The retirement of Dr. Jeffrey Drazen as editor of the New England Journal of Medicine, announced last week, has created an opportunity to bring a new perspective to what is arguably the world’s most prestigious medical journal.

Scientific publishing has changed a great deal during the 18 years that Drazen, who will remain in the post during the search for his replacement, has run the more than 200-year-old journal. Advances in technology, more scrutiny of publishing and peer review, and the emergence of some models — particularly preprints — threaten to erode the hegemony that journals like the NEJM have long enjoyed. Barely whispers at the turn of the millennium for most journals, open access and open data in medicine now are important parts of the discussion.

Along the way, despite the fact that some researchers hate NEJM the way baseball fans hate the Yankees, its stature has grown. Its impact factor, a loose — and some would say deeply flawed — measure of publishing glory in science, is now brushing up against 80, far outstripping its rivals The Lancet (53) and the Journal of the American Medical Association (47). NEJM’s Perspectives section has grown and matured, and has become a critical part of the conversations around both health care policy and clinical medicine.

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Drazen has had his share of stumbles, among them a wishy-washy stance on data sharing and ongoing debates over author disclosures of conflicts of interest, including questions about his own conflicts with drug makers when he took over the job.

To be sure, his successor won’t have a perfect tenure, either, but the new editor will inherit a platform with the potential to shape the future of medical publishing. So we asked a small group of current and former journal editors, active clinical researchers, and those involved in new models of publishing for what they’d like to see in the journal’s future. Some demurred, but here are thoughts from a few who responded.

Dr. Richard Smith, former editor of the BMJ, offered this advice: Change the raison d’etre. “The whole idea of the NEJM is based on a false premise — that it selects the studies that people need to read. ‘We do your work for you,’ as Jeff Drazen puts it,” Smith told STAT. “This is clearly nonsense.”

Drazen has written that, “We choose these [articles] because we think these articles will change the face of medicine.” But the journal receives only a sliver of the millions of papers scientists write each year — and publishes even fewer (about 200 per year, according to Drazen). “Even if some of these are the most important papers, it is still a selection,” Smith said.

Looking ahead, Smith said, as science moves away from journals as the most important medium for delivering information, the next editor of NEJM will have to adapt.

“The main job of journals will not be to disseminate science but to ‘speak truth to power,’ encourage debate, campaign, investigate and agenda-set — the same job as the mass media. The NEJM needs to strengthen that side of the journal.” (Smith may have a model in mind. Fiona Godlee, the current editor of the BMJ, has called her publication an outlet for “campaigning” against what see sees as flaws in the biomedical edifice.)

Jessica Polka, the executive director of ASAPbio, a nonprofit that pushes for the wider use of preprints in the life sciences, and a visiting scholar at the Whitehead Institute in Cambridge, Mass., said she would urge the next editor to “enable the early dissemination of research results by supporting preprinting and enhancing transparency by publishing the contents of the peer review process.”

Dr. Jerome Kassirer, who edited NEJM from 1991 to 1999, said the next editor will face two immediate challenges. The first is the ongoing confusion about how best to deal with authors’ financial conflicts of interest, particularly regarding editorials and review articles. “The journal has just reported that they’re going to put all of their conflicts of interest on a central site — implying that all that’s needed is to report what the conflicts are, and not deal with the conflicts themselves,” said Kassirer, a distinguished professor at Tufts University School of Medicine.

The second problem is more existential. Like all printed publications, NEJM is facing a decline in print subscribers, Kassirer said. “Doctors in the community and in academic medical centers are using less and less paper issues and relying more and more on sources of compiled information such as guidelines and electronic sources like UpToDate and the Cochrane Collaboration,” he said. The shift has “profound” implications for journals, like NEJM, which have made subscriptions a critical part of their revenue.

If subscription income falls, the next editor will have to make up the difference through other streams, especially advertisements from pharma and reprints of the articles it prints — again typically paid for by drug companies. “To the extent that the editor is not dependent on pharma revenue, then he or she can publish whatever they want. But if revenue begins to fall, there may be enormous pressure on the editor to publish more pharmaceutical studies to sell more reprints,” Kassirer said.

Who the next editor will be is anyone’s guess. (It wouldn’t be so bad if it were a woman; NEJM has had only one female editor in chief, Dr. Marcia Angell, in 206 years, and even then only for a year.) But we figure that anyone who can at least consider the thoughts we’ve gathered here will get a running start.

Kassirer, who recently published a memoir of his time at NEJM, said all is not dire. “You’re inheriting probably the premier clinical medical journal in the country or the world. It’s a great joy to edit the NEJM — at least it was in my time,” he said. “It didn’t matter where [an article] came from or who wrote it; all we cared about it was the value to our readers and the validity of the information. That decision-making process, which we did every Thursday, was one of the most exciting and interesting experiences of my life. I loved every minute I was there.”

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