Loefler, Imre (Nairobi Hospital Proceedings), (Nairobi), (Kenya).

I am well acquainted with both the big five medical journals and the big five game animals, having spent much time in their company. I have learnt from them, I cherish and admire them, and I appreciate the differences in their character. Why not match the two groups in pairs since animals have always been used as symbols for institutions?

JAMA is undoubtedly the elephant, and not only because of its size. It is dominant and loud, ranging over a huge territory, within which, however, it commutes on well trodden paths. It can do a lot of damage by pushing, shoving, and trampling, and ultimately it can devastate its own environment. It is a poor converter of food, and many other species thrive on its droppings. It has stamina, it is gregarious and supportive, and it has the wisdom of the conservative kind. It has a good memory. It revisits fruiting trees regularly. It can survive drought by adapting to meagre food supplies and by digging for water, an activity from which other species benefit.

The New England Journal of Medicine is the rhinoceros. Solitary and ill tempered, it can smell and hear but it cannot see well, hence its horizon is narrow. It charges everything that moves (but never anything that is immobile such as the churches and the universities). It can survive on coarse food, and it can swallow thorns. Of the five, it is the one most difficult to sex. Experienced hunters maintain the female of the species is more territorial and irascible then the male.

The Annals of Internal Medicine resembles the buffalo. It is the only ruminant of the five. It has better eyes than the former two; it can see far. It charges using its sight, not its nose or ears, and it does not often miss. However, its condition rapidly changes in accordance with food supply, therefore sometimes its ribs stick out. In good seasons, when there is plenty of nutritious forage, it can suffer from diarrhoea.

The two Britons are the carnivores: the lion and the leopard. They are higher in the food chain than the transatlantic herbivores. Both, but particularly the leopard, may be found in diverse habitats. Their food preferences change according to availability. They regularly kill prey much larger than themselves.

The Lancet is akin to the leopard. It has the better nose. It is the more subtle, more cunning, and more elegant of the two. When in pursuit of its quarry it is single minded and quiet, preferring to kill by stealth. It returns to the kill until it is completely consumed. It is a true cat, has its own ways, and is unlikely to change its spots.

The parallels between the BMJ and the lion are more subtle. The lion is loud and visible, spending much time in displaying. It is a strong and methodical hunter and uses multifarious strategies to bring down its prey. It has a big appetite and when game is in short supply it scavenges and may rob other predators. (It is said that the leopard has stories to tell.) It is gregarious and playful and carries on with most of its transactions in the daylight, yet it can behave like the leopard. It is known to have eaten men.

Loefler, Imre (Nairobi Hospital Proceedings), (Nairobi), (Kenya).

The New England Journal of Medicine, the Lancet, and the BMJ have for many years competed in the mid-Atlantic in the Blue Band. Now they navigate in different waters and can be distinguished by the cuts of their jibs.

The Lancet still sails the mid-Atlantic. She offers fast and safe passage. She surrounds her passengers with comfort and elegance, entertains them well, and insists on refined and beautiful language on board. The Lancet loathes delay and deviation, generally avoiding heavy seas and shallows.

The New England Journal of Medicine cruises in northern latitudes, where she is trying to find a new northern passage in cold and clear Puritan waters. She flies a new flag: the flag of fundamentalist political correctness, which, in the United States is compatible with liberalism and the quest for regulation. The journey between the calving icebergs is dangerous. It is perhaps for this reason that there seem to be two captains on the bridge. The journey offers solemn vistas of an austere landscape, and the crew sings pilgrim hymns.

The BMJ sails close to unpredictable tropical hot winds and is attracted by thunder and lightening as she seeks adventure in tumultuous seas. She does not put comfort high on her list of priorities, and she does not mind if the passengers become drenched in spray. The captain likes to engage the passengers in action, and he expects all hands on deck.

JAMA and the Annals of Internal Medicine do not care to compete in the Atlantic.

JAMA has always been a cruise ship that never strays further than Hawaii and prefers the Caribbean and the Bahamas. She rarely takes anyone but an American on board. Known for gluttonous dinners as well as for vigorous aerobics, she offers everything that one might want to do on a cruise, including a little gentle gambling and an occasional stop in a foreign harbour of exciting repute. She never sails to Canada for fear that the passengers might become infected with the “socialised medicine bug.”

The Annals of Internal Medicine has become an important carrier of cargo. She spends much time between Canada and the United States and frequents the St Lawrence Seaway. The Annals may venture to ports in the southern Caribbean as well, but she likes to remain in coastal waters most of the time and eschew oceanic traffic altogether. Hence she does not compete with the other four ships directly.

Marusic, Matko (Croatian Medical Journal), (Zagreb), (Croatia).

The World Cup makes nobody happy. The team that comes fifth is bitter because it missed the semifinals, the fourth lost the last two matches, the third beat the fourth and believes that it could have beaten the first, the second lost the crown, and the ultimate victor still trembles in the awe of a narrow win.

Although the best, Germany and JAMA come fifth. Slightly unsophisticated running, too much athletics. Wide repertoire but painful victories, dribbling but little art, good shooting but few scores. Fairness does not score sympathy; greatness is insufficient for a championship. Many rejoiced when Croatia crushed Germany, but the experts were embarrassed, Croats included. New cup, new chance.

The Dutch came fourth, but neither they nor the New England Journal of Medicine like it. The liberal world is stunned by another missed crown. They retain their pride, blaming nobody but looking down on everybody. They will certainly win the next time. Yet pure perfectionism cannot win: genius must have a flaw. Try beer or smoking.

Everybody pays lip service to the wit and elegance of Croatia and the BMJ, but neither is taken seriously enough. People glance at its pages and smile at their originality but turn to the New England Journal of Medicine and the Lancet for real data. Yet, Cockney spirit and Slavic charm defeated better Germany and lost to nearly defeated France. (Don’t drink at half time!) They shoot between the defenders’ legs, and the New England Journal of Medicine’s tall editor in chief lies broken on the grass, watching the unseen publishing the unacceptable.

The public loves Brazil and the Annals of Internal Medicine, packed with clinical wit, virtually unbeatable, humanly unbelievable. But deep down it is clinically unsound. Dunga and Ronaldo perform similarly but are as poor a match as digestive and kidney disorders. Against France they panicked, launched a lot of case reports, and appealed against decisions, but France turned them all down.

The championship went to France and the Lancet, relieving the experts and the public in equal measure. A Croatian victory would have been unbearable. The French used British calm to turn responsibility into seriousness and pressure into sympathy, neither affecting the wit nor spoiling the art. They published dangerously original works, but the editors were sober, the reviewers sound, and the public knowledgeable.

Football is like scientometrics: more than a game, less than a science. Liberals argue against any ranking and conservatives dispute it—but those who play must love the game and the rules.

Cleaveland, Clifton R (American College of Physicians), (Chattanooga), (Tennessee), (USA).

A heavy fog draped the land as the doctor herded his five cantankerous companions into the van. The journey from Point Uncertainty to Hotel Diagnosis was of uncertain duration even in fair weather.

“I have neither compass nor current map, but we must set out. There is not a moment to waste,” said the doctor as he snapped on his seat belt and turned the key in the ignition. “I must rely on your guidance if we are to wend our way safely through this fog.”

Hardly had he steered his vehicle on to the twisting highway than the debate began.

NEJM immediately occupied the front passenger seat and proclaimed, “I have considerable weight of scientific, legal, and sociological opinion underpinning my judgments so you can trust me without qualm. Because my perch is loftier than my peers I can perceive the big picture even when the atmosphere is hazy. Simply veer slightly to the left along the way, and I assure a safe and speedy journey.”

NEJM’s passionate breath clouded the windscreen and left the doctor struggling to wipe a clear place with his handkerchief.

“Just a minute!” Lancet protested from the rear seat. “I have the advantage of viewpoints from all over the world, Helsinki to Kathmandu, Cape Town to Manila. With such breadth of knowledge there can be no better guide than I. And I say that we should drive straight ahead, and you may without fear go faster. I have three case reports which strengthen my stand.”

The doctor squinted into the greyness, shifting into low gear on a tight curve.

JAMA intoned, “With all due respect to my illustrious colleagues they are wrong, wrong, wrong. I am right, right, right. This is about power and connections. I say we pull over now and let me use my very expensive, American-made cellular phone to call in air support. A few well placed, laser guided napalm bombs along the way will burn this fog off in a jiffy. Friends in high places owe me one.”

A deer bounded on to the roadway. The doctor swerved just in time to avoid a collision, all the time trying to listen respectfully to his passengers.

The sudden swerve roused Annals from his nap. “Clearly this requires scientific inquiry of the most elegant sort. Of course DNA analyses will identify which one of us is innately the best guide. And while that proceeds, my statisticians will carry out a multigeneration investigation to confirm my hypothesis. Pending the investigation, I suggest we return to base to arrange a symposium on medical aspects of orienteering.”

NEJM snorted. Lancet tittered.

After a long moment of silence, during which the doctor slowed to a crawl, BMJ at last weighed in. “You are such upstarts. My language is much more precise; it must surely follow that my analytical skills are likewise superior. Stop the van now. I took the liberty of loading my bicycle on to the luggage rack. While you quibble, I can peddle ahead to alert those at our destination to send a properly equipped party to fetch you. In the meantime, I can organise a press conference and reception for your arrival. I shall be quite pleased to chair both events.”

Annals’ snores punctuated the silence.

At last the opacity was pierced by a yellowish glow. The doctor steered towards it, bringing the van into the parking space before the hotel. “We have arrived, gentlemen. I have work to do, but I shall meet you for drinks in the library at seven. Mind your step.”

Howells, John (Department of Respiratory Medicine), (Stobhill NHS Trust), (Glasgow).

I think of the “big five” journals as cars encountered on the information superhighway. Like referees, I reserve the right to be subjective.

The Annals of Internal Medicine is a big Honda. Practical but dull, it has a certain appeal to conservatives. It’s well made, safe in collision, and will see you through retirement. Not the place to find innovation, it’s inexplicably popular. I might borrow my dad’s, but I can’t see me buying one.

JAMA, irresistibly, is a Mercedes. Top of the range, superbly engineered, huge. A hood ornament to covet. Built for cruising at speed on wide roads in another country. In collisions the other driver comes off worst. You’ll see it in the outside lane of the information Autobahn. Periodic clouds of diesel fumes blot the road from view. Pay attention.

The New England Journal of Medicine is the pride of Detroit. The ’99 model, Made in America. Computer aided design, precision assembly, minimal pollution. Not available in right hand drive. It has an ergonomic driving position, leather seats, and the digital sound system won’t be available in the United Kingdom for another three years. We’d all love to drive it, but they won’t let us near.

The Lancet is an old classic marque sports car. Unfortunately it’s been bought and done up by a mechanic. It’s quick and looks great from the end of the street, but he’ll never sell it. It has a supercharger, far too many dials on the dashboard, and something funny in the gearbox. It’s a car to be seen in and has a better 0-60 than any of the others, but the steering is dodgy. Pull over if you see it in the rearview mirror.

The BMJ reminds me of nothing more than Speed Buggy, the animated jeep of the early 1970s. It’s nippy, brightly coloured, and popular. It has a cute face, is eager to please, and is almost capable of speech (“brrrr, brrrr, yeah yeah”). It cruises the dunes of cyberspace, picking up chicks. But there’s not much room on the back seat, and, hey, it’s only a cartoon.

Abbasi, Kamran (BMJ).

Scary, Mel B (New England Journal of Medicine)—Loud, distinctive, and hard edged, Scary often speaks first, occasionally misfiring, but is big and brash enough to live with the consequences. She loves lead vocals, and her enemies have been known to feel the weight of her impact factor. Apart from oozing American style, she loves getting mixed up with African rights. Most likely Spice to tell you what she really, really wants and show you her belly while she’s doing it.

Sporty, Mel C (JAMA)—Game for anything, Sporty loves joining in and especially loves showing that her moves are cooler than Scary’s. She’ll try her hand at most things; she loves surfing, but cricket is far too British for her. Not many people’s favourite Spice—too plain and unglamorous—though she has a large but anonymous following and is dependable. Looks can be deceptive, for she can rap with a preacher’s zeal. You believe her when she says she’ll be there—you might not be.

Baby, Emma (Annals of Internal Medicine)—Deceptively sweet and innocent, Baby loves the company of her older, and bigger, sister Spices, and she can be noisy, but her voice is too easily drowned out by the others. Publicly she’s clear and simple—something her fans love—but her words can sound familiar. A dash of colour sets her apart from her soulmates Scary and Sporty, though at times she’s so quiet she’s not even noticed. No chance of this Spice missing her mamma—she doesn’t step out as often as the others.

Posh, Victoria (Lancet)—Lean, mean, and not as frightfully British as her name suggests, Posh loves catching the eye, usually in a little black number. In fact, she’s renowned as a jet setter, and globe trotting is her game, though when she speaks there’s no mistaking her accent. Posh’s favourite hobby is bashing the establishment. She’s not the greatest dancer, and when it comes to sport she’s more comfortable watching than playing. Posh is often serious and sultry, but you wouldn’t want to say goodbye to her piercing looks, even though she’s a touch narcissistic.

Ginger, Geri (BMJ)—Big mouthed and up front, Ginger loves mixing: kings and commoners she treats alike. At one time she was more British than roast beef and Yorkshire pudding, but now she is courting an international following. Some say she is too populist, a tabloid’s dream, and her sister Spices would be happy if they never spoke to her again. Ginger doesn’t care too much, though she would like to be taken more seriously. In wooing America she’s picked up the Western Journal of Medicine, on the west coast, but that doesn’t mean two will become one.

Searle, Alan (Group Health of Puget Sound), (Port Orchard), (Washington), (USA).

Annals of Internal Medicine—instant porridge. Unfortunately, the labelling of the individual packets is sometimes random, and the flavour is somewhat surprising. Moderate fibre, high sucrose. Like all cereals in this group, can produce somnolence.

BMJ—Muesli. Interesting mix from various sources. Usually tasty, but sometimes inconsistent mixture. Moderate fibre, variable sugar. Selected vitamins added.

JAMA—Cornflakes. The traditional cereal. Made only from government certified corn from selected fields in the Mid-West. No added vitamins and limited fibre and sugar. Corporate offices may need restructuring since parent organisation may not be aware of recent changes in consumers of cereals.

Lancet—Bran flakes. Good for most colons and recommended, although the occasional clumping of the contents and the variable presence of raisins can produce irregularity. High fibre. Moderate sugar.

New England Journal of Medicine—Porridge. Thick. Vitamins added. Apparently same cooking techniques produces different quality on separate days. Stiff but still edible when cold. Adequate fibre, low sugar.