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The future of medical journals in the western world

1998; Elsevier BV; Volume: 352; Linguagem: Inglês

10.1016/s0140-6736(98)90299-9

1474-547X

Rober H Fletcher, Suzanne W Flethcer,

Pharmaceutical industry and healthcare

View Large Image Figure ViewerDownload Hi-res image Download (PPT)Robert and Suzanne Fletcher are internists and epidemiologists. They graduated from Harvard Medical School in 1366, completed residency training at Stanford and Johns Hopkins, and served on the faculties of McGill University and the University of North Carolina. They were founding editors of the Journal General Internal Medicine and editors of Annals of lnternal Medicine (1990–94), where they studied the effectiveness of peer review. The Fletchers are currently professors of Harvard Medical School. "Predictions are hazardous, especially about the future" —attributed to Yogi Berra (American Folk Philosopher)Peer-reviewed medical journals such as The Lancet are at the pinnacle of their power. Never before have they had so much good science to publish,1McDarmott MM Lefevre F Feinglass J et al.Changes in study design, gender issues, and other characteristics of clinical research published in three major medical journals from 1971 to 1991.J Gen Intern Med. 1995; 10: 13-18Crossref PubMed Scopus (42) Google Scholar exercised such care to achieve fairness and accountability,2Daniel HD et al.Guardians of science. Fairness and reliability of peer review. VCH, New York1993Crossref Google Scholar, 3Rennie D et al.The Cantekian affair.JAMA. 1991; 266: 3333-3337Crossref PubMed Scopus (26) Google Scholar, 4Rennie D et al.Thyroid storm.JAMA. 1997; 277: 1238-1243Crossref PubMed Google Scholar and received so much attention from the medical community, the media, and the general public5Roberts L et al.The rush to publish.Science. 1991; 251: 260-263Crossref PubMed Scopus (7) Google Scholar But new technologies and trends in society are challenging nearly every aspect of medical journals as we now know them.What changes will result? The pace of events has quickened since a group of medical editors looked into the future 7 years ago.6Lock S The future of medical journals. British Medical Journal, London1991Google Scholar Some new themes seem certain. One is the power of electronic communications, which will transform how information is exchanged.7Dyson E et al.A design for living in the digital age. Release 2·0. Broadway Books, New York1997Google Scholar Another, we believe, is the growing efforts from outside medicine to influence the contents of scientific research and medical journals. Some old themes are likely to continue but take a different form. Medical editors, faced with growing scepticism and impatience with traditional peer review, will develop new ways to promote the quality of journals' information. Finally, we predict that general medical journals will continue to occupy a central place in medicine, despite increasing specialisation. However, a new generation of general journals, which summarise existing information, will offer better ways to look up information, and to keep up with new developments, and so rise in importance.Editing and publishingTo understand how medical journals might change, one must first recognise that these journals result from two separate but interdependent activities—editing and publishing. Although on superficial examination the two blend together, usually they are carried out by groups with different training, skills, and interests.Editing is directed by health professionals—typically, accomplished scholars either in clinical research or in medical journalism. They are the peers of the journal's authors and readers, prepared by experience and interest to act on their behalf. The editors have a unique, central role in medicine, ensuring the quality of the information-base for scientific discovery and clinical decision-making. Editors select the best articles that are appropriate for their readers and improve them; they also promote ethical standards is the conduct of research, peer review, and reporting. The success of their work is judged by how well their journals are read, cited, and respected.Publishing, on the other hand, includes all of the processes that bring the intellectual content of the journal to readers. Besides editing, these are maintenance of subscriber lists, printing and distribution, promotion, billing, solicitation and inclusion of commercial and classified advertisements, and sale of reprints. The people who do this work are experts in marketing, sales, database management, and other business applications. The success of publishing is judged by how well it gets the information to those who want it and by profits.From paper to electronic publishingThe transition from paper to electronic sources of information that is happening now will continue because of the advantages of digital information.8The Royal College of Physicians Committee on Medical Information TechnologyCollecting, communicating and using information: the educational issues.J R Coll Physicians Lond. 1992; 26: 385-386PubMed Google Scholar, 9Maddox J et al.Electronic journals have a future.Nature. 1993; 365: 689Crossref PubMed Scopus (5) Google Scholar, 10Maddox J et al.Electronic journals are already here.Nature. 1993; 365: 689Crossref PubMed Google Scholar, 11Edelson AM et al.On the future of scholarly journals.Science. 1998; 359: 359Crossref Scopus (10) Google Scholar Digital media can convey sound, colour, and movement—a gallop rhythm, jaundiced sclerae, abnormal gait, or fine tremor—whereas paper journals are restricted to written words and figures, with just a little colour (which is expensive). Electronic publication has no artificial limits on the length and number of articles, whereas paper journals operate within fixed page budgets. Electronic publication can eliminate the time lapse, commonly several months, from when a manuscript is accepted to when it is distributed to readers. Duplicate publications, all too common in the present system,12Susser M Yankauer A et al.Prior, duplicate, repetitive, fragmented, and redundant publication and editorial decisions.Am J Public Health. 1993; 83: 792-793Crossref PubMed Scopus (30) Google Scholar could be detected better, preventing the confusion and inefficiency they now cause. Electronic journals may be less expensive; about half of the cost of a paper journal is for printing and distribution and this could be saved if the contents were made available in electronic form. For all these reasons, digital sources of information will grow at the expense of paper journals.13Smith R et al.The end of scientific journals? No longer far away.BMJ. 1992; 304: 792-793Crossref PubMed Scopus (2) Google Scholar The Lancet and the British Medical Journal are already providing full text of their journals online.Even so, paper medical journals will persist. Enthusiasts for electronic communication have been predicting a paperless world for many years now and have so far been wrong.14LaPorte RE Mader E Akazawa S et al.The death of the biomedical journal.BMJ. 1995; 310: 1387-1390Crossref PubMed Scopus (104) Google Scholar A committee of the Royal College of Physicians commented in 1992 that "few of the major advances in information science and technology have yet been successfully introduced into health care"8The Royal College of Physicians Committee on Medical Information TechnologyCollecting, communicating and using information: the educational issues.J R Coll Physicians Lond. 1992; 26: 385-386PubMed Google Scholar Physicians have grown up with an emotional attachment to the familiar paper journal. They will continue to want to carry their journals to the breakfast table, on vacations, and to and from work.Different sectors of the medical community will adopt electronic journals at different rates. Young readers take to electronic media more readily than do older ones, who are not as familiar with computers. Computers are more widely used in some parts of the world than others. Some highly specialised groups of investigators now regularly share their work on the internet; in physics, for example, some groups have abandoned paper journals completely. Journals with small circulations will move more quickly to electronic form because the print journal is too expensive for individual subscribers or even libraries.11Edelson AM et al.On the future of scholarly journals.Science. 1998; 359: 359Crossref Scopus (10) Google ScholarLet us not lament the decline of Lhe familiar paper journal any more than the demise of hand-copied bibles after Gutenberg's invention. Readers eserve the information they want in whatever medium they want it in, and it is up to the publisher to make sure they get it. This is solely a practical matter, on which the publisher's business will survive or fail. If enough readers prefer paper journals, they will remain available. If not, paper journals will always be found in museums.Editing in the digital ageIf the electronic age will change publishing, what will it do to editing? Will peer review, the backbone of current efforts to maintain the quality and fairness of medical journals, survive the electronic age? Some have suggested that journal editing will no longer be necessary. Why not just post manuscripts as received, or perhaps after a bit of in-house editing, and let readers judge the quality for themselves? Proponents of this approach argue that it would spare the delay, expense, and occasional hard feelings that attend traditional peer review.15Judson HF et al.Structural transformation of the sciences and the end of peer review.JAMA. 1994; 272: 92-94Crossref PubMed Scopus (49) Google Scholar There would be ample opportunity to correct errors in the manuscript later, after many readers have provided feedback. The official version would not be frozen in time, as it is now (apart from official corrections and retractions), but would reflect whatever improvements result from feedback.The Lancet web siteShow full captionwww.thelancet.comView Large Image Figure ViewerDownload Hi-res image Download (PPT)In the future, peer review could include the best of both worlds. The foundation would be the solid (albeit imperfect) safeguard to quality embodied in traditional peer review, improved in whichever ways our imagination and scientific studies of its effects suggest.18Fletcher RH Fletcher SW et al.Evidence of the effectiveness of peer review.Sci Engineering Ethics. 1997; 3: 35-50Crossref Scopus (30) Google Scholar, 19Horton R et al.Prague: the birth of the reader.Lancet. 1997; 350: 896-899Google Scholar Online peer review after publication might provide an additional correction of the record that could be attached directly to the electronic version of the manuscript. Corrections and commentary could be more complete and timely than is possible with the present method of feedback, mainly through letters to the editor, only a few of which can be published.Protection from bias in reported researchAlthough the digital age will change the way we send and receive information, it will not change human nature.7Dyson E et al.A design for living in the digital age. Release 2·0. Broadway Books, New York1997Google Scholar For medical journals, this means that conflicts of interest rooted in intellectual passion, financial connections to industry, and personal relationships will continue to intrude on efforts to ensure the validity of published articles.20Barinaga M Marshall E et al.Confusion on the cutting edge.Science. 1992; 257: 616-669Crossref PubMed Scopus (21) Google Scholar, 21Fletcher RH Fletcher SW et al.Medical journals and society: threats and responsibilities.J Intern Med. 1992; 232: 215-221Crossref PubMed Scopus (7) Google Scholar So will some investigators' misunderstanding of research methods22Bailor 3rd., JC Science statistics, and deception.Ann Intern Med. 1986; 104: 259-260Crossref PubMed Scopus (43) Google Scholar If physicians' information sources are to he trusted, they will need to be protected against forces that would distort them.Peer-reviewed journals at their best are carefully designed to protect readers from influences that are extraneous to the accuracy of the articles themselves. Many journals are owned by professional organisations whose reputations depend on the success and integrity of their journals. Editors support each other against inappropriate control over editorial content by owners.23International Committee of Medical Journal EditorsUniform requirements for manuscripts submitted journals.Ann Intern Med. 1997; 126: 36-47Crossref PubMed Scopus (212) Google Scholar Editors and peer reviewers should not have a direct financial interest in any of the decisions in which they play a part. The participation of peer reviewers introduces a rich array of opinions into editorial deliberations. Moreover, the journals are directly accountable to their constituency in that authors will not submit their work, and readers will not subscribe, if they lose respect for the journals. Taken together, these safeguards make up an elaborate system of checks and balances that foster quality and integrity in journal articles.Attention to fairness in editorial decisions seems greater than ever now—in attempts to manage conflict of interest and fraud in the research itself24Lock S Wells F et al.Fraud and misconduct in medical research. British Medical Journal, London'1993Google Scholar and in peer review and editing,25Rennie D Flanagin A Glass RM et al.Conflicts of interest in the publication of science.JAMA. 1991; 266: 266-267Crossref PubMed Scopus (31) Google Scholar in recommendations for full disclosure of review procedures to authors and readers,23International Committee of Medical Journal EditorsUniform requirements for manuscripts submitted journals.Ann Intern Med. 1997; 126: 36-47Crossref PubMed Scopus (212) Google Scholar in the care with which disagreements about research and manuscripts are resolved,3Rennie D et al.The Cantekian affair.JAMA. 1991; 266: 3333-3337Crossref PubMed Scopus (26) Google Scholar and in efforts to base peer-review practices on a sound rationale.19Horton R et al.Prague: the birth of the reader.Lancet. 1997; 350: 896-899Google Scholar However, these efforts stand against a growing impatience, both outside and within medicine, with the restrictions that traditional journal processes impose. Calls for change are becoming ever more insistent with unbridled enthusiasm for an unrestricted free market and as respect for institutions of all sorts declines.External challengesMedicine in the news, 1998View Large Image Figure ViewerDownload Hi-res image Download (PPT)A good read in badView Large Image Copyright © 1998 Pia PiniThrough the popular media, the public has become preoccupied with medical news and wants it fast and without encumbrances. The scientific community and the media are interdependent.31Nelkin D et al.An uneasy relationship: the tensions between medicine and the media.Lancet. 1996; 347: 1600-1663Abstract PubMed Scopus (91) Google Scholar Scientists are in a rush to publish5Roberts L et al.The rush to publish.Science. 1991; 251: 260-263Crossref PubMed Scopus (7) Google Scholar and their work is directly affected by reports in the lay press.32Phillips DP Kanter EJ Bednarczyk B Tastad PL et al.Importance of the lay press in the transmission of medical knowledge to the scientific community.N N Engl J Med. 1991; 325: 1180-1182Crossref PubMed Scopus (313) Google Scholar The policy proposed by Franz Ingelfinger of the New England Journal of Medicine in 1969,33Definition of "sole contribution"N Engl J Med. 1969; 281: 676-677Crossref PubMed Scopus (63) Google Scholar whereby articles are considered only if they have not been submitted or reported elsewhere, is intended to protect the "orderly process of science".34Angell M Kassirer JP et al.The Ingelfinger rule revisited.N Engl J Med. 1991; 325: 1371-1373Crossref PubMed Scopus (90) Google Scholar This Ingelfinger rule is supported by the International Committee of Medical Journal Editors23International Committee of Medical Journal EditorsUniform requirements for manuscripts submitted journals.Ann Intern Med. 1997; 126: 36-47Crossref PubMed Scopus (212) Google Scholar and is generally respected by most journals and media. But there are many recent examples of authors, their funders, and the media bypassing peer review.35Steinbrook R Lo B et al.Informing physicians about promising new treatments for severe Illnesses.JAMA. 1990; 263: 2078-2082Crossref PubMed Scopus (14) Google ScholarWhere will this lead? Electronic publication should resolve some of the tension between medical journals and the lay press because it shrinks the time between acceptance and publication.36Kassirer JP Angell M et al.Prepublication release of journal articles.N Engl J Med. 1997; 337: 1762-1763Crossref PubMed Scopus (18) Google Scholar The scientific community should fight for an orderly process for communicating research results. It is in society's best interests to have a complete account of the research available to everyone at the same time to prevent some of the mischief and confusion that can surround partial accounts of research work.AuthorshipThe meaning attached to being an "author" will change. A basic tenet of medical journalism is that someone should take personal responsibility for each article. Authorship is a serious matter because investigators' careers depend on it. However, as the number of authors per article (7·3 per manuscript at last count1McDarmott MM Lefevre F Feinglass J et al.Changes in study design, gender issues, and other characteristics of clinical research published in three major medical journals from 1971 to 1991.J Gen Intern Med. 1995; 10: 13-18Crossref PubMed Scopus (42) Google Scholar) grows, along with their specialised roles and interdependence, it has become increasingly difficult to discern from the way authors are listed the nature and extent of an individual's contributions to an article.37Shapiro DW Wenger NS Shapiro MF et al.The contributions of authors to multiauthored biomedical research papers.JAMA. 1994; 271: 438-442Crossref PubMed Scopus (244) Google Scholar Rennie and colleagues have proposed that responsibility for articles should be taken not by "authors" but by "contributors", who describe in an attachment to the article the nature of their contribution to the work.38Rennie D Yank V Emanuel L et al.When authorship fails: a proposal to make contributors accountable.JAMA. 1997; 278: 579-585Crossref PubMed Google Scholar Some journals have already adopted this approach, as stake-holders become increasingly concerned about authorship and academic rewards.39Horton R et al.The unmasked carnival of science.Lancet. 1998; 351: 688-689Summary Full Text Full Text PDF PubMed Scopus (23) Google ScholarGeneral medical journalsGeneral medical journals such as The Lancet play a bridging function in medicine. They engage the interests of many different kinds of readers—from family physicians to neurosurgeons, and from molecular biologists to epidemiologists—in each issue, even within individual articles. They attempt to find a common language for all readers, even though the authors tend to be highly specialised investigators and many may have forgotten what people outside their specialty know and care about. General journals communicate with clinical readers and those with highly specialised research careers, who tend to have different interests in the articles.40Justice AC Berlin JA Fletcher SW Fletcher RH Goodman SN et al.Do readers and peer reviewers agree on manuscript quality?.JAMA. 1994; 272: 117-119Crossref PubMed Scopus (36) Google Scholar Smith notes that general journals add value because they "group together different sorts of material—not only original science but also comment, reviews, news, correspondence, and articles—in a way that makes a journal satisfying enough to read in bed".13Smith R et al.The end of scientific journals? No longer far away.BMJ. 1992; 304: 792-793Crossref PubMed Scopus (2) Google Scholar Perhaps for these reasons, even specialty journals are becoming more general in content.41Smith R et al.Through the crystal ball darkly.in: Lock S The future of medical journals. British Medical Journal, London1991Google ScholarWe believe that bridging is absolutely essential to a healthy profession42Fletcher SW Fletcher RH et al.Responsibilities of medical journals to readers.J Intern Med. 1992; 232: 223-228Crossref PubMed Scopus (5) Google Scholar However difficult it might be, finding a common mode of discourse will only grow in importance. Physicians need to find a way to see their profession in all of its dimensions—the biological, social, political, humane, ethical, and literary—and not allow specialisation to lead to balkanisation.Although general journals are an essential element of discourse within the profession, individual journals are not a suitable way of helping readers look up answers to clinical questions or keep up with all the advances in their field. The best articles on a question tend to be concentrated in a few strong journals, but, even so, good articles are scattered among many different journals,43Fletcher RH Fletcher SW et al.Evidence-based approach to the medical literature.J Gen Intern Med. 1997; 12: S5-S12Crossref PubMed Scopus (27) Google Scholar and readers would have to search the world's journals to find them. There is now a new generation of synoptic "medical journals" that can help readers to find the best research articles (eg, the Cochrane database44Bero L Rennie D et al.The Cochrane Collaboration. Preparing, maintaining, and disseminating systemic reviews of the effects of health care.JAMA. 1995; 274: 1935-1938Crossref PubMed Scopus (398) Google Scholar), and also to keep up with medical literature (eg, ACP Journal Club and Evidence Based Medicine). These information sources will become more numerous and useful, complementing the traditional general journals and allowing medicine to be practised with the best and most up-to-date information-base anywhere in the world.ConclusionsPeer-reviewed medical journals are both strong and fragile. Efforts to modernise and improve communication in medicine could dismantle some of these journals' best features. To become better, and not just different, medical journals need the understanding and support of their owners, readers, and authors. Social institutions (academic medical centres, government funding agencies) also have a stake in credible information to guide the care of patients and improve the health of the public. Continuing support cannot be assumed; there are already examples of successful journals that were dropped by their sponsoring societies.45Imperiato PJ et al.Demise of a peer-reviewed journal.Lancet. 1993; 342: 1160-1161Abstract PubMed Scopus (3) Google Scholar These institutions must recognise the central importance of peer-reviewed medical journals to the profession and act to preserve the basic elements that make them credible, even as many of the specific practices and the external appearance of these journals change. Robert and Suzanne Fletcher are internists and epidemiologists. They graduated from Harvard Medical School in 1366, completed residency training at Stanford and Johns Hopkins, and served on the faculties of McGill University and the University of North Carolina. They were founding editors of the Journal General Internal Medicine and editors of Annals of lnternal Medicine (1990–94), where they studied the effectiveness of peer review. The Fletchers are currently professors of Harvard Medical School. "Predictions are hazardous, especially about the future" —attributed to Yogi Berra (American Folk Philosopher) Peer-reviewed medical journals such as The Lancet are at the pinnacle of their power. Never before have they had so much good science to publish,1McDarmott MM Lefevre F Feinglass J et al.Changes in study design, gender issues, and other characteristics of clinical research published in three major medical journals from 1971 to 1991.J Gen Intern Med. 1995; 10: 13-18Crossref PubMed Scopus (42) Google Scholar exercised such care to achieve fairness and accountability,2Daniel HD et al.Guardians of science. Fairness and reliability of peer review. VCH, New York1993Crossref Google Scholar, 3Rennie D et al.The Cantekian affair.JAMA. 1991; 266: 3333-3337Crossref PubMed Scopus (26) Google Scholar, 4Rennie D et al.Thyroid storm.JAMA. 1997; 277: 1238-1243Crossref PubMed Google Scholar and received so much attention from the medical community, the media, and the general public5Roberts L et al.The rush to publish.Science. 1991; 251: 260-263Crossref PubMed Scopus (7) Google Scholar But new technologies and trends in society are challenging nearly every aspect of medical journals as we now know them. What changes will result? The pace of events has quickened since a group of medical editors looked into the future 7 years ago.6Lock S The future of medical journals. British Medical Journal, London1991Google Scholar Some new themes seem certain. One is the power of electronic communications, which will transform how information is exchanged.7Dyson E et al.A design for living in the digital age. Release 2·0. Broadway Books, New York1997Google Scholar Another, we believe, is the growing efforts from outside medicine to influence the contents of scientific research and medical journals. Some old themes are likely to continue but take a different form. Medical editors, faced with growing scepticism and impatience with traditional peer review, will develop new ways to promote the quality of journals' information. Finally, we predict that general medical journals will continue to occupy a central place in medicine, despite increasing specialisation. However, a new generation of general journals, which summarise existing information, will offer better ways to look up information, and to keep up with new developments, and so rise in importance. Editing and publishingTo understand how medical journals might change, one must first recognise that these journals result from two separate but interdependent activities—editing and publishing. Although on superficial examination the two blend together, usually they are carried out by groups with different training, skills, and interests.Editing is directed by health professionals—typically, accomplished scholars either in clinical research or in medical journalism. They are the peers of the journal's authors and readers, prepared by experience and interest to act on their behalf. The editors have a unique, central role in medicine, ensuring the quality of the information-base for scientific discovery and clinical decision-making. Editors select the best articles that are appropriate for their readers and improve them; they also promote ethical standards is the conduct of research, peer review, and reporting. The success of their work is judged by how well their journals are read, cited, and respected.Publishing, on the other hand, includes all of the processes that bring the intellectual content of the journal to readers. Besides editing, these are maintenance of subscriber lists, printing and distribution, promotion, billing, solicitation and inclusion of commercial and classified advertisements, and sale of reprints. The people who do this work are experts in marketing, sales, database management, and other business applications. The success of publishing is judged by how well it gets the information to those who want it and by profits. To understand how medical journals might change, one must first recognise that these journals result from two separate but interdependent activities—editing and publishing. Although on superficial examination the two blend together, usually they are carried out by groups with different training, skills, and interests. Editing is directed by health professionals—typically, accomplished scholars either in clinical research or in medical journalism. They are the peers of the journal's authors and readers, prepared by experience and interest to act on their behalf. The editors have a unique, central role in medicine, ensuring the quality of the information-base for scientific discovery and clinical decision-making. Editors select the best articles that are appropriate for their readers and improve them; they also promote ethical standards is the conduct of research, peer review, and reporting. The success of their work is judged by how well their journals are read, cited, and respected. Publishing, on the other hand, includes all of the processes that bring the intellectual content of the journal to readers. Besides editing, these are maintenance of subscriber lists, printing and distribution, promotion, billing, solicitation and inclusion of commercial and classified advertisements, and sale of reprints. The people who do this work are experts in marketing, sales, database management, and other business applications. The success of publishing is judged by how well it gets the information to those who want it and by profits. From paper to electronic publishingThe transition from paper to electronic sources of information that is happening now will continue because of the advantages of digital information.8The Royal College of Physicians Committee on Medical Information TechnologyCollecting, commun