and distinguished editor, died on June 17, 2014 from malignant melanoma. Relman, affectionately known as Bud (Figure 1), was a physician-scientist who began his research career at Boston University as a nephrologist studying patients with acid-base and electrolyte disturbances. He later became chair of the Department of Medicine at the University of Pennsylvania and subsequently professor of medicine at the Harvard Medical School. He served as the editor of the JCI from 1962 to 1967 and was the editor-in-chief of the New England Journal of Medicine (NEJM) from 1977 to 1991. I was fortunate enough to follow in his footsteps as editor-in-chief of NEJM and to know firsthand the impact of his work.
Arnold (Bud) Relman.
Bud was a member and former president of the American Society for Clinical Investigation. On May 5, 1969, he delivered one of his earliest public policy speeches as part of his presidential address at the annual meeting of the American Society for Clinical Investigation in Atlantic City. Bud had given and survived many talks to the same audience over the years, but these presentations had been based on his acid-base and potassium research. In fact, all of his publications before then were on renal and electrolyte subjects. This time, however, a Society tradition required that he rise above his research interests and address the group on a policy issue. And this was no ordinary medical audience. Society members (the “Young Turks”) were joined by members of the American Federation for Clinical Research (the “Squirts”) and members of the Association of American Physicians (the “Old Turks”). It was an assembly of the most prominent and influential members of the American academic, education, and research communities.
Bud had chosen a controversial topic, namely the role of academic medical centers and researchers in particular in contributing to the needed reformation of the nation’s health care system, especially its escalating cost. By the time he became engaged in the discussion, the federal budget’s support of the National Institutes of Health had grown to more than a billion dollars, and health care planners across the country had begun to look to the medical schools and teaching hospitals, including the research community, for help and involvement in needed change. Yet some distinguished, prominent, and influential academics had taken a rather purist view; they argued that taking on any medical care service function would jeopardize the scholarly work that advanced medical science (1).
Bud started his talk humbly, claiming that he had no special wisdom and no solutions to offer; yet by grounding his argument in the principle of medicine as a profession and the necessary obligation of a profession to serve society, he made the case that, by accepting such massive financial support, researchers had incurred a social contract with the public. The research community, he claimed, had a societal responsibility that transcended its work in the laboratory. He audaciously urged his colleagues not to be “frozen into a . . . posture of fruitless protest,” and because they had become a public institution, he urged them to “have a voice in the formulation of public policy” (1). He had expressed a principle that would inform his thinking for the next 45 years.
Bud’s earlier five-year stint as editor of the JCI in the mid-1960s had already yielded an important but little-known breakthrough in medical publishing. To many, editing this most prestigious biomedical research journal was only a rite of passage, just another impressive entry in an expanding curriculum vitae. For Bud, it was anything but: the role became an inspiration and proving ground for another of his major contributions in medicine, namely the beginning of a discipline that later became known as “journalology,” consisting of a set of technical and ethical policies governing publication in medical journals. In his 1966 editor’s report to the Society board, he drafted principles and standards that he had invoked for the major participants in the enterprise: authors, reviewers, and editors. For the system to work, he wrote, the author must offer material that is “new, valid, and of significance in its field” but the author must also be willing to face the judgment of his peers. The reviewer, he offered, must be no less knowledgeable on the subject than the author, and his critique must be not only rigorous and thorough but constructive and free of rancor and personal bias. He averred that the editor’s responsibility was to assure that manuscripts “receive a prompt, fair, and competent review” and that the editor must be an impartial, consistent judge and must protect the author against arbitrary and unjustified criticism. He believed that to preserve frank, dispassionate expressions of opinion, reviewer anonymity had to be preserved (an issue still in active discussion today).
“Journalology” later became a signature initiative of Bud’s subsequent fourteen years as editor-in-chief of the NEJM. Within a year of assuming this post, he and three other medical journal editors founded the Vancouver Group (named initially for the city in which they met). The group, which later expanded and became the International Committee of Medical Journal Editors, initially designed standards for the format of submitted papers, which allowed authors whose papers had been rejected by one journal to use the same format to submit to other publications. In later years, again with major input from Relman, the group also developed uniform standards that defined who could be considered among the author list, who would be appropriate to be included in an article’s acknowledgments, how to deal with misconduct in publishing, and what to do about other issues of ethical concern. These standards, the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, are updated every few years and have become requirements of hundreds of medical journals.
As editor of the NEJM, Bud had an uncanny capacity to identify important new trends that affected the profession and the health care system. The most widely acknowledged issue was his concern that the health system was rapidly being taken over by profit-seeking businesses that were not fulfilling the social contract that he believed should characterize the profession. In what is now considered a classic article, entitled “The new medical-industrial complex,” he foresaw that this trend would accelerate the cost of care (2). He raised concern about the corrosive influence on physicians of financial conflicts of interest and was the first to institute journal policies to limit their impact (3). He not only required that all authors disclose all such arrangements with industry but later restricted financially conflicted authors from writing editorials and review articles for the NEJM (4). To protect the public from media news about research that had not undergone peer review, he enforced the Ingelfinger rule that stipulated that the NEJM would not consider articles if public announcements of the findings were made prior to publication or if the substance had been already been published elsewhere (5, 6). He covered a broad range of policy issues, including gun violence, marijuana use, research integrity, and medical malpractice. He encouraged debate on what he saw as an unsustainable health care system. At a time when debate on the structure of the US health care system was especially active, he sent a reporter abroad and published descriptive analyses of the health care systems of Canada, England, Japan, and Germany, countries whose experiences he thought had important lessons for us. He gave space in the NEJM both to conservative commentators, who favored managed competition, and to progressives, who advocated for a single-payer system. He argued repeatedly that investor-owned enterprises, including health insurers, were raising the cost of care without adding value to the system and often pointed to the low administrative costs of Medicare to make this point. In many editorials in the NEJM and in dozens of articles in journals, in books, and in the lay press after he retired, he made a compelling case for a single-payer financing system with no private health insurers, joined to a nonprofit delivery system, consisting of independent multispecialty groups of salaried physicians, all working within a global budget (7).
He was tough but fair. He was a scold but often right. He was persistent, but he had fervent beliefs. He was intense but human. He was a fine man and a terrific editor.
It was both intimidating and an honor to be his successor. He will be sorely missed, but his legacy as an editor and tireless advocate for policy change will live on.
Reference information: J Clin Invest. 2014;124(10):4152–4153. doi:10.1172/JCI78352.