The BMJ

The first issue (1857) that was published under the name British Medical Journal.

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The BMJ is an influential medical journal that was founded in 1840, making it pretty old. It's published by a company simply named BMJ (formerly BMJ Group), which is owned by the British Medical Association. The journal was previously called the British Medical Journal before they decided to shorten it in 1988, leaving us only to obliviously ponder what "BMJ" now stands for. Its h-index was 477 for the years 2022-2023, which is outstanding.

It has a number of subsidiary journals also focused on medicine and health, such as BMJ Open, Heart, Gut, Thorax, and Tobacco Control. The BMJ is respected in its field for the most part and has a history of high-profile accomplishments: for example, The BMJ published the reports that exposed Andrew Wakefield's scientific fraud in 2011. A massive portion of the published papers in the company's various journals, even The BMJ itself, are simply so uncontroversial that they don't warrant much mention here.

However, it has noticeable shortcomings that have likely only worsened with time. Perhaps most worryingly, The BMJ appears to have a track record promoting certain alternative medicine practices such as acupuncture. On the brighter side, they have also published papers critical of such practices. Yet, their level of skepticism towards pseudomedicine leaves one wanting when they have essentially offered alternative medicine promoters a foot in the door to (grossly undeserved) mainstream respectability: the journal is widely read by doctors in the United Kingdom and is occasionally cited as a source by bodies writing important medical policy or recommendations.

Another major issue, at times, has been their choice of editors. Peter Doshi, a senior editor for The BMJ itself, is a concern troll regarding vaccines and has even previously waded into germ theory denialism territory. (Or would that be terrain?). One BMJ journal, Open Heart, previously had James DiNicolantonio for an associate editor.

Overview

The BMJ is owned by the British Medical Association (BMA), a large trade union for medical professionals in the United Kingdom. All members for the BMA receive issues of The BMJ free of charge. The journal is meant to be editorially independent of the BMA — though one has to wonder if that can truly be the case when such a large portion of its readership is made up of BMA members.

History

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  The first issue of the Provincial Medical and Surgical Journal, 1840. This is The BMJ in utero.

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  An illustration of an early inhaler. British Medical Journal, 1898.

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  A page from a 1917 issue of the British Medical Journal. Shows a photo from a trench during World War I.

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  Another 1917 page pertaining to World War I. Instructions for treating gunshot wounds.

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  An illustration of antimonial cups that appeared in a 1923 issue of the British Medical Journal.

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  1929 advertisement in the journal for a scarlet fever treatment.

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  1930 advertisement in the BMJ for insulin.

Surprise! The BMJ began not as the British Medical Journal, but as the Provincial Medical and Surgical Journal — which first published an issue on October 3, 1840. That journal later merged with the London Journal of Medicine to form the Associated Medical Journal in 1853. Then in 1857, that became the British Medical Journal.

The journal has a long-running rivalry with another top medical journal, The Lancet. Evidently, this rivalry dates back to the very founding of the Provincial Medical and Surgical Journal in 1840, with the two editors at the time gloating that they received just as much advertiser interest for their first issue as The Lancet (founded a bit earlier, in 1823) typically would. This rivalry can be observed to this very day, with high-profile critiques of papers published in The Lancet often finding their way into The BMJ.

In the 1840s, the journal had a number of papers written by James Young Simpson on chloroform, helping to popularize the drug's medical use. In the 1860s and 1870s, The BMJ published papers by the medical pioneer Joseph Lister about antisepsis in surgery, contributing to the foundations of germ theory. The 1890s brought papers on the mosquito as a vector for malaria.

A 1905 article reported a spontaneous human combustion of an old lady who loved drinking spirits. That article has managed to receive citations more than a century later. The journal also took a look at faith healing in a 1910 series of papers. Reading through some of them does not give the impression that its writers took a very critical view of the practice. The British Medical Association later inspected faith healing themselves in 1956, finding it to be effective for psychogenic problems but not for organic diseases.

The BMJ carried Richard Doll's articles written about the link between tobacco smoking and certain causes of death such as lung cancer in the 1950s. The journal stopped running advertisements for cigarette products in 1957, and we'd take a wild guess that Doll's papers probably had something to do with it.

Elaine Murphy, a psychiatric doctor and Baroness in the House of Lords, hoaxed the BMJ in 1974. She and her then-husband (John Murphy, a marketer) fabricated a condition called "cello scrotum", supposedly a chafing experienced by male cello players in their nether regions. It was submitted to The BMJ as part of a fake case report (i.e., a letter to the editor, thereby bypassing peer review and just needing editorial approval). Probably suspecting some gullibility on the part of the editors, the referenced an earlier case report to The BMJ of a condition that the author called "guitar nipple". It stood in the medical literature for decades, and even received some citations in relevant papers, though the condition's existence was seen as questionable. Elaine and John Murphy sent a letter to the The BMJ in 2008 admitting the hoax, and a correction was published in 2009.

Rapid responses

The BMJ's "rapid responses" section was added in 1998. It's basically a fancy comments section present on each BMJ article's online edition. That makes for a favorite point of citation for cranks looking to pass off said rapid responses as if they were scientific papers formally published by the BMJ. For a reader unfamiliar with the journal's nuts and bolts, it's easy to mistake a rapid response for that, and not everyone writing one has their head screwed on correctly. Though, the responses are manually approved by moderators, for whatever that's worth. There's some racial and gender bias in moderator approval of rapid responses, apparently. Rapid responses are also used as a platform for patients and professionals alike to mount honest critiques of the BMJ's work — some such responses are cited in this very article.

Christmas edition

The 2012 Christmas issue It rips off The Beatles' Sgt. Pepper’s album cover, while featuring 1) a poop-sniffing dog in the lower foreground, in reference to the article "Using a dog’s superior olfactory sensitivity to identify Clostridium difficile in stools and patients" and 2) a man wiping his buttock in reference to "Toilet hygiene in the classical era": putting the BM in BMJ.

The BMJ is known for its annual Christmas issue, which began appearing in 1982, and always contains many whimsical, novel, and strange articles. Apparently many of the articles are about food. One article debunked a claim that alcohol could be absorbed through your feet. Another mocked a reflexology conference because it fell for a hoax submitted by a skeptic. In one feature, one finds not a research article, but some guy playing through The Sims 4. Tongue-in-cheek articles contain blatantly obvious results, such as "sleep deprived people appear tired". Others appropriately focus on Christmas-oriented themes, such as Santa Claus.

Though the Christmas edition often contains sound research, a downside to this yearly event is that researchers also often torture data in order to reach a conclusion fit for publication during the festive spotlight. Some articles in the Christmas edition have won the satirical Ig Nobel Prize. One paper published in the 2010 edition purportedly identified the head of French King Henry IV. The paper somehow managed to reach controversial status, with a third of the authors calling for it to be retracted. It never was, though.

Peer review

See the main article on this topic: Peer review

Richard Smith, who edited the BMJ between 1991 and 2004, has been critical of peer review. One of the points he uses to bolster his argument for "slaughtering" the "sacred cow" of peer review is an experiment done by the BMJ, demonstrating that their peer reviewers were subpar at catching intentional errors. Smith wrote:

“”A fourth problem with peer reviews is that it does not detect errors. At the British Medical Journal we took a 600 word study that we were about to publish and inserted eight errors. We then sent the paper to about 300 reviewers. The median number of errors spotted was two, and 20% of the reviewers did not spot any. We did further studies of deliberately inserting errors, some very major, and came up with similar results.

This experiment may say more about the BMJ's peer review system (at least while it was under his watch) than peer review in general.

Contemporary controversies

Alternative medicine

See the main article on this topic: Alternative medicine

The BMJ's promotion of alternative medicine started in 1999 when it published a series of what could charitably be described as unevenly critical articles. They were published under the title "ABC of complementary medicine", and written by Andrew Vickers (a biostatistician) and Catherine Zollman (an integrative medicine MD). Notable articles included:

• Acupuncture
• Herbal medicine
• Homoeopathy
• Hypnosis and relaxation therapies
• Massage
• Orthomolecular medicine and megavitamin therapy.
• Osteopathy and chiropractic

In 2009, Steven Novella commented that The BMJ "is a strange journal – it is generally of high quality but seems to have a blind spot for certain CAM modalities, like acupuncture." He added, "While it will publish critical reviews […], it also has published some low quality positive reviews" such as one about "acupuncture and IVF (in vitro fertilization). The review glosses over the disparity in study quality and location. Other reviews published around the same time showed no effect from acupuncture in IVF."

The same year, Novella also covered an editorial published in The BMJ titled "Closing the evidence gap in integrative medicine". As Novella puts it:

The essence of the editorial can be boiled down to this – proponents of integrative medicine are disappointed that scientific research has not validated their failed modalities. Therefore they want to weaken the rules of evidence so that they can get the results they desire.

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Throughout the editorial the unstated major premise is that the authors know that the 'integrative' modalities they want to promote work. They simply need to figure out a way to support what they already know to be true with something that can be marketed as scientific evidence. Nowhere do they give a hint that they are concerned about using science to figure out IF a treatment works. They also do not give the slightest consideration to the fact that the evidence gap may be the result of the fact that the treatments simply do not work.

Nearly a decade later, Edzard Ernst and David Gorski (among others) took exception to "state of the art reviews" published by The BMJ in 2017, which seemingly promoted alternative medicine. The reviews used the term "complementary and integrated medicine", apparently a nonsensical allusion to CAM and/or "integrative medicine". In an article discussing The BMJ's reviews, Gorski commented that they could "only be described as fully buying into the false paradigm that quackery needs to be 'integrated' with medicine."

Acupuncture

See the main article on this topic: Acupuncture

As far back as 2000, the British Medical Association endorsed the usage of acupuncture, stating it "should become more widely available on the NHS and family doctors should be trained in some of its techniques". This received some push-back in the rapid responses, with challenges to the flimsy evidence that was used to reach this conclusion.

In 2008, The BMJ published a paper that was a meta-analysis and systematic review article, that suggested acupuncture could aid success with in vitro fertilization. David Gorski, writing in Science-Based Medicine, criticized the paper on several grounds. Among these points, he considered that one passage constituted a fallacious appeal to ancient knowledge. He referred to much of the authors' writing as speculation or based on poor citation. He added, "when clinical studies are done about a hypothesis with a very low prior plausibility, noise predominates, producing a disturbingly high proportion of seemingly 'positive' studies." Further, he criticized the lack of blinding ("much less" double blinding) in several of the examined studies. He concluded that the paper "does not provide particularly compelling evidence".

For some unknown reason, The BMJ published the journal Acupuncture in Medicine from 2008 to 2018 to "build the evidence base for acupuncture" (giving the game away that this would be an advocacy journal). It was published on behalf of the British Medical Acupuncture Society, which encourages the use of acupuncture for a number of ailments. The editor for the journal, Michael Cummings, wrote a 2016 column in BMJ Blogs complaining that Wikipedia "branded" (described, really) acupuncture as a pseudoscience.

One article published in Acupuncture in Medicine under BMJ's watch was criticized when it claimed that ear acupuncture (see also ear stapling) could help with weight loss. Sticking needles through your ears to lose weight is, of course, a brilliant idea.^{[citation NOT needed]} Another paper in the journal studied acupuncture performed on human corpses. Steven Salzberg, a professor of biomedical engineering, criticized the journal as "fake" (along with other journals that gave as examples published by other large "respectable" academic publishing groups) and "filled with fake science". Before BMJ gave the journal the boot in 2018, they retracted a paper about acupuncture and Chinese herbal medicine for stroke patients, that had misreported facts about the clinical trial.

A 2019 study published in BMJ Open said that acupuncture was effective for treating menopause symptoms. Several experts criticized the study. One stated that it was "deeply shocking that BMJ Open should publish a test of acupuncture in which the patients were aware of which group they were in." Many also pointed out that the purportedly positive results were likely to be due to a placebo effect. Steven Novella summarized a paper published in The BMJ in 2020 that tested the impact of acupuncture on migraines as "a study with high risk of bias showing a small reduction in subjective reports but no reduction in more objective measures of migraine." In particular, he pointed out that the study was only single-blinded rather than double-blinded, and that it may have had a geographical publication bias (99% of acupuncture studies from China show positive results; a Chinese government investigation also once showed that 80% of biomedical research in the country was fabricated). He was also skeptical that "acupuncture points" exist at all, since acupuncturists themselves can't agree on them.

In 2022, The BMJ itself even published an acupuncture collection funded by the Chinese government, long known as advocates for traditional Chinese medicine (which includes acupuncture). Edzard Ernst commented that it contained "a bonanza of logical fallacies, sloppy thinking, and uncritical promotion". Time magazine cited one of the analyses published in that collection as an example of acupuncture "going mainstream", quoting the paper in question as demonstrating the efficacy of acupuncture for a breadth of ailments — from post-stroke aphasia to lactation issues. To this uncritical coverage, infectious disease doctor Mark Crislip pointed to placebo: "What does post-stroke aphasia have in common with lactation issues? […] What all these processes have in common is a large subjective/psychological component."

Another paper in that collection gave recommendations for designing "high quality" acupuncture trials. In fact, the paper appeared to dissuade researchers from blinding acupuncturists and patients (though advocating blinding for data collectors, outcome assessors, and data analysts). In a blatant demonstration of bias, the authors argued that trialists should "carefully consider the desirability of a sham that leads to underestimation of acupuncture's treatment effects in clinical practice." Gorski commented, "The whole point of a placebo control or a 'sham' treatment is to reduce nonspecific (i.e., placebo) effects."

Despite the fact that there is no commonly accepted explanation for why acupuncture could be effective in the treatment of pain symptoms, the US Department of Health and Human Services (HHS) reports that "research has shown that acupuncture may be helpful for several pain conditions, including back or neck pain, knee pain associated with osteoarthritis, and postoperative pain. It may also help relieve joint pain associated with the use of aromatase inhibitors, which are drugs used in people with breast cancer. An analysis of data from 20 studies (6,376 participants) of people with painful conditions (back pain, osteoarthritis, neck pain, or headaches) showed that the beneficial effects of acupuncture continued for a year after the end of treatment for all conditions except neck pain." The HHS uncritically cited two papers published in The BMJ's Acupuncture in Medicine (the journal mentioned above) as well as another two published in the Journal of Alternative and Complementary Medicine, a journal that Quackwatch defines as "fundamentally flawed".

Vaccines

MMR vaccine and autism

See the main article on this topic: MMR vaccine controversy

In 2004, Brian Deer began publishing a series of exposés in The BMJ that would completely discredit Andrew Wakefield's proposed link between the measles, mumps and rubella vaccine (MMR vaccine) and autism. This proposed link had been published in The Lancet years earlier as part of a sham study based on conflicts of interest, unethical treatment, and fraudulent research, as Deer was able to demonstrate. Ten of Wakefield's 12 co-authors backed the retraction of the study. As far as the rivalry between the two journals goes (as seemingly one-sided as it is), this would be The BMJ's crowning achievement — Retraction Watch declared of Wakefield's paper, "If there were a Canon of Scientific Retractions, it would be in it."

Other researchers failed in 2008 to replicate Wakefield's supposed findings, and he was stripped of his medical license by the UK General Medical Council. Wakefield's sham research likely sparked (with a sensationalist British press as fuel to the fire) a resurgence in measles outbreaks in the United Kingdom to the extent that it went from an under-control disease to one that was again endemic in Britain. So, the exposure of fraud was clearly important.

In 2023, David Gorski commented that The BMJ's publication of Deer's investigations must have been run by the journal's lawyers first, because of the "very plaintiff-friendly" libel laws present in the United Kingdom. Wakefield had nonetheless attempted a libel lawsuit against Deer, BMJ editor Fiona Godlee, and The BMJ itself in 2012. Wakefield inexplicably enlisted a lawyer who was specialized in copyright instead of libel suits, one of many reasons that the suit was doomed from the start. It very quickly failed on jurisdictional grounds, since he filed it in Texas instead of the United Kingdom! D'oh!

Influenza vaccine

See the main article on this topic: Flu vaccine

Not all has been so right and well, however. Peter Doshi is currently a senior editor at BMJ, and has worked there for some time now. His writings (both in and out of The BMJ) have, for at least a decade, been received with delight by the anti-vaccination movement. He wrote on the subject of influenza death tolls as early as 2005, when he wrote in The BMJ that flu death estimates were heavily flawed. He posed the question: "Are US flu death figures more PR than science?" In March 2006, he wrote on the topic of influenza vaccines for the Christian Science Monitor (CSM) and Harper's Magazine. Reviewing his flu death statements and his CSM piece, 'Revere' of the blog Effect Measure said that Doshi "didn't understand the system or the basis for the estimates. Moreover if one really counted [non-respiratory] flu-associated deaths the figure could easily be a gross underestimate."

In the late 2000s, Doshi began studying for a graduate degree in the HASTS programme at MIT, describing his focus as "debates over causality, standards of evidence, and how to handle scientific uncertainty." He submitted his first "Rapid Response" to a BMJ article assessing respiratory virus prevention methods in January 2008. That year also saw a paper by Doshi questioning the risk of pandemic influenza published in the American Journal of Public Health. The paper took aim at the CDC statement that the "hallmark of pandemic influenza is excess mortality", arguing that this "notion" may represent an example of "generaliz[ing] the exception" of the 1918-1919 flu pandemic. He suggested that this event's death toll may have been high due to the limitations of medicine in 1919, holding that falling flu mortality rates in subsequent decades "cannot be the result of influenza vaccination", and may instead be the product of "improvement in living conditions or naturally acquired immunity." His 2011 doctoral thesis contended that "contemporary influenza policy" was an example of a "disease that for most people is rather unremarkable" becoming the "focus of intense (and costly) public health campaigns based on a shaky scientific basis."

Doshi spoke at a 2009 National Vaccine Information Center (NVIC) conference, which is an anti-vaccination group that gets a large chunk of its funding from Joseph Mercola. Unsurprisingly, the founder of NVIC has also stood in defense of Andrew Wakefield. Indeed, Wakefield showed up to the very same conference as Doshi to receive NVIC's "Humanitarian Award". One must wonder how The BMJ can keep a top editor who has spent his time at a conference undermining The BMJ's own past achievements in exposing scientific fraud.

But Doshi's biggest controversies in virology seemingly began in the early 2010s. In June 2013, Doshi wrote in JAMA Internal Medicine to challenge the assumption that influenza is a "major public health threat for which the annual vaccine offers a safe and effective solution." Bizarrely, he also claimed that "influenza viruses appear to be a minor contributor" to flu, which smacks of germ theory denial. That is perhaps unsurprising given that Doshi signed a letter supporting the HIV/AIDS denialist group Rethinking AIDS while a student at MIT. This letter states its intent is to counter an alleged false narrative promoted by "the AIDS industry and media" that "only a handful of scientists who doubt the HIV-AIDS hypothesis". When confronted about this by Forbes journalist Steven Salzberg in 2014, Doshi claimed that he had "written the list owner and asked for [his] name to be removed," but his signature is still there nearly ten years later.

For a prominent writer on vaccines, that is strange indeed. A month before the JAMA Internal Medicine article, he wrote one for The BMJ that was critical of the CDC's influenza vaccination drives, too. He emphasized the potential dangers of flu shots, and questioned their efficacy. His piece was trumpeted across anti-vaccination websites with headlines such as "Johns Hopkins Scientist Reveals Shocking Report on Flu Vaccines". Doshi's critics soon responded, with some pointing out that he was not an epidemiologist; rather, he is an anthropologist. According to Snopes, Doshi "completed a fellowship in comparative effectiveness research at Johns Hopkins. He conducted no research into influenza or vaccines at Johns Hopkins, nor does he speak for the university on that subject." Michael Simpson, a biologist, writes that Doshi "has no knowledge, training or expertise in these highly specialized fields, yet he pontificates in a manner that makes one believe he [does]."

Since their name had been invoked, Johns Hopkins felt it necessary to comment on the matter:

Johns Hopkins Medicine in no way endorses an article published in July^[sic] 2013 by a former fellow at our school of medicine questioning the validity of the annual flu vaccine. The writer has no scientific affiliation with Johns Hopkins, nor is he employed by any of the Johns Hopkins Medical Institutions. […] At Johns Hopkins, we are confident that the benefits of the flu vaccine to individuals and to public health are very strong. In an effort to protect our patients, Johns Hopkins Medicine mandates that its health care workers receive an annual influenza vaccination, assuming no personal allergies or medical conditions contraindicate it. Our vaccination rate is 97 percent.

Simpson added:

Doshi also vastly overstates the risks of the flu vaccine while understating the benefits in saved lives. […] In fact, a true skeptic weighs the evidence on the risk and benefit sides of the equation, then determines the value of the benefit to risk ratio.

Despite his lack of actual expertise in real vaccine research, Doshi was an "expert witness" for Children's Health Defense, Robert F. Kennedy Jr.'s anti-vaccine group.

VAERS

In 2017, Doshi wrote an entire article for The BMJ because he was upset that the website for the Vaccine Adverse Events Reporting System (VAERS) was temporarily troublesome to access for some popular Web browsers. He stated: "If anyone was looking for a good illustration of how little respect pharmacovigilance gets in the US healthcare system, this might be it." As he acknowledges, though, there are other methods to report an adverse event (such as by phone, fax, or mail). At the time, the website was merely undergoing a technical overhaul. VAERS is not considered (or treated as if it were) very robust, anyway. It's quite open for people to submit bullshit claims, and experts know this. In one demonstration of this fact, a doctor submitted a claim that a flu shot had turned him into the Incredible Hulk. VAERS required his permission to remove it from their database (fortunately, he obliged).

COVID-19 vaccine

See the main article on this topic: COVID-19 vaccine

Before the initial COVID-19 vaccine trials had even finished, Doshi got to work casting doubt on them — as early as September 2020. He suggested the trials couldn't prove that COVID-19 vaccines prevent severe cases (among some other miscellaneous complaints that mostly don't make a lot of sense). John Skylar, a virologist, criticized Doshi's statements:

I want to emphasize that Dr. Doshi is just wrong. He claims that the clinical trials for the vaccines contained a design flaw that has made them miss a large number of cases of COVID-19. Specifically, he believes it is inappropriate that they measured only confirmed cases of COVID-19 rather than looking at suspected cases of COVID-19. His argument is that if you look at suspected cases, you see a vaccine efficacy of only about 19%, where looking at confirmed cases gives an efficacy of 95%. The thing is, this analysis is wildly flawed. Dr. Doshi conveniently ignores the fact that many of the suspected cases turned out to be negative for SARS-CoV-2 infection. So many, in fact, that it would suggest that PCR tests only correctly detect 5% of tested cases. We know this isn't the case. While it is probable that some positive cases were missed, it is unlikely that this is a very substantial number.

Doshi additionally complained that Pfizer had excluded 0.5% of the subjects in one of their trials from the final analysis, due to protocol deviations. He notes that there were more exclusions in the vaccinated group than the control group, but David Gorski noted that "even given the imbalance in deviations between the placebo and vaccine groups this is a number too small to have significantly affected the final analysis." Other critics of Doshi on this topic included professor of public health & preventative medicine Jeffrey Morris, and scientist/health advocate , who provided their own respective write-ups.

Later, in 2021, Doshi testified for a panel led by GOP Senator Ron Johnson. There he claimed that it showed most COVID-19 hospitalizations were among vaccinated people; in fact, the report was an error, originating with a mistaken swapping of the word "vaccinated" with "unvaccinated". Doshi also claimed that mRNA vaccines (e.g. the Pfizer–BioNTech and the Moderna COVID-19 vaccine) are not really vaccines.

Paul D. Thacker (an anti-GMO guy who used to work for GOP Senator Chuck Grassley), published a 2021 "exposé" in The BMJ, alleging sloppy laboratory management by one company operating three clinical sites (out of 153 total) for Pfizer's large COVID-19 vaccine trial. This involved such abuses as placing sharps into biohazard bags instead of a sharps container box; much of it had little apparent impact on data integrity. Several experts such as Paul Offit questioned the authenticity of Thacker's report; David Gorski commented that it was framed deceptively. A spokeswoman for the company involved stated that the whistleblower's allegations "were investigated and determined to be unsubstantiated". The whistleblower alleged that she had only worked for the company for two weeks. The Thacker/Jackson report was later developed into a video on The BMJ's YouTube channel, which received over three million views.

In 2022, Doshi published a paper which Health Feedback, along with numerous other sources, described as engaged in p-hacking to bias its results "in favor of the conclusion that the risk of serious adverse [vaccine-related] events are greater than the risk of serious COVID-19 outcomes." Jonathan Howard and Harriet Hall (among others) wrote their own critiques of the paper; both point out that Doshi used VAERS as if it were a robust source. Originally gone viral among anti-vaccination activists while it was a mere pre-print, these "reanalyses" by Doshi somehow managed to receive publication in not only The BMJ, but also another major journal, Vaccine.

Chronic fatigue and CFS/ME

See the main article on this topic: Chronic fatigue syndrome

Skirting ethical review

In 2011, BMJ Open published a study investigating whether undiagnosed cases of chronic fatigue syndrome (CFS) (also called myalgic encephalomyelitis or ME) could be discovered among schoolchildren by examining school absence records. The paper was published without ethical review, as Esther Crawley and her co-authors claimed the paper should qualify for an exemption, applied to papers that only involve "service evaluation" (i.e. evaluating the current state of health service to people already diagnosed with CFS) rather than original research involving human subjects — though the paper was actually labeled explicitly as research by BMJ Open in a subheading and certainly did involve human subjects.

This was raised as a concern by the paper's pre-publication reviewer, who suggested the authors publish their correspondence with the REC (Research Ethics Committee) as well as more information about the researchers' contact with the involved families, however the paper was published anyway without such information. Later, the journal's editor agreed that the paper did not strictly constitute service evaluation, yet should still be exempt somehow.

Crawley cited a 2007 REC reference number regarding a separate procedure that would in fact have constituted service evaluation, attempting to apply it to the 2011 study, clearly outside the bounds of the original exemption. That the REC correspondence took place four years earlier was not apparently made clear to the pre-publication reviewer. She additionally claimed that the REC had indicated that a paper "recording outcomes on school based clinics run by school nurses" should be exempt from ethical review — which was seemingly irrelevant to the research at hand. As an example for why this research may have required ethical review, a letter to BMJ Open on the subject notes that inviting undiagnosed children to a meeting to determine whether they had chronic fatigue syndrome due to their school absences could cause anxiety and distress among parents. The 2007 REC letter was also cited to exempt at least ten other studies (or parts of studies) from ethical review, at least four of which were also published in BMJ journals; In one case, it was used to cite a study published in 2017, ten years after the original exemption letter.

An editor for BMJ Open stated in response to an email inquiry, that the school absence research would have been exempted from ethical review because it qualified as "research limited to secondary use of information previously collected in the course of normal care (without an intention to use it for research at the time of collection), provided that the patients or service users are not identifiable to the research team in carrying out the research". This was very obviously not the case with the given research. The journal's editor-in-chief later suggested that all was handled correctly by the authors in the original pre-publication review. The journal then submitted the case to the Committee on Publication Ethics (COPE). The COPE Forum responded in a way that made clear that ethical review should have been required. Instead of complying with the COPE's advice to review the paper's methodology (which would have yielded an obvious conclusion that it should have received ethical review), BMJ Open opted to simply close the case.

The Lightning Process

A clinical trial for the use of the Lightning Process (an alternative medicine commercial programme created by a former "tarot healer" that incorporates aspects of neurolinguistic programming and osteopathy) as a treatment for chronic fatigue syndrome in children was published in 2017 in Archives of Disease in Childhood, a BMJ journal. It found that the Lightning Process may be useful for these children. Crawley, who was also an author in this study, acknowledged many limitations and stated she was "not advocating people go out and get the Lightning Process". In a September 2017 article for The BMJ's "Research News" section about the trial, Nigel Hawkes was somewhat critical of the practice, commenting that "The Lightning Process is secretive about its methods, lacks overall medical supervision, and has a cultish quality because many of the therapists are former sufferers who deliver the programme with great conviction. Some children who do not benefit have said that they feel blamed for the failure."

A letter to the Archives of Disease in Childhood signed by 21 researchers critical of the study, calling for major corrections to the paper, was published in January 2018. It stated that the study's self-reported outcomes were vulnerable to bias. They also pointed out that the Lightning Process (which they called pseudoscientific) "encourages participants to report that it has made them better, another source of potential bias" and that "the study suffered from major cross-contamination between treatment arms and significant loss-to-follow-up, among other problems."

David Tuller (a Doctor of Public Health who signed the letter to the Archives of Disease in Childhood) also noted that the paper violated BMJ policy and International Committee of Medical Journal (ICMJE) recommendations (there to protect against bias and ensure research integrity) it was subject to, and suggested this may be grounds for the paper to be retracted entirely. In particular, he wrote that "more than half the participants were enrolled before the trial registration date" and "the outcome measures were swapped based on those first results – meaning that this was not a properly registered prospective trial."

The journal never retracted the paper when made aware of these flaws, but did instead issue a lengthy correction (that consisted of "mainly clarifications") that surprisingly culminated in a republication of the paper in 2019, allowing the dubious findings from the paper to stand. The paper's authors also acknowledged that the study lacked full compliance with ICMJE recommendations. A follow-up letter signed by 72 experts along with dozens of patient and advocacy groups for CFS/ME condemned the republication of the paper as "scientifically and ethically indefensible" and contrasted the decision with BMJ's previously stated policy on the matter.

Ola Didrik Saugstad (a Norwegian pediatrician) and Vincent Racaniello (a virologist), among others, further called for the paper to be retracted. Brian Hughes, an academic psychologist, criticized the paper's vulnerability to confirmation bias. Edzard Ernst stated: "The trial was designed as an 'A+B versus B' study which practically always generates a positive outcome. It did not control for placebo effects and is, in my humble view, worthless and arguably unethical. It certainly does not warrant the conclusion that [LP] is effective or cost-effective." Tuller further listed his gripes with the study in an opinion article for STAT News, a medical news outlet. He added: "BMJ's inability to detect problems in these cases, despite supposedly rigorous oversight systems, suggests that its peer-review and editorial processes might need a significant overhaul."

CBT with music therapy

In 2020, BMJ Paediatrics Open published a paper that examined the use of cognitive behavioral therapy (CBT) combined with music therapy in adolescent patients with chronic fatigue following Epstein-Barr virus (EBV) infection. One of the two peer reviewers stated in his review, "I haven't read beyond the abstract". Yes, really. The paper was fully retracted later due to its being labeled as a "feasibility study"; it was republished and re-labeled as a randomized controlled trial. Tuller listed several critiques of this study, including its premise that CBT is effective for treating CFS/ME; a CFS/ME patient also wrote a critical rapid response to the paper. BMJ refused to publish some other critical responses to the paper written by patients.

The study's main focus (physical activity levels between the intervention and control groups) showed that those who received CBT/music therapy actually fared worse. However, the researchers decided to emphasize self-reported measures of success instead, leading them to the conclusion that the treatment was feasible. Notably, 6 of the 21 patients in the intervention group had dropped out of the study during the treatment period, and there was no similar drop-out rate for the control group. The senior author for the CBT/music therapy trial, Vegard Bruun Wyller, noted that avoidance of school absence was cited by many as a reason for dropping out of the trial. Wyller was also a proponent for another planned trial of the Lightning Process but the trial was rejected by Norway's research ethics authorities.

Trans healthcare

See the main article on this topic: Transgender

Despite more recent publications covered below, The BMJ previously hosted writers who called for quicker transition care. For instance, James Barrett (a psychiatrist) wrote in a 2016 issue about how the British healthcare system was not doing enough for transgender patients.

"Too far, too fast?"

The BMJ cover from March 11, 2023

On March 11, 2023, the print edition of the The BMJ featured a front cover posing the question, "Transgender Medicine for Young People: Too Far, Too Fast?" In this issue, BMJ editor-in-chief Kamran Abbasi framed the "debate on gender dysphoria" as representative of "all that is unsavoury about the intersection of science, medicine, and social media." In the piece, Abbasi claims that "closer inspection" reveals "the strength of clinical recommendations [on treatment of trans youth] is not in line with the strength of the evidence", arguing that "the risk of overtreatment of gender dysphoria is real." Abbasi praised a Guardian op-ed defending the "cancelled" TERF artist Jess de Wahls as "an important and entirely feminist view" in a 2021 tweet.

Surgeon Alex Ashman tweeted that they found it "so sickening to open the magazine of [their] union and find that the culture war about trans people is right there on the front cover." The British Medical Association issued a statement in response, stating that, although BMA membership includes a BMJ subscription, the journal is "editorially independent" from the union and "BMJ coverage does not reflect BMA policy positions." It also affirmed its support for the right of trans people to access care that is "timely, patient-centred and meets their individual needs."

More JAQing off

See the main article on this topic: Just asking questions

The March 2023 issue featuring Abbasi's article included a related piece by Jennifer Block. The piece, actually a "BMJ Investigation" rather than a research paper, was published online in late February. Block describes herself as an "independent journalist who writes frequently about health, gender, and contested areas of medicine." The BMJ previously ran a cover story by Block in September 2021 on COVID vaccine mandates in the United States that argued "evidence is mounting that natural immunity is at least as protective as vaccination." Block co-authored a piece with BMJ editor Peter Doshi for a January 2021 New York Times series on COVID vaccine rollout problems, which called it "needlessly divisive to use pressure, shame or mandates to get people vaccinated." Block has more recently taken to Twitter to express her opposition to school mask mandates and vaccinating kids against COVID. She also has a long history of promoting a "natural" approach to obstetric care, advocating home birth and decrying medical interventions such as Caesarean sections, inductions, and epidurals. Block defended Goop in a 2020 New York Times piece co-written with a doula novelist.

Block's 2023 article for The BMJ rehashes anti-trans scaremongering about the surge in youth transition; Block's article cites Lisa Littman. The article presents "surgical removal or augmentation of breasts, genitals, or other physical features" as interventions that gender-dysphoric children may be offered under the standard of gender-affirming care practiced in the U.S. It uncritically quotes the claim of far-right detrans activist Chloe Cole that "many of us were young teenagers when we decided, on the direction of medical experts, to pursue irreversible hormone treatments and surgeries." Cole has spent much of 2022 and 2023 travelling across the U.S. to testify in support of bills banning gender-affirming care for minors. Nine U.S. states have passed bans on gender-affirming care for trans youth as of March 2023. Block's article also cites a 2022 study commissioned by the Florida Agency for Health Care Administration (AHCA), which had been stacked with Catholic Medical Association members (who have a "faith-based commitment" against homosexuality and transition care) by Ron DeSantis. The Human Rights Campaign now recognizes Florida's AHCA as a body that "is willfully misinterpreting studies, ignoring evidence, and lending credence to prejudice."

The BMJ published several rapid responses to Block's article in the weeks following its online publication. One supportive response came from Jonathan D. Block, a Utica, New York-based urologist. He did not disclose any conflicts of interest in his submission despite being married to the article's author.

London-based doctor George R. Huntington wrote that he was "disappointed in [the] lack of rigour" of the piece. Huntington found it "curious" that an "author criticising a medical consensus for lack of strong evidence" had relied on "quotations and single cases" drawn from "self-citations or Cornish QIPs" instead of citing primary sources. He noted that the article centered the "0.3% [who] regret their transition" while ignoring the "voices of the other 99.7%," concluding this was because it is "not a piece of scientific journalism" but rather a hit piece "lean[ing] on the authority of a medical journal to push an agenda, one of muddying the waters."

New Zealand psychiatrists Zoe Kristensen and David B. Menkes took issue with Block's conflation of social transition with surgical and hormonal therapies. They criticised her for "mistakenly equat[ing] the limited evidence underpinning gender affirming care with its propensity for harm", explaining that research on trans youth is complicated by small sample sizes and "other aspects of study design" such as the "ethical protection of minors", the "realities of studying a hard-to-reach community", and "prioritisation of clinical care over research" where resources are lacking. A group of three British surgeons (Ashman et al.) concluded that "the assertions made by Block are in some cases unsupported by reference, and in others are based on only some of the available evidence." They pointed out that the two studies that Block cited in her discussion of detransition do not support her claims. One study investigated HRT discontinuation rather than detransition and the other included "just five cases of detransition or regret and was not specifically looking at children and young people."

Three neurodivergent (ND) doctors objected to Block's mention of the scientific finding that trans youth are more likely to have depression, anxiety, autism, or ADHD. They found that this fact, presented out of context in a paragraph about the increase in youth transition, serves to "imply that there is less capacity [among ND people] for making good choices about our bodies, evaluating risks and benefits." Ashman et al. similarly held that, while the "co-existence of gender dysphoria with autism and ADHD is worthy of future study", this does not "represent a reason to deny these children effective treatment for gender dysphoria."

See also

• Elsevier
• Intelligence (journal)
• Nature (journal)
• Nobel disease

External links

• The BMJ's website
• Articles archive (also found here)
• See the Wikipedia article on The BMJ.
• The BMJ's entries in Retraction Watch
• "What the heck happened to The BMJ? (2023 version)". By David Gorski, in Science-Based Medicine.