No laughing matter

A small, highly specialized medical journal makes its first attempt at satire in 21 years. The New Year’s Eve spoof paper in question was a pretend randomized controlled trial (RCT), where toddlers were claimed to have been deliberately exposed to pain in order to study the efficiency of their mothers’ kisses at alleviating it. The author and the journal’s editor-in-chief intended this satire of evidence-based medicine (EBM) exclusively for their dedicated clinician readers, and did not expect a wave of anger, ridicule and confusion over social networks. Much less so, they did not expect being accused of predatory publishing. Now both found themselves in the need of explaining the humoristic nature of their publication and the original target of the satire.

The paper, which appeared on December 29^th 2015 in the Wiley-published Journal of Evaluation in Clinical Practice (JECP) was easily recognizable as satire to anyone who spent at least a minute considering its title or reading its abstract.

It was titled: “Maternal kisses are not effective in alleviating minor childhood injuries (boo-boos): a randomized, controlled and blinded study”. Authored by “The Study of Maternal and Child Kissing (SMACK) Working Group”, it claimed to have exposed almost one thousand children to “experimentally induced minor injuries”, by tricking them into touching a 50°C hot plate or bump their heads under the table. The toddlers’ mothers were then supposed to either kiss or not kiss the injuries, while “‘sham’ kisses were delivered by a trained researcher”. Children’s pain was then measured using “a 15-point, five-domain, non-verbal tool”.

The farcical hilarity of the study was maintained even into the literature references. There, citations pointed to invented papers like “Algebra and conversational Mandarin: it is never too early to start”, allegedly published in real journals like Child Psychiatry and Human Development.

Already in the end of the abstract, the SMACK group dispelled last doubts on the satirical nature of the paper by concluding:

“The practice of maternal kissing of boo-boos is not supported by the evidence and we recommend a moratorium on the practice”.

I was notified about this publication by the plant scientist and known sleuth of plagiarism and misconduct, Jaime A. Teixeira da Silva. My first reaction was: this must have been a prank on the journal and the respectable publisher Wiley, set to expose lax editorial oversight and lack of proper peer review, similar to the famous John Bohannon sting or a paper authored by the cartoon character Maggie Simpson. There, nonsense manuscripts have been submitted to a range of journals, some of which took the bait and eagerly accepted the papers, obviously expecting to receive a handsome publication fee in return. They had their predatory nature exposed, as it became obvious that no-one at those journals actually read the manuscript or at least cared the slightest bit about its quality. Was JECP another predatory journal, without a proper editorial board, yet published in subscription by Wiley? Who then was behind the prank?

I contacted the authors of the “boo-boo” paper at the provided authors’ email address as well as the journal’s Editor-in-Chief, Andrew Miles, a highly distinguished professor of clinical epidemiology and Secretary General of the European Society for Person Centered Healthcare. Miles replied immediately and confirmed that the paper was

“a piece of medical satire by Dr. Mark Tonelli, Professor of Intensive Care Medicine and Bioethics at the University of Washington, Seattle, USA. It forms part of the JECP´s latest thematic issue on evidence-based medicine (EBM). The JECP has contributed to the international EBM movement for over two decades under my editorship. As satire, the piece is entirely fictional, a spoof, as it were, but directly intended to lay out a series of observations and critiques of EBM that remain relevant today, even though the EBM thesis has changed markedly five times and is currently in its sixth re-constitution.

The Editor-in-Chief Miles, obviously highly distressed seeing his journal fall under suspicions of predatory publishing, sought to explain the editorial decision:

“From Horace and Lucilius to the present day, satire has always been regarded as a valuable tool, a device, with which to stimulate intellection. […] There is no joke or hoax or  “prank”, merely the use of a time honoured editorial device, exercised through the mechanism of a specific commission with the rigorous process of external peer review which the JECP employs via its S1 system, being inappropriate in the context of the current case”.

Miles sees satire “in small and appropriate doses” as very important in medical education.  He further admitted being inspired by the British Medical Journal (The BMJ), which Christmas edition regulary contains satirically inspired or outright parody research articles. However, JECP was less publicly known for any kind of satire tradition, in fact Miles admits:  “ In 21 years of publication, it is our first attempt!”.

Tonelli, the real and only author behind the SMACK study, also replied to my inquiry and chimed in:

“The piece, as written, really has nothing to say about the very real problems of editorial oversight, peer review or fraud in science. […]

As to the intended purpose of the paper, writing a report of a fictional clinical trial as satire allowed multiple limitations and pitfalls of clinical research to be addressed beyond simply the limits of RCTs. While those lessons should be quite evident to many clinicians and scientists, they are expected to be harder to discern by members of the public. Clearly, most readers of the abstract recognized the absurdity of applying a methodology (blinded, “sham” kissing) to a question that simply cannot be answered through that approach. Unfortunately, such misapplication of method to question happens not infrequently. The treatment of subjects that pushed ethical boundaries (causing boo-boos in toddlers) raises the limitations of institutional review boards to actually protect human subjects. Attempts to quantify (the Toddler Discomfort Index) what are inherently non-quantifiable phenomena are a major staple of clinical research, which generally assumes you cannot study what you cannot measure.

The corruptive influence of industry sponsorship (the SMACK study is funded by a manufacturer of self-adhesive bandages and ointments) on determining not only what gets studied but how the results are presented is a clear and present danger to society.  When the world practices evidence-based medicine, he who controls the evidence wins (or at least gets rich). The failure of voluntary conflict of interest disclosure rules and the self-serving tendency of clinical researchers to always call for more clinical research are also highlighted. In addition, there are several other intended lessons in the piece.

I would hope that the article would be used by practitioners and trainees in journal club settings. By picking apart the obvious errors in the SMACK trial, participants would be primed to look for similar problems in reports of clinical research”.  

In another email, Tonelli explained his and Miles’ thinking while placing the article:

 “I think I can speak for Andrew when I say that neither the Journal nor I intended for this piece to be debated in the public domain. Hence, there was never any consideration of a press release”.

Exactly this seems to have been the problem, unforeseen by Tonelli and Miles: the article, despite their original intentions, has reached an audience way outside of the usual JECP readers. There, it was occasionally taken either to be real or a prank at the costs of the journal. What have the two well-meaning professors done wrong then?

In this regard, it is useful to look again at The BMJ to learn how such satire publications should be handled. Last Christmas issue offered a good example, with a study explaining a weird walk the Russian president Vladimir Putin and his KGB cronies allegedly display: Gunslinger’s gait”: a new cause of unilaterally reduced arm swing. Unlike Tonelli’s SMACK study, the BMJ readers did not have to contact the journal or follow satiric email addresses, since the Putin analysts were clearly as visible authors of the paper: Bas Bloem, neurology professor at the Radboud University Nijmegen, as well as other named neurology professors and clinicians. This author naming alone made clear that the paper could not have been a prank on the journal, even to those unaware of The BMJ’s Christmas tradition of satire. In fact, quite the opposite happened: a number of serious media, including the BBC, Radio Liberty, The Guardian and even the serious science news outlet Phys.org took the publication at face value and failed to spot any irony in it. Therefore, this satiric paper by Araújo et al not only satirize the questionable practice of distance-diagnosis of television personalities and even long-dead historical figures in medical publications. It also helped exposing poor science journalism, which often unquestioningly depends on sensationalist press releases and makes it a common practice to report even most outrageous announcements in science and medicine without even a hint of critical thinking. In regard to the JECP satire, Bloem shared with me this brief comment:

” I like the acronym for the group of authors! In general, journals should combine humour and content more, to bring seriousness messages better across”.

Tonelli and Miles were apparently determined to avoid getting involved into a media hype and wished to restrict their satire to a selected and well-informed audience. Miles issued an accompanied editorial to introduce the educative satiric piece, but what he did not anticipate was, as he put it,”Wiley´s much cherished rapid on-line early system”. He confesses that it did not occur to him that, because of certain editorial delays in the preparation of journal’s 21 (6) issue focusing on EBM, “Mark´s paper would appear in advance of my own intro in which the nature of Mark´s paper is made clear”.

As a consequence, instead of informed light-hearted discussion among clinicians, angry emails and requests from science journalists started pouring in. The joke got out of control, an explanatory piece in Nature News became necessary.

Tonelli expressed to me his readiness to be officially named as paper’s real author instead of the mysterious SMACK Working Group, in fact he indicated: “My name does actually appear in the paper, if you read the first letter of the references down (Though I did not expect many to note this, it makes it clear I was not planning on avoiding detection.) All responses to the gmail account are returned in my name.”

Miles is now considering clearly label the “boo-boo” paper as satire:

“Since not everyone will read my introduction before or after reading Dr. Tonelli’s piece it will be a good idea to annotate the PubMed Abstract with a cross reference to the introduction and I will consult with Wiley about how this might be done”.

Wiley already reacted, and made things worse. The only initial give-away of the editorial origin of the spoof article was its open access availability, in an otherwise subscription-paywalled journal. But soon enough, some overeager Wiley executives have plugged this hole. The full text has disappeared behind the publisher’s paywall. It now costs $38 to learn about the efficiency of maternal kisses, but until Wiley finds out and interferes, you can get your free copy from The Federalist.

Update 11.01.2015, 17:40: an error about when and in which issue Andrew Miles’ explanatory editorial was scheduled to appear has been corrected, with appropriate changes to the text. Also, a link to free copy of the paper has been added (courtesy of The Federalist). LS

Update 14.01.2015: a short comment freshly provided by “Gunslinger” lead author Bas Bloem has been integrated in the text above. LS