Former editor: outsourcing puts Medical Journal of Australia at risk

AMA president Brian Owler said the decision to outsource production was financial, describing the publisher’s financial position as “perilous”. Lukas Coch/AAP

Publishing is a volatile and competitive business. The Australian Medical Association (AMA), the owner of the Medical Journal of Australia (MJA), rightly wants to ensure the highly trusted journal is produced with maximum efficiency while satisfying its editorial objectives.

The MJA’s twin objectives, expressed in the first issue 101 years ago, are to inform the medical community about recent advances and provide an evidence base to inform health policy for the nation.

I took the job as editor-in-chief because those goals are congruent with my 50-plus years of health research, management and leadership. But the recent decision to outsource production of the journal to international publishing company Elsevier – and the route it took to get there – made my position untenable.

Ethical concerns

Elsevier is highly successful but has an approach to business that worries many academics and researchers. From 2000 to 2005, the company’s Australian office created “custom publications” paid for by pharmaceutical companies to present favourable data on its drugs.

Elsevier created the Australasian Journal of Bone and Joint Medicine, for instance, for pharma company Merck to promote Fosamax, a drug for osteoporosis, and Vioxx, an arthritis drug that was recalled for increasing users’ risk of heart attacks and strokes.

Professor Paul Zimmet, one the 19 (out of 20) editorial advisory committee members to sign a letter of resignation over the MJA’s decision to outsource production to Elsevier, explained to the ABC:

My concern is that the next step could be to follow up with appointing editorial staff that follow Elsevier’s agenda.

Readers can make their own assessments of Elsevier’s reputation. I made mine and concluded that I did not take the MJA job to work with Elsevier. This put me at odds with the board of the Australian Medical Publishing Company (AMPCo), the AMA’s publishing company, and my three-year contract was terminated a week ago, one year early.

Costs and quality

AMA president Brian Owler said in a press release the decision to outsource production was financial, describing AMPCo’s financial position as “perilous” and “on the brink”:

… to keep AMPCo on a sound long-term footing, and to ensure the ongoing publication of the MJA, further changes had to be made, including outsourcing some production functions and making AMPCo less dependent on the AMA to remain viable.

The audited circulation of the MJA is about 30,000. It costs the AMA A$2.35 million to deliver the MJA to all its members (almost 30,000, though this number is kept under wraps). The A$78 each member pays for a year’s subscription is cheaper than any other medical journal, and certainly a bargain compared with The New Yorker or The Economist.

Nevertheless, the publisher ought to investigate and scrutinise the many ways to save money. Giving AMA members a choice of receiving the MJA only online is just one example of many.

The MJA is printed and posted out-of-house. The new outsourcing plan includes production, some administrative functions and sub-editing. Brian Owler describes this as:

essentially … rearranging words on a page or making sure things sit together.

This does not accord with the extensive intellectual contribution of the MJA’s sub-editorial and production staff to the journal. Like all medical association-owned journals – The British Medical Association Journal, its Canadian and American counterparts (BMJ and JAMA) and The New England Journal of Medicine (NEJM) – the MJA’s sub-editing, design and production have been integral to the editorial process and have been kept in-house to retain autonomy and flexibility.

The MJA publishes multiple categories of articles such as perspectives, editorials, critical comments and correspondence. This requires more editorial judgement than journals that publish nothing more than research papers, for which outsourcing of production may be straightforward.

In-house production ensures we make use of the creative talents of the full editorial team to ensure the journal is contemporary and responsive to readers’ expressed requests. Other association journals have ventured into new fields of publication with encouragement from their boards that have secured them financially, including speciality journals (JAMA) and continuing education (NEJM).

The outsourcing process

Towards the end of 2014, I found out that the board of the AMPCo had sought bids from publishers to outsource the production of the MJA.

Elsevier was the front runner and presented to the board about what it could offer. The chairman informed me after the presentation, but I had not been aware of the process and the bid had been prepared with no discussion with the editorial team.

Until that time, I was also not aware of the extent of the financial problems AMPCo faced or the urgency with which the board intended to address them. In the following months, I developed various proposals for additional revenue lines that closely matched the financial gains from outsourcing, but the board pressed on with the proposal to outsource.

All journals face challenges because of rapidly evolving information technology and the many alternatives to paper that now exist.

Once journals were paid for mainly by subscriptions and advertising. Now many journals are supported by fees paid by authors – several thousand dollars per paper in the more prestigious journals. The very notion of a paper is changing and hallowed phenomena such as peer-review are under threat.

Outsourcing production, in the face of these challenges, reminds me of the ill-fated A$7 co-payment for bulk-billed Medicare services that sank as a budget failure in 2014. It may relieve a problem briefly but it carries a heavy freight of side-effects, such as losing creative and experienced staff, at a time when they are needed to plan for the future. And it is not alone a satisfactory whole-of-system strategy to achieve financial sustainability.

The MJA needs a sophisticated and imaginative, future-informed business plan. While this shouldn’t be the exclusive domain of the editorial group but they should be intimately involved.

It’s unclear how the MJA will plot its course from this point. The waters are turbulent and it will require wisdom and much greater business and management acumen to survive and flourish. I certainly wish it well.