Recently Richard Smith, editor of the BMJ, called out the NEJM for failing to publish critical letters. His post in the BMJ blog network calls out NEJM as elitist. If electronic space is unlimited, he asks, why limit letters?

Good point. Buy why assume that conversation is controlled by the NEJM?

This is a great illustration of what I have come to call medicine’s culture of permission.

As physicians we’ve been raised to seek approval before approaching the microphone.  For the hundreds of years you could only say something if someone gave you permission.  It used to be that the only place we could share ideas was in a medical journal or from the podium of a national meeting.  Our ideas were were required to pass through someone’s filter.

The angry scientists cited by Smith are of a generation when someone else decided if their ideas were worthy of discussion.  They are a generation trained to contain what they think and believe.  They are the medical generation of information isolation.  Our culture of permission has bred a generation of obsequious followers.

In Poke the Box, Seth Godin calls this the tyranny of the picked:  Waiting and hoping “acknowledges the power of the system and passes responsibility to someone else to initiate.”

This is unfortunate.  When I think about my peers, I think about the remarkable mindshare that exists.  Each is unique and brilliant in the way they think and see the world.  Each sees disease and the human condition differently.  They carry stories and experiences that can ease minds and save lives.  But their brilliance and wisdom is stored away deep inside.  They are human silos of unique experience and perspective.

But the way the world communicates and creates ideas is changing.  The barrier to publish is effectively non-existent.  The democratization of media has given every physician and scientist a platform to the world.  But somehow we still believe that NEJM is running the show.

Going forward, the conversion of medical information into knowledge and knowledge into wisdom can only happen in a culture of participation.  In the emerging networked world, we are all individuals endowed with unique skills, abilities and gifts.  The unique mindsets and views that define us will allow us to offer something that was never before available.

The assumption here is that the only place for dialog and publication is within the boundaries of a paywall-controlled platform.  This ignores the way the world communicates and shares information.

The problem here is not the antiquated ways of the NEJM, but the dated, permission-based thinking of the medical public.