TRD Fiona Godlee interview transcript

18 October 2017

> Download a PDF


Ray Moynihan:              Hello, and welcome to The Recommended Dose, a podcast encouraging a more questioning approach to healthcare. Today, it's our great privilege to feature Dr. Fiona Godlee, editor in chief of the British Medical Journal, one of the oldest and most influential journals in the world, which has a reputation for upsetting vested interests. Pushing, for example, for much greater transparency about [00:00:30] the ties between doctors and drug companies, or as Fiona says, stirring up hornets' nests. And as we'll hear, while she leads one of the top doctors' journals on the planet, owned by the British Medical Association, or BMA, she's actually not that keen on visiting doctors herself, unless it's really necessary.

Fiona Godlee:               I think I'm one of those people who'd rather not take pills if I don't have to, and rather not see doctors if I don't have to, so that's my bias.

Ray Moynihan:             [00:01:00] Whether you're a hardened researcher, a hard-working student or health professional, someone running a hospital or health system, and especially if you don't work within the world of medicine, I have no doubt you'll love listening to the BMJ's editor in chief, Fiona Godlee, and hear her stirring up a few more hornets' nests.

Fiona Godlee:               Well thanks Ray, I do see it as a privilege. The BMJ or any major journal has the huge advantage or benefit of dealing with wonderfully interesting issues, fantastically [00:01:30] talented and thoughtful people, both within the journal itself and of course through authors and peer reviewers and advisors around the world, yourself included, working with great groups like Cochrane and other international groups around the world. So I do think it's a huge privilege, and to be sort of in charge of the ship, if you like, for the last 12 years, and to know that I'll pass it on to someone talented and wonderful in a few years’ time is [00:02:00] a good feeling.

Ray Moynihan:             The BMJ, or the British Medical Journal is owned by the British Medical Association, a doctors’ group in Britain. It's not some large global corporation, and there are explicit rules, I think, saying that you have editorial freedom. Do you have editorial freedom?

Fiona Godlee:               I do, Ray, I have editorial freedom. The BMA is a very good owner of the journal. They've understood, I think, for a long time that the best interests of everyone are served if the journal [00:02:30] editor and team are allowed to do their job, which means to cover international issues, publish the best research we can find, be as transparent and open as we can, and to stir a few hornets' nests.

That's inevitably part of the job and so we will upset people. In my entire experience as editor for last 12 years, I've only come across a couple of occasions where the BMA has expressed concern, [00:03:00] but it's always been on the basis that they let me know and I listen to their concerns. And then we act as we see fit.

Ray Moynihan:             Is it fair to say that the BMJ is in some way the voice of the British medical establishment?

Fiona Godlee:                Well, I think in some ways we're a bit anti-establishment. And I think that's where we're comfortable being. I mean, we're sort of within but also ... I mean, people listening to this might think that is absurd, you know, we're 170 years old, and [00:03:30] absolutely part of the establishment. But we certainly don't see ourselves as the voice of the BMA, and to some extent, we're not really the voice of doctors as such.

                                             I think our main aim is to be the voice of medicine and healthcare, healthcare in particular. So there are occasions where the best interest of public and the patients are not in line with the best interest of doctors, as such, and I think that's where sometimes people [00:04:00] might think we would speak for doctors, when in fact, I think we speak for, hopefully, patients and the public.

Ray Moynihan:               Let's talk about some of those hornets' nest that you like to stir up. The BMJ has, unlike other journals, has explicitly said that it wants to campaign, and indeed the BMJ has a whole number of campaigns that you've been engaged in. The Too Much Medicine campaign, campaigns on statins, cholesterol [00:04:30] drugs, campaigns to engage more patients.

                                             First of all, let me ask you, is it the role of medical journals to campaign? A lot of people listening would think that medical journals are there to publish the results of peer-reviewed science. What on earth are you doing campaigning?

Fiona Godlee:                 Well, I think it's a really interesting question and there are various ways in which I can approach it. Just to say from the outset, of certainly the two [00:05:00] major journals in the UK, so that's the Lancet and the BMJ, the Lancet is slightly older than the BMJ. Both have at times, and the Lancet, when it was founded, had a campaigning stance and Wakley, the founder of the Lancet, very much saw himself as against the medical establishment, challenging vested interest and bad doings.

                                             The BMJ began much more as a membership, the provincial medical [00:05:30] and surgical journal in 1840. But at various times in its history, it has been campaigning. So our most, I suppose, famous or revered editor, Ernest Hart, in Victorian times, took on various campaigns. One in particular gets mentioned, which was against baby farming, where illegitimate children were farmed out to families and the families themselves or [00:06:00] the foster families would either kill them or leave them out in the cold or let them starve and die. And it was a kind of money-making thing and Ernest Hart put an investment in them in the national papers to try to find such foster parents and then wrote about it in the BMJ. And I think that as well as other political things going on at the time led to a change in the law.

                                             So that's something that we were able to refer back to when we thought we would take a more campaigning stance. Stephen Lock, my predecessor, but one, had a sort of campaigning energy about him around improving peer review and looking into peer review and then Richard Smith, my predecessor, who you know, Ray, took on all sorts of things but didn't necessarily call them campaigns. And one of them was the conflicts of interest problem. He took a lot of sort of strides forward in that, and also the question about too much medicine, which he was the [00:07:00] sort of editor when the BMJ began to think about medicalisation with your input, Ray, you were very much part of that development in the journal.

                                             And I think what I've done or what the team has done with me, has been to formalise or to pick up on some of those things and, I mean, specifically with the too much medicine thing, the little mini-change we made was we took the question mark at the end of the phrase away, so that it wasn't Too Much Medicine, question mark, but is now Too Much Medicine. When you begin [00:07:30] to say, yes, we've got a real problem here, we know that, let's try to shine more of a light on it and begin to look at solutions.

Ray Moynihan:             You're listening to The Recommended Dose, today with Dr Fiona Godlee, the editor in chief of the British Medical Journal, talking there about the BMJ's campaign to address the problem [00:08:00] of Too Much Medicine, a campaign I've helped work on over the years, during my occasional writing for the journal.

                                            Another of the BMJ's high profile campaigns has been to push for open data to try and stop drug companies, for example, burying evidence that's unfavourable to their products. The campaign has included many articles in the BMJ, on companies trying to exaggerate benefits or play down side effects about a bunch of drugs, including [00:08:30] some anti-depressants, diabetes drugs and anti-arthritis drugs. The open data campaign is an example of a move towards much greater transparency about evidence within healthcare, to allow all of us to get much closer to the truth about how well treatments work and what their harms might be, so that we can stop being misled so often.

                                            One of the most powerful examples is Tamiflu, the anti-flu drug that was stockpiled [00:09:00] around the world to fight the flu pandemic a few years back. Fiona Godlee explains how the BMJ worked closely with researchers from the world of Cochrane, to try to uncover the truth about Tamiflu, ultimately finding the world had likely wasted billions of dollars.

Fiona Godlee:                So I think the Tamiflu saga has become kind of iconic and for me it was an incredibly radicalising episode, because [00:09:30] it began with a simple request, really, to check on the evidence for whether this drug Tamiflu should be bought by governments around the world, specifically in the UK, but obviously it would have implications internationally. And the Cochrane group were originally just going to update their review and say their previous finding, which was that it was effective in preventing people getting sicker with influenza and having to go to hospital.

                                             They thought they'd just update this and confirm it, but they were alerted to the fact that the data on which that conclusion had [00:10:00] been based were very poor and that there were 10 trials, only two had ever been published in full in journals. The other eight were just abstracts of meetings. All 10 of those trials were funded and performed by the manufacturer of the drug, Roche.

                                             So the Cochrane group quite rightly said we need to get the data and they wrote to the authors who said they didn't have the data. They wrote to the manufacturer who said they couldn't have the data. And then they came to the BMJ and we worked together over a period of five years to get the data [00:10:30] and when the data were finally released, in the end, after huge amounts of resistance, suddenly released as if with no problem at all on a pile of the CD ROMs, all of the fuss about patient confidentiality suddenly swept aside.

                                             And the Cochrane group reviewed the data and it's all now in the public domain because the Cochrane group refused to do this under wraps of confidentiality and quite rightly. And their analysis really found that the drug doesn't [00:11:00] really do very much, maybe similar to paracetamol, in terms of symptom control. And has undisclosed harms.

                                             So the reason it's radicalising, the reason it's important is huge amounts of public money was spent. The extraordinary situation in which data, which have huge public health significance, in terms of not only money spent but patients being treated, was not available for scrutiny. And that most of the trials that they then uncovered, I [00:11:30] don't want to say the number, I think we're going to say 160, but I may have got that wrong, trials, instead of the 10 that were the basis of the original conclusion, had been sort of hidden from view.

                                             So the whole thing is laughable, if it wasn't so serious.

Ray Moynihan:               The whole move to an evidence-based approach to medicine has meant that we focus now on evidence when we make decisions, but is it the case that the Tamiflu example shows us just [00:12:00] how distorted that evidence can be and how misleading it might be and how on earth do we ever get to the truth about how well drugs and other medical treatments work, when there's so much industry engagement in generating that evidence?

Fiona Godlee:                That's certainly my view, Ray. There are other people who ... the other view is that we absolutely need to collaborate with the industry to develop new drugs. [00:12:30] I think we do want industry to develop new drugs and we do want them to do that in conjunction with patients and doctors and researchers, obviously, because that's necessary.

                                             My concern and I'm not alone in this, is the dominance of the drug industry as a funder and doer of research, beyond the initial kind of development stage of the drug. So this is the evaluation of the drug [00:13:00] and I at heart think that industry doesn't really have a legitimate role in that evaluation. We shouldn't have people with such a huge vested interest in the outcome involved so closely as they are.

                                             Now the difficulty then, people say, well, how will these drugs be evaluated? Well, that's the solution we've got to find. I think we've got to accept the fact that the current system is delivering distorted information. I need to say here that [00:13:30] it's not just industry, academia also has a lot of distorting influences and we could talk about those, but if we're specifically talking about the industry distortion, I think it's real. Study after study finds it, people say, oh, that's historical, we've just published an article in the BMJ this year, which finds exactly the same thing, that the principal investigators with links to industry published studies that are largely favourable to the product.

                                             So it's not something [00:14:00] that has gone away. There have been improvements, we've got trial registration. Industry is much better than academia it turns out, in terms of getting their trials registered and publishing the results quickly, but there are so many ways in which ... and I was just talking by email to John Ioannidis at Stanford about this, there are so many ways in which the study design and the way it's reported can distort the result, that I think, in an ideal world and it's a world we would like to be moving towards, [00:14:30] we wouldn't have this irreducible conflict of interest in the research that is affecting people's health.

Ray Moynihan:              So what you're saying is that you would like to see independent evaluation of drugs and presumably other therapies as well, that that would be a major change in the way things are done at the moment, would it not?

Fiona Godlee:                It would be a major change and there are models. In Italy, Silvio Garattini [00:15:00] at the Mario Negri Institute and his colleagues there managed to get a law passed where they now have the ... I think it's, I'm going to say 5% of industry marketing spend is put into a pot, a central pot, which is managed by independent advisory group. And that money's put towards independent studies, head-to-head comparisons, especially neglected drugs or neglected areas.

                                             [00:15:30] So there are models and I think people who dream of a better future, say, well, why couldn't we have a central pot into which industry, if they want to market their drugs or license them, would put a proportion of their profits and that money would be used to evaluate their drugs in an independent and transparent way.

Ray Moynihan:               Are we hearing the beginnings of another BMJ campaign here? Is there a campaign brewing where the BMJ will [00:16:00] take a lead and essentially call for a rewriting of the relationship between the health professions and the pharmaceutical and other medical industries?

Fiona Godlee:                 I think that is probably where we're heading. Just something to say about the evidence based before we get on to that, we have stopped publishing a while ago, research funded by the tobacco industry. That seemed a slightly no brainer move, so that was ... we did get pushback [00:16:30] on that even so, but we've made that decision. The food industry is another one. I think we've got a lot of evidence that the food industry behaves in ways that are similar to tobacco in terms of trying to distort the evidence base and hijacking the research agenda. And the drug industry, the difficulty there is we need those drugs and they're the big player in town and how would we do it without them?

                                             So I think what [00:17:00] we've tried to do with the BMJ campaigns is always walk the walk and talk the talk, so rather than simply say this is what's got to happen, we've tried to think what can we do to advance that and also to change the way we do things. So with the open data campaign, we've made changes to our own policies to say we won't look at clinical trials unless they've been registered, obviously, but also unless the trialists are willing to share their data. And we're thinking to move towards a further step, which would be to say [00:17:30] we want the trialists to put a deadline, when they will actually make the data available, so we're actually kind of upping the ante on that.

                                             If it came to something about independent research, the obvious step for us would be to say we're not going to publish any ... she says this with a bit of a pause...we're not going to publish any trials funded by the pharmaceutical industry and I think that's probably the right thing to do. And whether we'll go that way is obviously [00:18:00] a huge problem because those are the studies that are most influential. Any journal wants to get large drug trials. The BMJ doesn't publish very many at the moment, that might make it an easier decision for us.

                                             So I think we're on the cusp of something and it just depends on how far we feel able to go.

Ray Moynihan:              One obvious response, if you do decide to go down such a route and start campaigning for much greater independence [00:18:30] between the health professions, doctors and industry, people will immediately point to your sources of revenue that come from drug advertising. One presumes that pharmaceutical advertising is only a small proportion of the BMJ's total revenue. Have you considered simply letting that go?

Fiona Godlee:                It's an important point. I don't think we could let it go. I [00:19:00] think the revenues of the BMJ, like probably most journals depend on a mix of things. We get subscriptions from libraries and individuals, we get open access fees, because we're an open access journal, and we get advertising revenue, a combination of drug advertising and job classified advertising. And actually, the advertising side is quite a substantial part of our income.

                                             So [00:19:30] various options offer themselves. One would be to, yes, not have drug advertising and to charge our subscribers more. Another would be to, which is what we do to make sure we have extremely clear and absolute barriers between the selling of the advertising, our sales teams and the editorial team, so there's no connection at all. We don't discuss copy or coverage, they didn't discuss who they're getting advertising [00:20:00] from.

                                             We have a very strong support from our commercial, our chief exec, for example, if advertisers were to stop advertising with us because of something we published, that's just understood to be the cost of doing business. We wouldn't ever ... I've never been put under pressure on that score.

                                             As of this year, this month, we're going to publish our revenues from the pharmaceutical industry, that will be sponsorship for some things and our advertising revenues. And [00:20:30] we're going to be the first journal to do this. PLOS Medicine does it because it's a U.S. charity and it is obliged to publish its revenues, which of course is good.

                                             So I think we're trying to do our very best to be transparent about this and to also make sure that the safeguards are in place to prevent editorial influence.

Ray Moynihan:               You're listening to a podcast called [00:21:00] The Recommended Dose with me, Ray Moynihan. Today talking with Dr Fiona Godlee, editor in chief of the globally influential British Medical Journal, on how BMJ is campaigning to get much greater independence between doctors and drug companies and other vested interests. And how the journal is trying to walk the walk, not just talk the talk.

                                             As an example, the BMJ recently introduced new restrictions on which researchers can write educational content, essentially [00:21:30] banning doctors who accept money from drug or device makers when that money is relevant to what's being written about. And it's put some noses out of joint.

Fiona Godlee:                Another thing the BMJ has done after the last two or three years is we have instituted a policy whereby for our clinical updates that go to practicing doctors, we will not have those written by anyone with financial relationships that impact on [00:22:00] the topic that they are covering.

                                             So this is really difficult to do. The New England Journal tried to do it back in the 2000s and then they abandoned it when the new editor came on board, because he said it was not working. In fact, the old editor said it was working fine, but the new editor, Jeff Drazen, felt that it was going to make it difficult for them to get really good clinical reviews into the journal.

                                             We've decided that a really good clinical review is defined as one that's written by someone who is independent and as far as possible, that's what we're trying to achieve. It's [00:22:30] difficult because in some areas of medicine, finding independent people is very hard. It's also difficult because it takes more time and it's difficult because we piss people off and they get upset, understandably, because we seem to be impugning their integrity, which we're not doing, but we're saying for this particular job, writing an educational article in the BMJ, we need someone who has the following characteristics. One of which is that they don't have a financial interest in the treatments they're recommending. Or even in the treatments [00:23:00] they're critiquing. It's got to be the whole sphere.

                                             Really hard, because it also includes private income. If you're an orthopaedic surgeon and you do a specific knee implant or an arthroscopy, and that's how you make big proportion of your income, that's a conflict.

Ray Moynihan:               So with all this stirring up of hornets' nests, does the responsibility of running this major journal give Fiona Godlee energy or does it weigh her down?

Fiona Godlee:                 Honestly, I'd have [00:23:30] to say it varies.

Ray Moynihan:               Day to day.

Fiona Godlee:                 Probably day to day .I've worked out the other day that there are usually pretty much three things going on and I think it may be like a mother duck, you can't count more than five, so you only know you've got five ducklings.

                                             But I find that sometimes when I'm weighed down, I'm helped by thinking, well, these are the three things at the moment, and then a month after that, the three things have either changed or you're in a good phase. When I say things, I mean a legal challenge [00:24:00] and a complaint from a whole specialty who feel they've been done down by it or called to retract something we published. Those are the sort of big issues that sort of come across your desk.

                                             But then again, the other thing that I think is helpful is to realise that's what the job is and not to feel ... without those things, what would be the purpose? So I find that keeping resilient in [00:24:30] other ways, I can list how I do that if there's interest in that, but trying to maintain one's physical and emotional and spiritual resilience is very helpful for when those things hit.

Ray Moynihan:               You raised that issue of resilience, do you want to tell us, tell the listener a little bit about some of the ways in which you maintain that resilience?

Fiona Godlee:                 Yes and I don't want to claim for a moment that I'm always resilient. My husband will tell you the times I arrived home and just lie on the floor weeping, [00:25:00] but they're not too often, but they do happen. I know anyone will have those experiences.

                                             But things like trying to keep physically active is hugely important. I cycle, my journey to work involves cycling across Cambridge and then a little bit of cycling in London, and then if I go to meetings in London, I cycle. I'm not taking enough exercise so that's something that always I'm trying to do more of.

                                             Trying to get enough sleep. I meditate every morning, [00:25:30] that's been something- a long-standing thing - and I'd like to say it's every morning, but that's the plan. At times I do that thing of journaling where I'm on the train and I just write for 15 minutes, keeping the pen on the paper, just keeping writing, just sort of not for posterity but for just the act of getting one's thoughts flowing.

                                             I have a life coach who I've had for 17 years. [00:26:00] She and I started working together in 2000 and we speak about once every month or two months by phone. It's been such a regular part of my professional life that we've gotten to a very good ... we know each other very well, she's amazingly effective and good and I'm always recommending her to other people. So that I think is hugely helpful because that's someone who's completely on your side and you can just bounce off thoughts, but they can also challenge you and say, [00:26:30] why are doing this and have you thought of that?

                                             And I have a final thing, which I mustn't forget to mention. I have a fantastically supportive husband who gave up the work he was doing when we started having kids. We have two kids and he has done everything, really. Not just doing the occasional this and that, but he runs the family.

Ray Moynihan:               And how valuable or important has that been to your career success and your ability [00:27:00] to run this extraordinary journal so well, as you do?

Fiona Godlee:                 If he was working in a job that he wanted to continue in and was very financially rewarding, we might have come up with a different solution, but he was happy to give up work. He was in farming, dairy farming, and so that seemed to work well as a model for us. And I think the benefit has been we haven't had huge childcare costs or lots of having to employ people and he's been at home [00:27:30] all the way through. The kids I think have benefited hugely from that. I think it's been very hard for him at times, being at being a dad at home. I think it's just the model that's been how we've managed things. It's meant that when I go traveling, there's not a lot of sort of worry about what's going on back home and that's been ... I don't want to claim it's been perfect for anyone, we've obviously had our ups and downs but I think it's a fantastic support.

Ray Moynihan:               [00:28:00] What's the source of this interest in really challenging and being iconoclastic and shaking things up?

Fiona Godlee:                 I don't know Ray, it's very hard to look at one’s self in that way. I suppose for whatever reason, if I see something that seems wrong and who am I to judge what's right and wrong, but one has to go with one's gut. And also you surround yourself I suppose with people who you can bounce ideas off and then you get [00:28:30] courage and confirm, yes, this doesn't sound right, yes, this is actually wrong, or this is the better way forward.

                                             I feel, I don't want to say duty-bound, but I suppose that is a slight sense or at least energised by the prospect of being able to highlight injustice or highlight wrongdoing and to think about and encourage better ways forward. My family background,   suppose, has [00:29:00] contributed a great deal to that and I won't bore people with that, but wonderful parents who've guided me in that way. And my education.

                                             But I think certainly since going into medicine, working at the BMJ after training in general medicine, I think you're suddenly exposed to so many issues and given exposure to so many thoughtful people and given the tools, if you like, to actually begin to make a difference to those things. So [00:29:30] I think it would be hard to not want to do that, given the situation I'm in.

Ray Moynihan:               I think one of the people deep and buried in your family tree somewhere is a Dr. Joseph Lister, who may have been one of the pioneers of sterilisation. And I wonder, A, is that true and B, whether there's a bit of a continuation here about you wanting to clean things up.

Fiona Godlee:                 So yes, it is true, Joseph Lister is [00:30:00] a relative, an ancestor of my father's and was a Quaker and was a radical and I think there is an element of that in our family and I'm very proud of it. It's not sterilisation so much as shining a light. I think that's what we would like to say.

Ray Moynihan:               While we're on personal matters too, one of the things that happens to people of a certain age is that we're encouraged to be screened for certain cancers and [00:30:30] going back to the mention of too much medicine earlier and the BMJ support for trying to prevent over diagnosis, one of the examples is the over diagnosis that can occur through breast cancer screening.

                                             Is your decision-making about whether or not you undergo mammography? Something you'd want to talk about here?

Fiona Godlee:                Yes, I'm happy to talk about it. I think I'm one of those people who'd rather not take pills if I don't have to [00:31:00] and rather not see doctors if I don't have to, so that's my bias.

Ray Moynihan:              And you're the editor of the BMJ.

Fiona Godlee:                Says the editor at the BMJ. On the other hand, when one needs medical treatment and whether that be pills or surgery or whatever, obviously, I'm always incredibly grateful for that and I've had fantastic experiences of that with my family and myself. But obviously, if it doesn't need to be done then I'd much rather it wasn't.

                                             So when [00:31:30] it comes to breast screening, I think that again, it was a sort of radicalising experience being the editor at the time when that was being discussed. The BMJ was being slightly accused to being anti-screening, we were publishing stuff that was questioning the information that women were being given. And so we tried to provide balance, we got other people to contribute, they ended up being even more convinced of the limitations of screening and the potential to do harm and the harm being, worrying well women and false positives and leading to [00:32:00] further tests and sometimes surgery, chemotherapy, radiotherapy.

                                             So in the process of this, I became much better informed, I think, than I would have done if I just been the recipient of one of these leaflets, and in particular, I was very struck by the idea that actually if you end up having radiotherapy unnecessarily, that can actually cause damage to your heart. So in terms of where the mortality line cut off, in terms of benefit, is, I think rather interesting.

                                             Clearly, if treatment improves and ability to detect [00:32:30] the troublesome cancers from the less troublesome, then that would change one's decision, but I think at the moment for me, I didn't want to go down that route. I have relatives who've died of breast cancer in later life, not a genetic risk. I think if you have a high risk obviously that's a different thing again.

Ray Moynihan:               I think I'm right in saying Fiona, that one of the things you've tried to do at the BMJ is [00:33:00] bring a more, I don't know, if it's fair to say, a literary style to the writing, to make the writing as accessible as possible. Is literature something that's important to you?

Fiona Godlee:                 It is important Ray, yes, absolutely and I do try and read. I am glad you think ... coming from you as a great journalist and we've relied on people like you to improve the journalism itself, so I'm very glad if that's the case.

                                             As for reading, [00:33:30] I have a train journey and I've just recently restarted trying to make sure I carry a book with me so that on the journey home when I'm sort of tired and can't do any more emails, I don't just read the throwaway newspaper. I read something decent. And I've just finished Margaret Atwood's The Handmaid's Tale, which is a very gruelling but a brilliant read and is being televised at the moment and is something everyone should read, if they can bear it.

Ray Moynihan:               I have to ask, have you read the Ferrante novels about the Neapolitan-

Fiona Godlee:                 I have [00:34:00] read them all. I loved them. I lived them and loved them and I just thought they were fantastic. So Elena Ferrante, My Brilliant Friend, etc. I read them back to back and they were-

Ray Moynihan:               Unbelievable.

Fiona Godlee:                 And the other thing which is maybe if people are interested, Dadland, D-A-D-L-A-N-D, Dadland by Kitty Carew, fantastic. It's a memoir of her father and he's developing Alzheimer's and she builds both backwards and forwards across time, it's a really superb read, I loved that.

Ray Moynihan:              Could we talk briefly about the Cochrane [00:34:30] Collaboration? No doubt you're a long-time observer of the Cochrane Collaboration. The first Cochrane Centre in the world was in Oxford, not far from where you live. What's your take on the Cochrane Collaboration?

Fiona Godlee:                I love the idea as an Australian, Ray, you think Oxford (laughs)... I live in Cambridge of course, which is miles away and completely ...

Ray Moynihan:              A stone's throw! (laughs)

Fiona Godlee:                I've been a great fan of the Cochrane Collaboration from the outset. I attended I think it may have been a second meeting in Hamilton, in 1994, when [00:35:00] I was in America for a year. I went to America to study this thing of getting research into practice back in the '90s and Cochrane was the sort of shining light of trying to pool what we knew about medicine together in a sensible, systematic and critical way. And I think it's been an extraordinary intervention, if you like, in healthcare and the people involved I think are exceptional. I've met some really wonderful people who are now my great friends and collaborators on a number of things.

                                             So I think it's been a really important contribution and it faces all sorts of problems in terms of scale, quality, feasibility, continuing funding, all of those things, but I think it's a thing we need and we should all give it our support.

Ray Moynihan:              Why is it relevant to listeners? Why would listeners care or be interested in the Cochrane Collaboration? How important are those Cochrane reviews [00:36:00] that come out to the decisions that all of us are making about our health and the health of our loved ones?

Fiona Godlee:                So I think it's important both in the reviews it produces and in what it represents. So the reviews themselves pull together what we know about a topic in a very systematic and critical way and they lay that out in a way that not only can come up with an answer, does this treatment work or not? Does it cause harm or not? But also can help to guide future research because it can show [00:36:30] the holes in the evidence or the problems of the research base so far. What was done well, what was done badly in terms of the research itself.

                                             It also, as I've referred to, has been a huge influence on this whole business about transparency, access to the data. At the moment, most Cochrane reviews rely on data that's already available. I'm hoping that somehow or other we'll move to a situation where the data themselves will be much more available and we can do much more intensive scrutiny on key treatments, [00:37:00] which currently isn't the case.

                                             So I think Cochrane is also a movement in the true sense of the word in that it is actually changing the culture around it, already has changed the culture. And the BMJ sees itself as an intervention in some cases to change the culture of medicine for the better. And I think Cochrane and the BMJ are therefore sort of natural partners in that journey.

Ray Moynihan:              One of my frustrations with the BMJ is that it publishes such fantastic material, particularly let's say about the [00:37:30] harms of medical treatments or this issue of conflicts of interest, but it's so inaccessible to the lay public. Things are either behind a paywall or they're not written in ways that all of us can understand. Is there any sense in which you can make the BMJ's output more accessible? Have you considered a BMJ for the public, for example?

Fiona Godlee:                We have considered it, Ray, and [00:38:00] at the moment, anyway, we haven't been able to find a way to make that work in terms of finances and how would it pay for itself, if that makes sense. But we are continuing to explore that and an idea just emerged, which I'm busy discussing with others about, how we could maybe make that work online, with some sort of more lay explanations of what's in the journal, and also more broadly.

                                             But we're very clear that at the moment, the BMJ is for health professionals, [00:38:30] doctors mainly, and we work more to try to bring the patient voice into that, so that we're trying to kind of help doctors understand the patient perspective. But it's still very much for health professionals to improve what they do rather than for the public.

Ray Moynihan:               I think I'm right in saying that one of the big pushes at the moment within the BMJ and it's something that I think is very close to your heart is to try and start to change the system the healthcare system to engage [00:39:00] patients and the public, citizens, much more in the design of research, the way in which healthcare operates. Can you talk a bit about that and why you're pursuing that?

Fiona Godlee:                 Yes, it has become a big theme across the journal and I have to give huge credit to Tessa Richards, one of our long-standing editors who herself has been a patient and carer and is a GP and physician trained. So she's incredibly experienced and has taken this movement within the BMJ, developed a fantastic international group of patient advisers. We've [00:39:30] got patient editors. Sadly, our patient editor Rosamund Snow died earlier this year and was already doing fantastic work in this area.

                                             So we're building up a lot of ways of trying to encourage people to involve patients in the research agenda in the doing of research and in the interpretation of the research and also in the delivery and design of healthcare. And this gets back to this idea of what can we, the BMJ do, apart from sort of badgering other people [00:40:00] to do things better?

                                             And obviously that to me is a hugely important thing to walk the walk, as well as talk the talk. So we've introduced patient peer reviews to our research papers, we've got patient co-authors of educational material. We have a section in every article saying how a patient's involved in the development of this article. Very often with research, the answer is not at all, and that is something we're trying to raise awareness about, because it just seems not okay not to have patients involved.

                                             [00:40:30] But partly as a result, I hope of this campaign, but because of cultural change anyway, there's already big shifts happening and I think we will see quite a lot of change over the next few years.

Ray Moynihan:               In terms of looking forward to the future, the world as we know it just seems to be shifting under our feet, ever more rapidly, daily. Silicon Valley appears to be taking over more and more of our lives. Media organisations [00:41:00] that have been around forever are withering on the vine. Is the future of the BMJ, is the future of medical publishing also under pressure from the dramatic changes that are happening in information technology, in the marketplace? Are you immune from that?

Fiona Godlee:                 I don't think we're immune from it. We've been protected from it, I think, because to some extent, there's a kind of must have a quality to medical journals because of the need for people to publish their research and because of [00:41:30] the need for doctors to sort of be educated and to learn.

                                             I think that will change. Open access is already changing it. I think my prediction or even my hope is that at some point, research won't be published in journals. I think it's not the place research should be published. I think research should be published on open access databases and journals should become the secondary kind of review function of saying which research is worth looking at, for which particular audience.

                                             So that's been [00:42:00] something that's been talked about for quite a few years now and doesn't seem to be any nearer because the publishing industry, it works quite well, the current system, for the publishers, as well as for other groups. So I don't know what will be the sort of disruptive force that will bring that change about, but that seems to me to be where the future should lie.

                                             And as for the sort of educational function of journals, I think people will increasingly, as [00:42:30] they're overwhelmed with torrents of information, will look to people, certain groups, trusted voices, to help them navigate through the morass of information. And if journals want to survive, they're going to have to serve that need very directly, in a whole host of different ways. It will be digital, it will be mobile, it will be data-driven. And I think it will have to increasingly speak to the public as well as the professions.

Ray Moynihan:               Fiona Godlee, it's an absolute pleasure to talk to you as always. Thank you very much for talking with us on this podcast.

Fiona Godlee:                 Thank you Ray, great pleasure.

Ray Moynihan:               That was Dr Fiona Godlee talking to The Recommended Dose, a podcast funded by Cochrane Australia. Production by Shauna Hurley and edited with assistance from Ben Griggs. If you enjoyed it, please recommend The Dose to others and watch out for more episodes coming soon.


- END -