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lnterrtol M e d i c i n e 1992 ; 2 3 2 : 223-228
Responsibilities of medical journals to readers S. W. FLETCHER & R. H. FLETCHER Editors. Annals 01lnterrial Medicine, 1990Philndelphicc. PA. USA
Types of readers
Medical journals exist primarily for their readers. Although most are launched for other reasons - t o provide more visibility for the medical society starting the journal, to give a new publishing outlet for researchers, to supply a new venue for advertisers the primary goal of most medical journals should be to assist their readers. Stephen Lock has listed the basic responsibilities of scientific journals toward readers : they should ' inform, instruct, comment, possibly amuse '[ 11. This paper explores current and future challenges medical journal editors face as they attempt to live up to these responsibilities.
Types of journals Many journals, such as the Journal of the American Medical Association and the British Medical Journal, are published by medical societies, and most subscribers to these journals automatically receive the journal as part of their membership. It could be argued that physicians do not highly value such journals because they have not explicitly subscribed to the journal. However, members of the American College of Physicians, in periodic surveys, routinely rank the journal they receive as part of membership (Annals of Internal Medicine) as the most valuable service of that organization (Gorsuch G, personal communication). Some medical journals (including the two most frequently cited medical journals in the world, the New England Journal of Medicine and the Lancet) are primarily or completely subscriber based. Others are sent to physicians free of charge. The articles in these ' controlled-circulation ' or ' throw-away ' journals are not usually peer reviewed and tend to be more for education than for sharing new information [2]. They are most commonly supported entirely by pharmaceutical advertising.
Medical journals serve many types of readers [ 3 ] .The readership of large general medical journals consists primarily of practising clinicians. Apparently, clinicians receive a large number of medical journals. In 1991, one physician in the United States complained that his office was inundated by more than 40 medical journals each month [4]. How much and in what manner physicians use and read the medical journals they receive are questions that to date have not been subjected to rigorous inquiry. In the United States, most routine surveys of physicians' journal reading habits are carried out for pharmaceutical companies [S, 61. These companies have financial interests in determining whether and how physicians read medical journals ; they use the information to help determine in which journals to place their advertisements. Although these surveys are not directed primarily at how physicians read the editorial content of medical journals, it is clear from their results that readers approach journals in different ways: some read through the entire issue, whereas others selectively scan only those articles of interest. Readers also vary in how regularly they read different journals. Medical journals serve more than clinician readers. Small journals in highly specialized fields primarily serve research scientists in that field. Larger, more general journals also serve this function, as evidenced by high citation indices. Researchers use medical journals both to keep up with important information in their fields and to communicate their work to others. Journals help researchers to improve their chances of promotion and successful grant proposals. Both the quality and the quantity of published articles ' determine success in medical academia. The lay public, through the news media, use medical journals to keep up with important advances. Special-interest groups, such as pharmaceutical company representatives, stockbrokers, and manufacturers of medically related products, carefully 223
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follow the news reported in medical journals that is relevant to their commercial interests. As the above summary indicates, medical journal readers are a heterogeneous group, with many different requirements. Nevertheless, most readers of medical journals, particularly those journals covering a broad spectrum of medical subjects, are physicians engaged in the practice of medicine. It is the editors’ responsibilities to these readers that are stressed in this paper.
Readers’ requirements What clinicians want from medical journals has not yet been subjected to careful scientific inquiry. From casual discussions with individual clinicians, it appears that many use medical journals to keep up with medical progress, so as to give better medical care, which in turn will lead to improved health of their patients [7]. They equate being an excellent physician with having access to current medical information. In an environment of increasing regulation and accountability, some physicians see medical journals as one vehicle for mandated continuing education. Having up-to-date medical knowledge may be seen as an important way to minimize the possibility of malpractice litigation. Many physicians also enjoy the intellectual challenge of mastering new medical information. Finally, they seem to enjoy communicating through medical journals and contribute actively to Letters to the Editor sections.
Increase in medical knowledge The task of informing, educating and entertaining practising physicians is becoming more difficult because of the rapidly increasing volume of medical information. The growing volume presents different challenges to editors and readers.
The editors’ challenge The editor must decide the appropriate balance in types of articles to be published, a task that grows in complexity as the amount of medical information grows. ‘Medical ’ research has expanded over the past few decades. Clinical research remains central, but biomedical research on one side, and populationrelated research on the other, are growing. Disciplines such as health education, sociology and
economics are increasingly relevant to the practice of medicine ; research from these disciplines competes for space in medical journals. How does an editor choose the appropriate balance from this expanding smorgasbord ? Trends in medical research determine what papers are written, but the papers do not necessarily reflect an appropriate balance for the clinician reader. In the United States and elsewhere, for example, the active research programme on the acquired immunodeficiency syndrome (AIDS) has led to an avalanche of AIDS-related manuscripts. At Annals in Internal Medicine, AIDS-related research accounted for 14% of original research articles submitted in 1991 ; few readers have a medical practice in which one in six patients is infected with the AIDS virus. Thus, what is ultimately published is usually the result of an essentially passive process. Journal editors can only choose from what is sent to them, even though they can and do invite some submissions. Potential authors often scan journals to get a sense of what kinds of articles a particular journal is likely to publish. If articles on AIDS appear regularly, the journal may well receive even greater numbers of AIDS-related submissions. There is no negative feedback loop. Editors must actively determine the right balance of journal articles for readers, not merely passively accept the balance assumed by submitted manuscripts.
The readers’ challenge The large volume of medical research presents a different challenge to readers. Whereas editors must decide about balance in a single journal, the challenge presented to readers is how to master the growing amount of medical information published [8]. The challenge has grown to such proportions that in the early 1980s it was estimated that 4 million articles were published annually in the biomedical literature [9]. As the volume of medical research increases, the amount of time physicians have to master it through reading journals may be decreasing. The number of hours physicians spend on administrative duties related to patient care has been increasing. In addition, there are more alternatives for keeping up with medical innovations, including continuing education seminars, audiotape cassettes of lectures, and even television programmes geared to practising physicians.
RESPONSIBILITIES OF MEDICAL JOURNALS TO READERS
Coping niechanisnis Abstract services began in the early 1880s, and have grown steadily since [lo]. These were initially in print form, but more recently, computerized medical literature searching has been developed. In 1990. the National Library of Medicine performed 4.5 million Medline searches, many initiated by practising physicians (Eichenberger C, personal communication). Newer technologies, such as CD ROM, allow medical literature searches without direct connection to the National Library of Medicine computers. These new coping mechanisms can help readers to survey the medical literature and sort articles by topic, but few help sort articles according to quality. Some abstract services implicitly sort by quality, using editors’ judgments, without stated ground rules and select only ‘important’ articles for abstracting. Editors have increasingly focused on the quality of the research their journals report. With the development of more powerful methods and explicit standards for clinical research, as well as increasing numbers of clinical epidemiology faculty in medical schools, proper methods for clinical research have been clarified. Some medical journals have incorporated methodological standards into their peerreview processes by recruiting personnel with expertise in research design and statistics to their editorial staff. Taking the quality-selection process one step further, in 1991 Annals of Internal Medicine began a supplement service for its readers that abstracts clinical articles from more than 30 of the world’s medical journals. ACP Journal Club, edited by Dr R. Brian Haynes, abstracts articles only after they have met explicitly stated standards for both scientific strength and clinical usefulness [l l-131. Reaction from readers has been positive ; not surprisingly, most have commented how helpful ACP Journal Club is to their efforts to keep up with the medical literature, because it helps them to deal with the three problems of volume, time and quality. Perhaps most reassuring for readers is the relatively small amount of new medical information that is both clinically important and methodologically sound enough to be ready for clinical use. In 1991, ACP Journal Club editors found a total of only 298 original research articles from 4 7 medical journals that met their criteria. Fewer than one article per two issues of nine ‘core’ journals and less than one 14
225
article per five issues of 30 other, primarily subspecialty, journals were abstracted [ 141. Although the number of medical articles published is staggering, the number to be mastered for the purposes of clinical care may be far more manageable than was previously thought. This finding may be disturbing to editors. It appears that to practise medicine well, it is not necessary to master the information in the majority of original research articles, at least in internal medicine journals. This is not to say that such research is inappropriate for publication. Medicine is not a trade but a profession, indeed a ‘ learned profession ’. Part of being a learned professional must be to expand the mind, to learn about medical progress, perhaps for future medical application, perhaps only to gain a more complete understanding of medical science, but certainly not only to learn what is immediately useful. Much of the research relating to genetic discoveries falls into this category. These findings are important not for immediate application but for what they explain and may portend. The distinction between studies that provide interesting new information and those definitive $enough to affect medical practice should be made clearer. In sum, the volume of new medical information presents different challenges to editors and readers. Editors are faced with a growing need to consider what is an appropriate balance in the types of articles they should offer to readers. For readers, the challenge is to sift through the ever-increasing volume from a growing number of journals, to find those articles relevant to their practice. To date, most innovations designed to meet this challenge have helped sift the medical literature according to topic, not quality, of article. When the sifting includes quality as a criterion, the amount of clinically applicable new information shrinks considerably. Editors should consider specific steps to help their readers cope with the volume of medical information.
The medical tower of Babel - a growing problem Centripetal forces, born largely of the successes in medical research, are beginning to tear at the fabric of the profession of medicine ; medical journals, particularly general medical journals, are experiencing the effects of these forces. The profession of medicine is being increasingly fragmented. In the United States, specialty societies began to appear in I M R 232
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the latter half of the nineteenth century. In 1991, there are now 2 3 separate officially recognized specialties, each with its own certifying examination. Within many of these specialties, there are subspecialties (in internal medicine, alone, there are 11 subspecialties) and sometimes sub-subspecialties (in cardiology, there is now a separate electrophysiology certifying examination). With the appearance of each of these new official entities, journals have sprung up for researchers and practitioners. In addition, new journals have developed in areas not officially recognized as ‘separate’. For example, in the past few years, many new medical journals have appeared that are devoted exclusively to AIDS [15]. The fragmentation of medicine, strongest in the United States but growing in many other countries of the world as well, is not likely to decrease in the foreseeable future. Research gains, increases in the number of medical interventions. interests of young physicians who, at least in the United States, are clearly turning towards specialty and subspecialty medicine [16, 171, and the growing political power of the specialty groups in medicine all suggest continued centripetal forces. narrowly based medical journals add to the impetus. The increased specialization in medicine, together with the increased availability of medical journals in the specialties, may threaten medical journals that attempt to speak to physicians as a whole, to communicate across separate medical disciplines. Readers may be less interested in reading about medicine outside their own ever-narrowing areas of interest. This trend is particularly likely if they have less time to read and sense that the task is hopeless anyway. Medical terminology is growing more specialized and less easily understood by physicians in other fields, adding new challenges to editors and readers interested in broad-based medicine (specialization is occurring throughout science and technology, not only in medicine). Laboratory methods well known to researchers in a particular field may be incomprehensible to practising physicians. Most readers are unlikely to know whether and when ELISA and RIBA tests are appropriate for testing serum for hepatitis C virus, or even what the tests are. Clinical research methods have become complicated with the introduction of new research designs and the increasingly sophisticated biostatistical analyses of the studies. Most physicians, even most modern medical students, have had little education about case-control
studies, logistic regression, odds ratios and confidence intervals. Thus the methods of clinical research, which in the past were relatively easy for physicians in different fields to understand, have grown complex and difficult to grasp. Authors have changed, as well as medical content and research methods. Authors who spend most of their professional time communicating with other physicians in their particular field have difficulty communicating with the broader community of physicians. It may well be that modern authors are less literate than their predecessors, having stressed sciences rather than literature in their premedical education. Finally, there is the increasing trend for authors whose native language is not English to submit work to the large English-language medical journals [18]. Many of the submissions from these authors contain excellent scientific work but are written in poor or substandard English. It is reasonable to ask why medical journals, or medicine in general, should resist the effects of specialization, especially since there is much good that has come from it. Why is it necessary for physician scientists and clinicians to communicate with each other across disciplines ? Why should medical journal editors be concerned with these developments ? Too much narrow specialization could have negative consequences for patient care, society, the profession, and individual physicians [19]. Clinical science could also suffer if readers do not have the opportunity to come into contact with new ideas from different fields.
Improving communication Medical journal editors, particularly editors of general medical journals, must deal with the challenges posed by all of these relatively new developments. It is time to consider carefully ways to bridge the widening communication gaps in medicine [20]. Medical journals have a long tradition of working to improve submitted manuscripts before accepting them for publication. The peer review process itself aims not only to select which work should be published, but also to improve articles chosen for publication. In the editorial office, manuscript editors work with authors to standardize and improve the presentation. For some journals this work represents substantial effort. For example, at Arinals o/ Interrial Medicine. manuscript editors make an average of 3 changes per manuscript line (Case K, personal
RESPONSIBILITIES OF MEDICAL JOUKNALS TO READERS
communication). Over the years, the editing efforts of scientific journal personnel have given rise to new professions and new organizations, such as the Council of Biology Editors and the European Association of Science Editors. Medical journal editors as a group have worked to improve communication in other ways, first by standardizing the format of articles with the IMRAD (Introduction, Methods, Results and Discussion) method for reporting original research. In 1 978 the lnternational Committee of Medical Journal Editors (the ‘Vancouver group’) was formed and specified the order and method of citing references [21]. Since then, most major medical journals have adopted the method. The Vancouver group also developed other standards for submitted manuscripts. Another attempt to improve communication with readers has been the evolution of the article’s abstract. Summaries at the end of articles developed in the first half of the twentieth century [22], then migrated to the beginning and were called abstracts. More recently, the structured abstract (with specific sections for the objective of the study, design, setting, patients or participants, interventions, main outcome measures, results and conclusions) has been introduced [22, 241. to ensure that all relevant information is systematically included. Structured abstracts are gaining in popularity among medical journals [25], but whether such an innovation improves comprehensibility has not yet been ascertained. Formal studies are planned (Haynes RB, personal communication). The increasing fragmentation of medicine challenges medical journals to continue, and indeed to accelerate, their efforts to communicate better with readers. These efforts should include rigorous studies to determine what readers understand and how much editing efforts improve readers’ comprehension. Systematic studies of editing effects may not come easily. To date, editors of peer-reviewed medical journals have made little effort to study communications with readers. Editors usually come from academic backgrounds, with strengths and interests in medical research rather than in medical communication research. Several simple communication innovations are worthy of consideration. Perhaps articles on relatively narrow medical topics should contain introductory paragraphs addressed to physicians outside the specialty. Editors may need explicitly to request authors to write for non-experts.
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To save space, medical journals traditionally eschew simple tables and figures in articles, requesting authors to incorporate the material in the text instead. It may be that this practice should be reversed. Simple, clear figures and tables should help to improve communication. A single, well-prepared figure can often ‘tell it all’. Titles of articles, as well as those of figures and tables, need to be both scientifically correct and clear. Too often the latter is sacrificed for the former. Major medical journals have recently moved to using international units when reporting laboratory test results. This move, although likely to help international medical communications in the long term, has hindered reader understanding in some countries, such as the United States, in the short term. Editors concerned about communication and reader understanding must find solutions. Inclusion of traditional local values or a conversion table in the article may help. Similar problems are encountered when using only generic names for drugs: readers complain that they do not know what drug is being written about. Acronyms, well known to physicians in one field, may be foreign to those in other fields. Editors should be able to overcome these challenges with simple tables listing key conversions, acronyms, and drug brand name equivalents. The visual presentation of written words is a field about which few physician editors know or care before entering the world of journal editing. For many, this remains so after they have entered the field. It is time to learn about fonts, weights, points and tints. It is time to care about the art of journalism. Perhaps this is one way to ‘amuse’ readers.
Conclusions Throughout this paper, we have pointed out how little is known about what readers of medical journals want and need. As numerous editors before us have made clear, when it comes to medical editing, there are too few facts carefully gathered by the rigorous scientific methods that virtually all medical journal editors embrace for clinical work and yet somehow do not demand for editorial work [26]. Perhaps editors are like old-time clinicians who did not have a scientifically sound information base for their work, and instead relied upon personal experience and opinion. What we have proposed in this paper should be 14-2
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treated as hypotheses. These may or may not be correct, but it is time to begin to find out. First, we suggest simple descriptive studies (such as focus group studies and surveys) : later, analytical studies should be undertaken : and finally, carefully evaluated intervention trials will be in order [27]. Both the medical journals and their readers can only benefit from such an approach.
Acknowledgements We thank Edward J. Huth, MD, our predecessor and mentor, and our colleagues, Kathleen Case and Pamela Fried, for reviewing early drafts of this manuscript and for many helpful suggestions.
References 1 Lock S. A Iliflcult Balance: Editorid Peer Review in Medicine. London : Nuffield Provincial Hospitals Trust. 1985. Reprinted London : British Medical Journal, 1991. 2 Rennie D. Bero LA. Throw it away, Sam. The controlled circulation journals. CBE Views 1 9 9 0 : 1 : 31-5. 3 Haynes RB. How clinical journals could serve clinician readers better. In : Lock S . ed. The Future of Medical /ournals. London : British Medical Journal, 1991. 4 Highkin I>]. Unwanted journals and the environment (letter). A n n Intern Med 1 9 9 0 : 113: 996. 5 Media-Chek/Apex, A Studg of Medical /ournal Readership and Advertising Page Exposure. Princeton : Healthcare Communications, Inc. : 1991. 6 Focus. December 1991. Wilton. CT: I’erq Research Corporation, 1991. 7 Fletcher R. Closing the gap between what researchers can do and what clinicians use: the journals’ role. In: Lock S. ed. The Future 01 Merlicctl /ournals. London : British Medical Journal. 1991. 8 Huth EJ. The information explosion. Hull N Y Acad Med 1989 : 6 5 : 647-61. 9 Department of Clinical Epidemiology and Biostatistics. McMaster University. How to read clinical journals: I-V. Can Med ASSOC / 1981: 124: 555-8, 703-10. 869-72. 985-90. 1 1 56-62.
10 de Solla Price D. Science Since Hdiglori. New Haven: Yale University Press, 1961. 17 Haynes RB. The origins and aspirations of ACP Journal Club. A n n lriterri Med 1991: 114 (Suppl. 1 ) : ,418. 12 ACP Journal Club purpose and procedure. Arin Iriterri Merl 1 9 9 1 : 114 (SUPPI. 1 ) : A6-7. 1 3 Haynes RB. Change in criteria for studies of diagnostic tests. A n n Interri Med 1 9 9 1 : 1 1 5 (Suppl. 3): ,413. 1 4 Haynes RB. ACP Journal Club’s modus operandi. Atin Irrtertr Med 1991: 1 1 5 (Suppl. 3): ,414. 1 5 Lock S . Journalogy : evolution of medical journals and some current problems. / lnterri Med 1992; 232: 199-205. 1 6 Schwartx MI). Linxer M. Babbott D. Devine GW. Broadhead 13. medical student interest in internal medicine. Initial report of the Society of General Internal Medicine Interest Group survey on factors influencing career choice in internal medicine. Ariri lnterrr Med 1991: 114: 6-15. 1 7 Babbott D. Levey G. Weaver SO, Killian CD. medical student attitudes about internal medicine: a study of U S . medical school seniors in 1988. Ann Intern Med 1991 : 114: 16-22. 1 8 Stossel TP. Stossel SC. Declining American representation in leading clinical-research journals. N Errgl / Med 1 9 9 0 : 322: 73942. 1 9 Fletcher R. Fletcher S. Internal medicine: whole or in pieces? Ann Intern Mcd 1 1 9 1 : 115: 978-9. 2 0 Riis 1’. New paradigms in journalology. / lriterri Med 1992: 232: 207-213. 21 Huth 131. Uniform requirements for manuscripts. Ann Iriterrr Med 1 9 7 9 : 90: 120. 22 Lock S. As things really were? In: Lock S . ed. The Futitre o/ Medical /ournals. London: British Medical Journal, 1991. 2 3 Ad Hoc Working Group for Critical Appraisal of the Medical Literature. A proposal for more informative abstracts of clinical articles. A m Intern Med 1 9 8 7 : 106: 598-604. 24 Haynes RB. Mulrow CD. Huth I3J. Altman DG. Gardner MI,. More informative abstracts revisited. Arm lriterri Med 1 9 9 0 : 1 1 3 : 69-76. 2 5 Rennie D. Glass RM. Structuring abstracts to make them more informative. / Am Med Assoc 1991 : 266: 11 6-7. 26 Peer review in scientific publishing. Papers from the First International Congress on Peer Review in Biomedical Publication (sponsored by the American Medical Association). Chicago: Council of Biology Editors. 1991. 27 Fletcher SW. Research agenda for medical journals. In: Lock S. ed. The Future of Medical /ourrials. London: British Medical Journal. 1991.
Correspondem; Suzanne W. Fletcher. MI), Annals of Internal Medicine, Independence Mall West. Sixth Street at Race. I’hiladelphia, PA 19106-1 572, USA.
lnterrtol M e d i c i n e 1992 ; 2 3 2 : 223-228
Responsibilities of medical journals to readers S. W. FLETCHER & R. H. FLETCHER Editors. Annals 01lnterrial Medicine, 1990Philndelphicc. PA. USA
Types of readers
Medical journals exist primarily for their readers. Although most are launched for other reasons - t o provide more visibility for the medical society starting the journal, to give a new publishing outlet for researchers, to supply a new venue for advertisers the primary goal of most medical journals should be to assist their readers. Stephen Lock has listed the basic responsibilities of scientific journals toward readers : they should ' inform, instruct, comment, possibly amuse '[ 11. This paper explores current and future challenges medical journal editors face as they attempt to live up to these responsibilities.
Types of journals Many journals, such as the Journal of the American Medical Association and the British Medical Journal, are published by medical societies, and most subscribers to these journals automatically receive the journal as part of their membership. It could be argued that physicians do not highly value such journals because they have not explicitly subscribed to the journal. However, members of the American College of Physicians, in periodic surveys, routinely rank the journal they receive as part of membership (Annals of Internal Medicine) as the most valuable service of that organization (Gorsuch G, personal communication). Some medical journals (including the two most frequently cited medical journals in the world, the New England Journal of Medicine and the Lancet) are primarily or completely subscriber based. Others are sent to physicians free of charge. The articles in these ' controlled-circulation ' or ' throw-away ' journals are not usually peer reviewed and tend to be more for education than for sharing new information [2]. They are most commonly supported entirely by pharmaceutical advertising.
Medical journals serve many types of readers [ 3 ] .The readership of large general medical journals consists primarily of practising clinicians. Apparently, clinicians receive a large number of medical journals. In 1991, one physician in the United States complained that his office was inundated by more than 40 medical journals each month [4]. How much and in what manner physicians use and read the medical journals they receive are questions that to date have not been subjected to rigorous inquiry. In the United States, most routine surveys of physicians' journal reading habits are carried out for pharmaceutical companies [S, 61. These companies have financial interests in determining whether and how physicians read medical journals ; they use the information to help determine in which journals to place their advertisements. Although these surveys are not directed primarily at how physicians read the editorial content of medical journals, it is clear from their results that readers approach journals in different ways: some read through the entire issue, whereas others selectively scan only those articles of interest. Readers also vary in how regularly they read different journals. Medical journals serve more than clinician readers. Small journals in highly specialized fields primarily serve research scientists in that field. Larger, more general journals also serve this function, as evidenced by high citation indices. Researchers use medical journals both to keep up with important information in their fields and to communicate their work to others. Journals help researchers to improve their chances of promotion and successful grant proposals. Both the quality and the quantity of published articles ' determine success in medical academia. The lay public, through the news media, use medical journals to keep up with important advances. Special-interest groups, such as pharmaceutical company representatives, stockbrokers, and manufacturers of medically related products, carefully 223
224
S. W. FLETCHER & R. H. FLETCHER
follow the news reported in medical journals that is relevant to their commercial interests. As the above summary indicates, medical journal readers are a heterogeneous group, with many different requirements. Nevertheless, most readers of medical journals, particularly those journals covering a broad spectrum of medical subjects, are physicians engaged in the practice of medicine. It is the editors’ responsibilities to these readers that are stressed in this paper.
Readers’ requirements What clinicians want from medical journals has not yet been subjected to careful scientific inquiry. From casual discussions with individual clinicians, it appears that many use medical journals to keep up with medical progress, so as to give better medical care, which in turn will lead to improved health of their patients [7]. They equate being an excellent physician with having access to current medical information. In an environment of increasing regulation and accountability, some physicians see medical journals as one vehicle for mandated continuing education. Having up-to-date medical knowledge may be seen as an important way to minimize the possibility of malpractice litigation. Many physicians also enjoy the intellectual challenge of mastering new medical information. Finally, they seem to enjoy communicating through medical journals and contribute actively to Letters to the Editor sections.
Increase in medical knowledge The task of informing, educating and entertaining practising physicians is becoming more difficult because of the rapidly increasing volume of medical information. The growing volume presents different challenges to editors and readers.
The editors’ challenge The editor must decide the appropriate balance in types of articles to be published, a task that grows in complexity as the amount of medical information grows. ‘Medical ’ research has expanded over the past few decades. Clinical research remains central, but biomedical research on one side, and populationrelated research on the other, are growing. Disciplines such as health education, sociology and
economics are increasingly relevant to the practice of medicine ; research from these disciplines competes for space in medical journals. How does an editor choose the appropriate balance from this expanding smorgasbord ? Trends in medical research determine what papers are written, but the papers do not necessarily reflect an appropriate balance for the clinician reader. In the United States and elsewhere, for example, the active research programme on the acquired immunodeficiency syndrome (AIDS) has led to an avalanche of AIDS-related manuscripts. At Annals in Internal Medicine, AIDS-related research accounted for 14% of original research articles submitted in 1991 ; few readers have a medical practice in which one in six patients is infected with the AIDS virus. Thus, what is ultimately published is usually the result of an essentially passive process. Journal editors can only choose from what is sent to them, even though they can and do invite some submissions. Potential authors often scan journals to get a sense of what kinds of articles a particular journal is likely to publish. If articles on AIDS appear regularly, the journal may well receive even greater numbers of AIDS-related submissions. There is no negative feedback loop. Editors must actively determine the right balance of journal articles for readers, not merely passively accept the balance assumed by submitted manuscripts.
The readers’ challenge The large volume of medical research presents a different challenge to readers. Whereas editors must decide about balance in a single journal, the challenge presented to readers is how to master the growing amount of medical information published [8]. The challenge has grown to such proportions that in the early 1980s it was estimated that 4 million articles were published annually in the biomedical literature [9]. As the volume of medical research increases, the amount of time physicians have to master it through reading journals may be decreasing. The number of hours physicians spend on administrative duties related to patient care has been increasing. In addition, there are more alternatives for keeping up with medical innovations, including continuing education seminars, audiotape cassettes of lectures, and even television programmes geared to practising physicians.
RESPONSIBILITIES OF MEDICAL JOURNALS TO READERS
Coping niechanisnis Abstract services began in the early 1880s, and have grown steadily since [lo]. These were initially in print form, but more recently, computerized medical literature searching has been developed. In 1990. the National Library of Medicine performed 4.5 million Medline searches, many initiated by practising physicians (Eichenberger C, personal communication). Newer technologies, such as CD ROM, allow medical literature searches without direct connection to the National Library of Medicine computers. These new coping mechanisms can help readers to survey the medical literature and sort articles by topic, but few help sort articles according to quality. Some abstract services implicitly sort by quality, using editors’ judgments, without stated ground rules and select only ‘important’ articles for abstracting. Editors have increasingly focused on the quality of the research their journals report. With the development of more powerful methods and explicit standards for clinical research, as well as increasing numbers of clinical epidemiology faculty in medical schools, proper methods for clinical research have been clarified. Some medical journals have incorporated methodological standards into their peerreview processes by recruiting personnel with expertise in research design and statistics to their editorial staff. Taking the quality-selection process one step further, in 1991 Annals of Internal Medicine began a supplement service for its readers that abstracts clinical articles from more than 30 of the world’s medical journals. ACP Journal Club, edited by Dr R. Brian Haynes, abstracts articles only after they have met explicitly stated standards for both scientific strength and clinical usefulness [l l-131. Reaction from readers has been positive ; not surprisingly, most have commented how helpful ACP Journal Club is to their efforts to keep up with the medical literature, because it helps them to deal with the three problems of volume, time and quality. Perhaps most reassuring for readers is the relatively small amount of new medical information that is both clinically important and methodologically sound enough to be ready for clinical use. In 1991, ACP Journal Club editors found a total of only 298 original research articles from 4 7 medical journals that met their criteria. Fewer than one article per two issues of nine ‘core’ journals and less than one 14
225
article per five issues of 30 other, primarily subspecialty, journals were abstracted [ 141. Although the number of medical articles published is staggering, the number to be mastered for the purposes of clinical care may be far more manageable than was previously thought. This finding may be disturbing to editors. It appears that to practise medicine well, it is not necessary to master the information in the majority of original research articles, at least in internal medicine journals. This is not to say that such research is inappropriate for publication. Medicine is not a trade but a profession, indeed a ‘ learned profession ’. Part of being a learned professional must be to expand the mind, to learn about medical progress, perhaps for future medical application, perhaps only to gain a more complete understanding of medical science, but certainly not only to learn what is immediately useful. Much of the research relating to genetic discoveries falls into this category. These findings are important not for immediate application but for what they explain and may portend. The distinction between studies that provide interesting new information and those definitive $enough to affect medical practice should be made clearer. In sum, the volume of new medical information presents different challenges to editors and readers. Editors are faced with a growing need to consider what is an appropriate balance in the types of articles they should offer to readers. For readers, the challenge is to sift through the ever-increasing volume from a growing number of journals, to find those articles relevant to their practice. To date, most innovations designed to meet this challenge have helped sift the medical literature according to topic, not quality, of article. When the sifting includes quality as a criterion, the amount of clinically applicable new information shrinks considerably. Editors should consider specific steps to help their readers cope with the volume of medical information.
The medical tower of Babel - a growing problem Centripetal forces, born largely of the successes in medical research, are beginning to tear at the fabric of the profession of medicine ; medical journals, particularly general medical journals, are experiencing the effects of these forces. The profession of medicine is being increasingly fragmented. In the United States, specialty societies began to appear in I M R 232
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the latter half of the nineteenth century. In 1991, there are now 2 3 separate officially recognized specialties, each with its own certifying examination. Within many of these specialties, there are subspecialties (in internal medicine, alone, there are 11 subspecialties) and sometimes sub-subspecialties (in cardiology, there is now a separate electrophysiology certifying examination). With the appearance of each of these new official entities, journals have sprung up for researchers and practitioners. In addition, new journals have developed in areas not officially recognized as ‘separate’. For example, in the past few years, many new medical journals have appeared that are devoted exclusively to AIDS [15]. The fragmentation of medicine, strongest in the United States but growing in many other countries of the world as well, is not likely to decrease in the foreseeable future. Research gains, increases in the number of medical interventions. interests of young physicians who, at least in the United States, are clearly turning towards specialty and subspecialty medicine [16, 171, and the growing political power of the specialty groups in medicine all suggest continued centripetal forces. narrowly based medical journals add to the impetus. The increased specialization in medicine, together with the increased availability of medical journals in the specialties, may threaten medical journals that attempt to speak to physicians as a whole, to communicate across separate medical disciplines. Readers may be less interested in reading about medicine outside their own ever-narrowing areas of interest. This trend is particularly likely if they have less time to read and sense that the task is hopeless anyway. Medical terminology is growing more specialized and less easily understood by physicians in other fields, adding new challenges to editors and readers interested in broad-based medicine (specialization is occurring throughout science and technology, not only in medicine). Laboratory methods well known to researchers in a particular field may be incomprehensible to practising physicians. Most readers are unlikely to know whether and when ELISA and RIBA tests are appropriate for testing serum for hepatitis C virus, or even what the tests are. Clinical research methods have become complicated with the introduction of new research designs and the increasingly sophisticated biostatistical analyses of the studies. Most physicians, even most modern medical students, have had little education about case-control
studies, logistic regression, odds ratios and confidence intervals. Thus the methods of clinical research, which in the past were relatively easy for physicians in different fields to understand, have grown complex and difficult to grasp. Authors have changed, as well as medical content and research methods. Authors who spend most of their professional time communicating with other physicians in their particular field have difficulty communicating with the broader community of physicians. It may well be that modern authors are less literate than their predecessors, having stressed sciences rather than literature in their premedical education. Finally, there is the increasing trend for authors whose native language is not English to submit work to the large English-language medical journals [18]. Many of the submissions from these authors contain excellent scientific work but are written in poor or substandard English. It is reasonable to ask why medical journals, or medicine in general, should resist the effects of specialization, especially since there is much good that has come from it. Why is it necessary for physician scientists and clinicians to communicate with each other across disciplines ? Why should medical journal editors be concerned with these developments ? Too much narrow specialization could have negative consequences for patient care, society, the profession, and individual physicians [19]. Clinical science could also suffer if readers do not have the opportunity to come into contact with new ideas from different fields.
Improving communication Medical journal editors, particularly editors of general medical journals, must deal with the challenges posed by all of these relatively new developments. It is time to consider carefully ways to bridge the widening communication gaps in medicine [20]. Medical journals have a long tradition of working to improve submitted manuscripts before accepting them for publication. The peer review process itself aims not only to select which work should be published, but also to improve articles chosen for publication. In the editorial office, manuscript editors work with authors to standardize and improve the presentation. For some journals this work represents substantial effort. For example, at Arinals o/ Interrial Medicine. manuscript editors make an average of 3 changes per manuscript line (Case K, personal
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communication). Over the years, the editing efforts of scientific journal personnel have given rise to new professions and new organizations, such as the Council of Biology Editors and the European Association of Science Editors. Medical journal editors as a group have worked to improve communication in other ways, first by standardizing the format of articles with the IMRAD (Introduction, Methods, Results and Discussion) method for reporting original research. In 1 978 the lnternational Committee of Medical Journal Editors (the ‘Vancouver group’) was formed and specified the order and method of citing references [21]. Since then, most major medical journals have adopted the method. The Vancouver group also developed other standards for submitted manuscripts. Another attempt to improve communication with readers has been the evolution of the article’s abstract. Summaries at the end of articles developed in the first half of the twentieth century [22], then migrated to the beginning and were called abstracts. More recently, the structured abstract (with specific sections for the objective of the study, design, setting, patients or participants, interventions, main outcome measures, results and conclusions) has been introduced [22, 241. to ensure that all relevant information is systematically included. Structured abstracts are gaining in popularity among medical journals [25], but whether such an innovation improves comprehensibility has not yet been ascertained. Formal studies are planned (Haynes RB, personal communication). The increasing fragmentation of medicine challenges medical journals to continue, and indeed to accelerate, their efforts to communicate better with readers. These efforts should include rigorous studies to determine what readers understand and how much editing efforts improve readers’ comprehension. Systematic studies of editing effects may not come easily. To date, editors of peer-reviewed medical journals have made little effort to study communications with readers. Editors usually come from academic backgrounds, with strengths and interests in medical research rather than in medical communication research. Several simple communication innovations are worthy of consideration. Perhaps articles on relatively narrow medical topics should contain introductory paragraphs addressed to physicians outside the specialty. Editors may need explicitly to request authors to write for non-experts.
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To save space, medical journals traditionally eschew simple tables and figures in articles, requesting authors to incorporate the material in the text instead. It may be that this practice should be reversed. Simple, clear figures and tables should help to improve communication. A single, well-prepared figure can often ‘tell it all’. Titles of articles, as well as those of figures and tables, need to be both scientifically correct and clear. Too often the latter is sacrificed for the former. Major medical journals have recently moved to using international units when reporting laboratory test results. This move, although likely to help international medical communications in the long term, has hindered reader understanding in some countries, such as the United States, in the short term. Editors concerned about communication and reader understanding must find solutions. Inclusion of traditional local values or a conversion table in the article may help. Similar problems are encountered when using only generic names for drugs: readers complain that they do not know what drug is being written about. Acronyms, well known to physicians in one field, may be foreign to those in other fields. Editors should be able to overcome these challenges with simple tables listing key conversions, acronyms, and drug brand name equivalents. The visual presentation of written words is a field about which few physician editors know or care before entering the world of journal editing. For many, this remains so after they have entered the field. It is time to learn about fonts, weights, points and tints. It is time to care about the art of journalism. Perhaps this is one way to ‘amuse’ readers.
Conclusions Throughout this paper, we have pointed out how little is known about what readers of medical journals want and need. As numerous editors before us have made clear, when it comes to medical editing, there are too few facts carefully gathered by the rigorous scientific methods that virtually all medical journal editors embrace for clinical work and yet somehow do not demand for editorial work [26]. Perhaps editors are like old-time clinicians who did not have a scientifically sound information base for their work, and instead relied upon personal experience and opinion. What we have proposed in this paper should be 14-2
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treated as hypotheses. These may or may not be correct, but it is time to begin to find out. First, we suggest simple descriptive studies (such as focus group studies and surveys) : later, analytical studies should be undertaken : and finally, carefully evaluated intervention trials will be in order [27]. Both the medical journals and their readers can only benefit from such an approach.
Acknowledgements We thank Edward J. Huth, MD, our predecessor and mentor, and our colleagues, Kathleen Case and Pamela Fried, for reviewing early drafts of this manuscript and for many helpful suggestions.
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Correspondem; Suzanne W. Fletcher. MI), Annals of Internal Medicine, Independence Mall West. Sixth Street at Race. I’hiladelphia, PA 19106-1 572, USA.
