BMJ  2004;328 (28 February), doi:10.1136/bmj.328.7438.0-g

Editor's choice

Nothingness: the role of journals

A whole issue of a journal devoted to what doesn't work. An orgy of failure. Isn't this a mad idea? Don't our readers want to hear about medicine's remarkable successes rather than its ignominious defeats? Maybe some do, but many, I suspect, will experience a shiver of delight on reading this litany of ineffectiveness. It's much closer than usual issues of the journal to the real world of misunderstood patients, wrong diagnoses, lost tests, illegible writing, incomprehensible instructions, failed treatments, broken relationships, and shattered dreams. For this week at least we will be closer to Shakespeare than Enid Blyton.

So this celebration of what doesn't work is, I think, a brilliant idea, and I can say that because I didn't have it. The idea came from Trish Groves, one of the BMJ editors, who, together with Phil Alderson and others, has created a treasure trove of negativity (p 473). But this isn't all negative because doing nothing is often the right and wisest thing to do. It takes courage and experience. "Good surgeons," the medical saw says, "know how to operate. Better surgeons know when to operate. The best surgeons know when not to operate." Doesn't this apply right across medicine?

Samuel Shem promotes the idea of "not doing" as fundamental to good medicine in his book The House of God. Jo—the unloved, unlovable, top of the class, senior resident—embodies action: "I'm the captain of this ship, and I deliver medical care, which for your information, means not doing nothing, but doing something. In fact, doing everything you can." Her interns make her team the most successful in the hospital by ignoring her commands and energetically doing nothing: "To do nothing for the gomers [elderly patients who never die] was to do something, and the more conscientiously I did nothing the better they got."

Where, I wonder, do medical journals fit in the galaxy of nothingness? Do they work? The questions are hard to avoid in a week in which the ways of medical journals—and the Lancet in particular—have made the front page of newspapers and the top items on broadcast news (p 483 and p 528). The Sunday Times alleges—among other allegations—that Andrew Wakefield, one of the authors of the Lancet's infamous paper linking the measles, mumps, and rubella (MMR) vaccine with autism, had conflicts of interest that he failed to disclose. The Lancet says that if it knew then what it knows now it wouldn't have published the paper. Wakefield has hit back with counter accusations. A member of parliament has criticised the Lancet and called for an inquiry.

All is turmoil, not nothingness. But journals are better at turmoil than nothingness. Journals (words on paper) are poor at changing behaviour but good at creating debate, stirring the pot. So a journal that creates debate around what doesn't work is a paradoxical triumph.

rsmith{at}bmj.com

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