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Inconsistent messages // An inefficient process // The value of online publications // The medical journal as we know it

Probing Medical Journals

By Timothy Gower // Illustrations by Brian Stauffer // Winter 2013
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ILLUSTRATION BY BRIAN STAUFFER

Physician Michael Romac runs a busy family practice in Hoosick Falls, N.Y., a small village near the Vermont border. Romac sees a wide variety of patients, from newborns to the elderly. “It can be a challenge to keep current in all aspects of medicine,” Romac says. Toward that goal, Romac spends a few hours each week reading American Family Physician and The New England Journal of Medicine. He likes the former for its review articles, which summarize findings from studies on common conditions. And Romac considers NEJM a must-read for the latest, most important research. That Romac has consistently scored among the top 10% of his peers on the American Board of Family Medicine’s certification exam—a routine test of a family doctor’s comprehensive medical knowledge—suggests that his method for keeping tabs on new developments in medicine is working. Yet using medical journals to stay current can be maddening when the messages are inconsistent, he observes. “One day it is ‘Take statins to lower cholesterol,’” Romac says, “but now it is ‘What the hell are these statins doing to our muscles and memory?’”

Many doctors find themselves in the same boat. For them, scientific journals are an indispensable part of the medical landscape, yet also a frequent source of frustration. The researchers who provide these periodicals’ primary content express similar discontent. Many feel that this means of publishing their work is inefficient and often unfair. The process editors use to review submissions can be long and tortuous, and it may favor certain kinds of studies—and suppress negative results or findings that undercut long-established medical wisdom.

Criticism of medical journals is hardly new. When the editors of the Chicago Medical Journal and Examiner surveyed the rapidly expanding universe of biomedical publications available in 1879, they offered a scathing assessment. “Some are absolutely worthless,” they wrote, “and a few are undeniably worse than worthless—they are dangerous and disgusting parasites upon the body medical.”

While it’s unlikely that many doctors or scientists would employ such tart rhetoric today, recent research on the state of journals suggests that the enterprise continues to have inherent problems—ranging from what to publish, and in what kinds of media, to how to fund journals. Those are largely the same challenges that have plagued medical publishing for more than a century, says medical historian Scott H. Podolsky, a primary care physician at Massachusetts General Hospital who wrote about the evolving medical journal earlier this year in NEJM. Podolsky feels it has never been more relevant to ask, “Is the present journal system the ideal one, moving forward?”

A growing chorus of voices is saying maybe not. During the past decade or so, a fresh philosophy and approach to sharing new medical knowledge has gained a foothold. “Open access” publications, presented online, get studies into “print” relatively quickly, publish a broader range of research and eliminate high subscription fees. That model is putting pressure on traditional journals, and its supporters believe it’s the key to producing a better medical journal. But many others aren’t so sure.

The first English-language general medical journal, Medicina Curiosa, appeared in 1684. It vanished after two issues, yet the idea of disseminating scientific knowledge to doctors in periodical form eventually caught on. Today there are more than 5,600 journals represented in the National Library of Medicine’s database of journal citations, known as MEDLINE/PubMed. Three times a year, a library selection committee considers 180 or so new titles to add to the database.

Until recently, most of these journals operated like consumer magazines, earning revenue by selling advertising space and charging subscription fees ranging from less than $1,000 per year to $20,000 or more. Online journals also sell access to scientific papers and other material à la carte for up to $30 or more per article. But medical journals don’t pay writers. Instead, scientists submit manuscripts for free in hopes of having their research findings distributed to an interested audience.

Journal editors read manuscripts and send the papers that seem promising to peer reviewers, who critique the works’ scientific quality and relevance. Peer reviewers, who are usually unpaid, typically are doctors and scientists from the same fields as the authors of the manuscripts they read. Although journal editors make the final judgment about a manuscript’s fate, the comments of peer reviewers are highly influential.

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Dividing the Best From the Rest

An influential measurement uses a Moneyball approach to rank medical journals.

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1. “The Evolving Roles of the Medical Journal,” by Scott H. Podolsky et al., The New England Journal of Medicine April 19, 2012. A concise examination of the origins of U.S. medical journals; how they have persisted despite long-standing concerns about quality, ethics and financial stability; and how they have influenced the practice of medicine.

2. “The Paper Is Not Sacred,” by Adam Marcus and Ivan Oransky, Nature, Dec. 22–29, 2011. Marcus (a journalist) and Oransky (a physician turned journalist) argue that journals can increase their own value and standing among physicians and researchers by no longer thinking of scientific papers as “done” once they’re in print or online, but as living entities that can be enhanced by post-publication critique and commentary.

3. “Anatomy of Open Access Publishing: A Study of Longitudinal Development and Internal Structure,” by Mikael Laakso and Bo-Christer Björk, BMC Medicine Oct. 22, 2012. The rise of open access journals is “disrupting the dominant subscription-based model of scientific publishing,” say the authors. That’s especially true in biomedicine, which witnessed a sixteenfold increase in the number of papers published in OA journals between 2000 and 2011.

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