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New Annals editor--Championing evidence-based medicine

From the March 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Deborah Gesensway

With the March 1 issue, Frank F. Davidoff, FACP, became Editor of Annals of Internal Medicine. ACP's Senior Vice President for Education since 1987, Dr. Davidoff brings to the editorship a conviction that the future of the 68-year- old journal lies in championing evidence-based medicine. The science of clinical medicine should be at the fore, he said, and the science of caring should be close behind.

Dr. Davidoff came to ACP from a clinical career that included academic and community practice in general internal medicine and endocrinology. He held faculty appointments at Harvard Medical School and Beth Israel Hospital in Boston and the University of Connecticut Medical School in Farmington, Conn. He was chief of medicine at New Britain General Hospital in New Britain, Conn. ACP Observer readers know well his monthly Education Update column, which debuted in 1992.

In a recent interview, Dr. Davidoff outlined his plans and goals for Annals, circulation 98,000, citing a commitment to improving the readability of the nation's premier scientific and clinical journal of internal medicine.

Q. Internists these days barely have time to see all their scheduled patients, let alone keep up with the thousands of journal articles published each year. What is Annals' role in helping doctors confront this dilemma?

A. This is a very real problem. The general point is that if you are going to bother to spend your time reading stuff, at least you ought to have the sense that it is the best possible stuff to be reading. First of all, Annals must always ask, "What is the quality of evidence being presented?" As far as I am concerned, the College should be supportive of the whole move in the direction of evidence-based medicine. The information that is provided must be the best possible information, so it is worth people spending their time on it.

Then, given the best possible evidence, the question is how best to present it. We should try to boil it down to its essentials--where there's enough detail that it's usable and applicable--but sufficiently filtered and refined, so that you are not spending a lot of time wading through extraneous material.

Another reassurance to readers that a journal is worth reading is the whole peer review process. [Former Annals Co-Editors Suzanne and Robert Fletcher] were pioneers in doing research on peer review, and the journal is going to continue to be a strong supporter of that work, even though that's not my particular expertise or interest.

Q. Will Annals in the Davidoff era have a different look or feel?

A. There's a certain virtue in being staid and not hysterical and jumping for every fad. But one thing I've been attracted to in other journals is how editorials and articles explicitly refer to each other, so people can link them. It is helpful to readers to have a discussion about the pros and cons and limitations of a study.

Another thing that interests me is the notion of putting a box within an article that summarizes its points: What are the key elements and what are the clinical implications?

The other thing that Annals has relatively less of than it might are educational reviews and summaries of areas and topics. The journal tends to focus substantially more heavily on original articles. That's not wrong, but maybe there needs to be some shift in balance. Why not publish a "MKSAP question of the fortnight"?

Then there are some stylistic details. One example is that at the top left of the front cover--where most people start reading--is the listing of the letters to the editor. If we think the core of the journal is the original articles, then that's the first thing that should be listed. It's a tiny detail, but maybe it's emblematic.

Q. Should articles be shorter?

A. Less is usually more. If you do the calculations, it costs $3,200 to publish a page of Annals. That means every page of Annals is very valuable. If we could, for example, shorten articles by 10% without doing them harm and in fact probably making them more readable and accessible, that opens up 10% more pages for other good material we simply cannot publish now. The rational thing to do, it seems, is to shorten and clarify, although shortening and clarifying is very hard, labor-intensive work.

Q. During their tenure, the Drs. Fletcher added more articles about socioeconomic issues relating to internal medicine. Some other medical journals have begun reporting medical news. What is your view?

A. I don't know where I will come out on that. Those are things I am going to explore with readers, with College staff and Regents, with other journals. Annals has [commissioned news and policy articles] rather less than some other journals, so I think there is some room for more of that and perhaps a little less of just responding to what comes in over the transom.

Q. Will Annals continue to publish ACP position papers and guidelines?

A. I agree with [former Editor] Edward Huth, who thought guidelines and position papers ought to be subjected to peer review. It seems to me that the peer review process is a quality filter, and if readers are looking for a quality filter, we have got to provide it. There have been one or two instances where [position papers] have not passed [peer review] and they were not published.

There might be another way to approach it, however. The CEAP [Clinical Efficacy Assessment Program] papers have tended to be quite long, extraordinarily exhaustive and exhausting. One possibility would be to publish a somewhat boiled-down version in Annals and make all the detailed information, the extensive bibliographies and the extensive tables available from some other archival service, such as the National Technical Information Service.

Q. Should Annals publish more negative trials?

A. It's actually a broader issue, and it relates back to us supporting evidence-based medicine. If you believe that data from randomized clinical trials is the most reliable and useful data, then it follows more generally that all the well-done randomized clinical trials ought to be published. That doesn't necessarily mean they all should be published in Annals, but somebody should publish them. And studies have shown that as much as a third or 40% of the relevant clinical trials are never published. These are principally the negative ones, but not entirely. Whether this means we will be publishing more negative trials, I'm not sure, but maybe it would.

Q. Should Annals continue to feature short stories and poetry?

A. I think On Being a Doctor has been important for a lot of reasons. For one, the readers like it. And I think it says something quite important about internal medicine as being more than just bench science or clinical research. I've talked about there being a science of caring. And I think that's true. It's an art. But there's more to it than art. To care for people is something you can learn, something with a structure, a rationale.

Maybe it also would make sense to develop a parallel section, On Being a Patient. A fair amount of the literature in medicine has to do with the experience of being a patient. It has been argued that patients' description of illness is information that could be useful to doctors in helping to make a diagnosis and then helpful in management.

Q. You have said you plan to involve readers more in these kinds of editorial decisions. How?

A. I've learned the hard way not to just go plunging ahead with my own notions. I really am serious about getting information from readers and authors about what makes more or less sense. I have been impressed with the kind of information that comes out of focus groups. Another possibility would be to set up a standing panel of reader-advisers, who would agree to critique issues. Another possibility would be to add a practicing generalist physician or two to the group of associate editors.

Q. What do you think of the lay public's interest in articles published in medical journals, including Annals?

A. I have a real serious concern about that. The news media care about things that will make news. And things that make news are usually narrowly focused, somewhat exotic or have some special twist to them. That is antithetical to science.

What tends to happen is [the media] report on Study A, which found one result, and then they report on Study B, which found the opposite result. And they glory in the fact that [the studies] disagree, because they love conflict. But that's not necessarily in the best interest of anyone, because what tends to happen is that the public says "I don't believe anybody." [What the media does] fundamentally undermines the scientific process, in a way.

And I think the scientific press has been just as guilty, in that when it wrote review articles, it took all kinds of evidence--good, bad and indifferent--threw it all together, and came up with weak syntheses of misleading data. This has really concerned me.

Q. What will be the relationship of Annals to the new interactive, electronic publishing technologies?

A. My job is to produce good content. The point is not to produce an electronic journal. The point is to produce information and to get it into doctors' heads in a better way. And electronic publishing may or may not be the best solution. It clearly is happening, and whatever happens, Annals is going to be part of it. To do otherwise would be nuts. But we need to keep clearly in front of us that all the glitz and the glamour and excitement of this new toy are beside the point. People tend to be dazzled by electronics, but a lot of [electronic publications] have fallen on their faces because they got so bedazzled by the gimmickry that they lost sight of the fact that they weren't producing anything very useful.

Q. What do you see as the role of Annals in helping promote the profession of internal medicine?

A. Annals can make a useful contribution to helping medical students see internal medicine for what it is and as desirable. I could see something along the lines of a student edition in support of the College's effort to recruit student members. This is an area that I would like to pay careful attention to and try to do whatever is useful.

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