George Lundberg Former editor of AMA Journal February 17, 1999 George Lundberg : I value your school a great deal.for many years specificlly in tech rep;roting in medical scince reportingwhich specific to there is a lot of fresh science and health reporting My name George Lundberg. I am from rural Alabama. where my grandparents all came from Sweeden. They came from Chicago about 100 years ago. anda s legen goes they missed the train in Minneapolis and ended up in Mobile Alabama of all places. Most of the Swedes...in Wisconsin and Minnesota and places like that. A few got to Oregon... Nebraska. Nobody went to Alabama except the folks that founded this little town halfway beween Mobile and Pensacola about 20 miles north of the Gulf of Mexico. A nice little town named Saberville(?) My mother was the first chid there. She was about one year old. The train arrived in Mobile They put them on a boat to go across Mobile Bay because there wasnıt a bridge or road. [They got a] oxcart and took it out to the land they bought. They ...land colony company in Chicago. They cut down trees and started to grow food and built a shack and stayed. They did very well. So I grew up in the South knowing little about the South because you donıt learn much about Southern History living in a Swedish colony.I finished hig school at fifteen. My mother was a first grade teacher. She was a very powerful and dominant woman. She also wrote a column for the local newspaper once a week. I watched her write it and maybe that had a lot to do with what I became. Came to North Port(?) college on Foster and Kedzie. Why? Because my parents didnıt trust me at fifteen to go anywhere but a religious school under close supervision of religious people in a fundemental Christian school. I was a junior college. I finished and went abck to the University of Alabama got my bachelors degree. Went to medical school in Birmingham at the Medical College of Alabama. Why there? I didnıt have much money and it was decent. It was close to home. Then I had an eleven year tour in the United States Army. It was to ... that draft that I was in medical school. I had been deferred because of the Korean War cause I was a premed. SO I was a cinch to get drafted. So I did apreemptie strike and I enrolled in the United States Army So they paid for my fourth year of medical school. The armyıs senior offical program, which still exists, as a way to get people voluntarily into military medical service. I got married. My wife was pregant quickly. I had to do an internship so I applied for a military internship although it wasnıt required. They accepted me and assigned me to Honolulu, Hawaii for an internship. I said I guess Iıll take that and went out there for a year. Lived in Waikiki. Had a great internshipIt was great fun. Tripper Hospital was the name of the hospital.When you get to the island. When you get off the airplane in Oahu. You look up in the mountains and there is this pink building that looks kind of spread out. Thatıs the army hospital. Itıs the army, navy air force, VA public hospital. After a year there I went to San Antonio for four year as a resident in pathology. I got a masters degree from Baylor University by doing extra work during that four years. And I finished in 1962...went to the letterman hospital in the presidio in San Francisco. IN the Bay Area, you go across the Golden Gate Bridge. On the south end of the bridgeis the Presidio of San Francisco. There used to be a great hospital there. The army closed it. The presidio is still there. Itısa national park. The developers all want to build. They all want to build big high rises there but the government has been able to fight them off. ITıs a wonderful place, a great place to walk through the trees down to the water, watch the Golden Gate Bridge with the sun on it. Itıs a great place. We were there for two years, lived in Marin County in San Rafael. Then the army said youıve been there for too long. Two years, youıre going to have to go somewhere else. I said OK where El Paso, Texas I said youıve got to be kidding me. Why would I go there. Because we told you to. They need somene to be director of pathology at the army teaching hospital. Two years out of residency Iıd have my own department to run. For three years I did that. It was very interesting. I wrote my first research paper in a medical journal when I was still a resident in San Antonio and I liked it alot. It was pubished in the New England Journal of Medicine. Still the best journal in the world although JAMA was getting close. I liked that. I liked that. My mother was very proud. I was hooked on the writing, the publishing. I continued to publish papers during my two yeas in El Paso. Two years into that I wrote letters to medical schools in the South and West. I wrote letters to eight schools and I was invited to five interviews. Atlanta, Birmingham, Dallas, Houston and Los Angeles. I got job offers from all five but I picked the one in Los Angeles for a lot of reasons. The first one was that they offered a little more money. IT was an associate professor ship with tenure and thatıs pretty unusual. .. To do what I wanted to do which was to teach and research especially drug abuse and disease. The second reason is that I didnıt want my kids growing up with a Southern accent. Cause Iıve seen the prejudice going back and forth, back and forth. Iıve been a Southerner in Yankee land without an accent. Iıve experience the anti south predjudice of Yankees even though I talked strange to a Southerner. And in the the south, I was predjudiced against as a Yankee even though I was from farther south than most of they were. I was from the Gulf Coast. I didnıt like that at all, so I wanted my kids to grow up with basically no accent. So I went to LA in Pasadena. The fourth reason wasthe guy who recruited me at USC had been to El Paso as a visiting professor. We had got along real well. He had a house in Pasadena and for my second recruiting visit out there he said, ³Well why donıt you come out and you can staya t my house. Go to the Rose Bowl and do all that stuff.² That was Rodriguezı year for Purdue. They played SC. It was 15-14...So itıs tough to beat the Rose Bowl on New Years Day and even Northwestern knows that once. (inaudible) at SC wrote a bunch of papers. Got to be expert in toxicology, drug abuse, that kind of stuff. Did a lot of teaching, spent time at the free clinic, like to Haight Ashbury free clinic created in San francisco. So after 10 years at SC. Iwas promoted. I got recruited to go as chair of pathology at Univerty of California at Davis Medical Center in Sacramento. Did that for five years. Taught, researched, wrote. Itıs an easy place to get in the public eye. You say stuff. You get on television. A lot of TV, some radio, not much newspaper. (inaudible) Editor in chief, multimedia at ...with responsibility for all of its scientific publications. Moved to Chicago, January 1. I had 17 years and 15 days in that employment situation. We built the JAMA from one United States edition with 290,000 circ. per week. Intıl editions in Japanese, German and French. into the JAMA with 350,000 circ. in English and 18 Intl editions. in 11 languages doubling our circulation worldwide. to 750,000 in 17 years. The newest ones are Jama Brazil in Portuguese JAMA Russia in Russian started in Spt. of last year in Moscow JAMA Greece in Greek, started in Oct. of last year. JAMA Poland in Warsaw. That was the week I was canned. I was supposed to be in Warsaw to lauch it instead I was at home trying to figure out what to do with my life and nursing my broken elbow. It lauched alright in Warsaw. SO thatıs 19 intl editions in 12 languages since Poland started. Itıs been an extraordinary adventure. I am eternally grateful to the American Medical association for giving me the opportunity to live and work in that environment. ...that Iım very very proud of. We turned something that was good and 100 years old into something great and has a chance to last a long time from now forward if the peopel in charge do it right. IF they donıt , itıs so hard to go up. Itıs very easy to freefall. Thatıs the risk that the organziationıs at right now. Along the way, they gave me responisbiity for the 10 archived journals that are monthly journals. Internal medicine, itıs twice a month actually. It has 100,000 circ. Archives of surgery, archives of psychiatry. all those are monthly. archives of family medicine is every two months.Each one has its own editor who are are professors or deans at major medical schools inthe Untied States not other countries. Weıre a classy bunch. Itıs the best one family of medical journals in the world by any criteria and then three years ago I was given responsibility for the weekly newspaper called Amercian Medical News. Circ. 250,000 - the best american medical newspaper by far. In 1995, we brought up the Web Site. www.ama.assn.org. You canıt say that very fast I was on Neil Rosenbergıs show on WGN. He said whatıs your website. He said orgy what orgy. I said come on. So Iıve been very careful to sayorg so as not to be misunderstood and misrepresented. There are always people who want to misunderstand and really want to misrepresent soI try not to give them stuff if possible. So thatıs there. Academically, as your professor already pointed out, Iım adjunct professor health policy, Harvard University for 7 yeras. I go to Harvard tomorrow, which is 8 weeks in a row in the Winter quarer...Professor of Critical pathology at Northwestern medical school. These are both nonpaying appointments. So thatıs basically my background. I brought almost nothing to show you except one sheet that weıve used to recruit the best papers. Thisis our marketing sheet with picutres of all the stuff that we have. the reasons why they ought to come to JAMA. Thatıs my intro. now itıs up to you guys. Thank you very much. Student Question: inaudible All scientific periodicals should have a mission statement. It can be a simple one sentence, a paragraph, a list of objectives. In any of those forms, itıs still a msision statement. The mission statement is the single most important thing the editor should accomplish with the publsiher. The editor and the publisher have to agree on the mission statement. They have to sign off on it formally. The editor has to do waht the mission statement says. IN the mission statement, it would not be unreasonable for an ideology to be explicitly stated or to be deduced by someone trying to figure it out. Ideology is a broad word. It can be narrowly defined or broadly defined but to me the idedology of the AMA is contained within its ... key objective which comprise a mission statement. and they key objective is to promote the science and art of medicine and the betterment of public health. I consider that an ideology. I consider it a statement of ethics, a statement of trust a ststement of value. And it really says what itıs all about. It basically says the patient comes first, the health of the people come first. They medical profession is a way to accomplish health of people, health of patients. So yeah, it shoudl have an ideology. Should it have an ideaology of a more constrained view, ...A good medical journal will be balanced. To take all points of view in an open and balanced way. The editorial position of a journal need not be balanced. The editorial position can be very strictly wht the editor in the mission statement beleives. Prof. Abrahamson: (inaudible) How do you grade success? Iıve published 16 criterion for success. (inaudible, somethingıs up with the tape or my recorder.) what the rejection rate is, what manuscripts youıve sent to the publication. What the bottom line is, revenue minus . you rate success in a periodical such as a magazine and in my first interview with the ___news in 1982 I said ³Donıt call this a magazine its a journal. You grade success of an editor with circulation figures with leadership by syndicated research, with how much revenue comes from the publication and where it comes fromwith how many articles and of what quality articles are sent to the publication for consideration for pubilcation what the rejection rate is for manuscripts sent to the publicaion. Whqat the bottom line is revenue minus expenses direct .l. what the readers tell you in letters, how easy or difficult it is to get the best people in your field to serve free of charge on your editorial board, with them considering it an honor, if the best people considerit an honor to be on your board, then youıre a tall(?) guy. ...judiciously is of great importance to a scientific journal. The amount of political heat and pressure the editor gets, knowing that unless you are getting a fair amount, you are not doing your job right,. If youıre getting too much, you know youıre doing your job especially right. then you ahve to worry about how much can you take. Thatıs how you judge. Now, oh thereıs another way. With medical science journals, thereıs a thing called the science citation index, This is a numerical score of the frequency with which otherleading publications reference your publication by article and by publication. andyou can grade yourself against hundreds of other publications. based on the actual score of referencing and figure out where you ought to be with that based upon your mission statement. You might want a low one or you might want a really high one depending on what you are trying to accomplish with the journal. Those are, on the top of my head, ways to measure success...Thereıs no question that the editorıs in the mix. Thereıs no question. If you can get a medical publication picked up by the associated press every week, one two or three articles, this is of great value to the publication. Because the AP isnıt going to run with it unless they know itıs right. Then success breeds success. And if the New York Times has something from your journal every week, or damn near every week, then you know you are doing fine. The same thing applies to the washington post, the wall street journal, the LA Times, only recently the Tribune, whihc has been very sloppy on science reporting, I²m sorry, on medical science reporting for quite sometime. If you can get articles out of your publication on Tom Brokaw, Dan Rather, CNN , Peter Jennings, fairly consistently, you know youır e doing all right because theyıre not going to run with it unless itıs interesting and you know the readers who watch the evening news and havenıt picked up your magazine, If Brokaw says lead story from the JAMA is so-and-so the doctors are going to go, ³I better read this thing. The patients are going to ask about it.² This is a major way to cyle readership Advertising revenue follows readership. It doesnıt follow media publicity at all. When the New York Times and the Sunday Magazine interviewed me and my friend at the New England Journal last June, long Sunday magazine story, and said that we went after media publicity in order to sell more advertising, thatıs just not true But readership does follow buzz. Now buzz is different from hype. Hype is something you pay PR people to do. Next Wednesday, the press conference, thatıs hype. Everything that happens between this morningıs Tribuen article and next Wednesday is buzz. Iıve always preferred buzz. Itıs mouth to mouth without having to have somebody paid to do something is a hell of alot better because people tend tobelieve that, to trust that, because their friend told them. Hype is a PR person. You pay them to do it and they get real good at it. And we got a real good firm to work with next week. Thatıs hype and itıll be big-time hype. You never know if it will work, you never know if itıs going to work until it works. but I prefer buzz. Student: I was wondering about politics and journalism. It seems to me kind of odd that the AMA would have a problem with editorial content that is influenced by politics Š when they are so involved in politics. Lundberg: I am unable and unwilling to comment on anything regarding my cessation of employment with the AMA or any individuals who are leaders of the AMA at this time. Quotes. Having said that, as a genearal questions, it is my opoinion that the better medical jounrals have as one of their fundamental missions to inform public policy debates with data. one of the worst things that this health care reform in this country from 1991-1994 or 5 was the fact that most of the national debate which was overcoming the uninsured, which we count as 44(?) million people on any one day, Itıs a dreadful tragedy and terrible scandal , That deabte was uniformed by data on a national level. The better journals tried very hard to inform that debate with data and we didnıt penetrate at all and the way it got lost and this is a matter of huge importance to this country. Itıs a trillion dollar industry and 70 percent of gross national product. and there are still 44 million Americans uninsured. thatıs up from 33 million from when I started working hard to get coverage for everybody. But the better medical journal editors believe that their journals should inform public policy debate with data. So if informing public policy debate is puttinga journal into politics, and I guess it is, then thatıs where it belongs. Thatıs its mission. Thatıs been an objective of JAMA for seventeen years. Now the other side of the coin is should politics affect what the journal publishes. I donıt see any way it can. Of course humans are political. Anything thatı sopinion is in theory political iin some way. I fyouıre goign to publish opinion piece that going to affect other people thereıs a political angle here. But yo inform the reader that itıs opinion. You call it opinion. You call it commentary, you label it. This is not data, this is this guyıs opinion. And if you want to read it, fine. If you donıt want to read it, fine. Same thing with editorials. As the Tribune reported accurately this morning, I believe it all starts with data. You donıt let the authors go beyond the data in terms of conclusions. The thing is you can editorialize beyond the data as you feel is right. For example, when we said in 1982, January 14, We said in the journal boxing should be banned in civilized countries, A position we came back to several times in the past 10 years. We published that editorial with a research paper with data from Cleveland that demonstrated that about 75 to 80 percent of fighters who had a significant number of fights suffered from chronic brain damage. I said, ³What 75 to 80 percent.Do they know that? They didn;ıt know that. It had never been reported. Everybody knows about punch drunk syndrome , but most people thought it was an occassional thing. 5 percent or someting like that. Everybody know that once in while blows to the head will rupture blood vessels and you die. But thatıs 5 times a year. thatıs bad but itıs rare. But 75 to 80 percent. Holy Cow Thatıs terible. So the Journal said, that there have been many studies since, and theyıve all come out iwth the same answers. ...Editorially we took the next step beyond debating. Editorially We said look, the public health includes protecting people from themselves. sometiems, thatıs an ideological jump. There are a lot of ppl in Amer who think the public health doesn not include protecting ppl from themseles. the libertarian view is that ppl do what they damn well please. If they want to hurt themselves thatıs nobody elseıs busienss. but 300 years ago, John Snow in London observed that people who got Cholera visited a certain area and got their water from a certain spot. and he noticed that in other places they didnıt get that. So he took the pump out and they stopped getting Cholera. A great experiment and the birth of public health. so Libertarians might argue that if those ppl want to get water at that pump its their pump. If they want to take their chances, let them hve the water. The public health position is, uh-uh [meaning no] we hve to protect them from getting sick, because they die from it. They donıt know any better, weıll take the handle of the pump. or weıll make ppl have seatbelts, or we wonıt let ppl drink and drive. even if theyıre only gong to kill themselves. or weıll say ppl shouldnıt participte in an activity that has an 80 percent likelihood of chronic brain damage. because itıs the wrong thing to do. Then if you take the postion that the only sport there is in which winning is done by damaging your opponents brain on purpose. I have no prblem with calling that morally wrong. You paly football, you get your brain damaged maybe but it isnıt the deliberate attempt to win the game by damaging your brain. So the Journal said medically wrong by data, morally wrong by intent, we didnıt succeed but a lot of things happened. Mosta states requre a lot of medical testing before somebyody can fight. So Nevada, California, New York,