Should original medical research go straight to the Net?
From the April 1996 ACP Observer, copyright © 1996 by the American College of Physicians.
By Edward Doyle
Try surfing the Internet for new medical research, and you will probably be disappointed. Sure, you will find plenty of sites electronically publishing research results for physicians, but most offer only abstracts--not full text--from journals that have already appeared in print. For now, most medical research on the Internet is nothing more than "shovelware," text that has been taken from print journals and put into an electronic format.
But it doesn't have to be that way. Other professions like physics have used the Internet for years to get new research and scholarly articles directly to colleagues, bypassing print journals. Physicists with a computer and a connection to the Internet can directly publish their work via a computer repository at Los Alamos National Laboratory in New Mexico and get instant feedback from their peers. Electronic publishing is so popular in physics that this single repository handles more than 60,000 electronic transactions a day. Print journals are still alive and well in physics, but--and here's a switch--they are seen as a paper archive for important research that has already been published electronically.
While e-publishing is booming in some professions, medicine has so far been unwilling to embrace these more freewheeling forms of publishing. There is strong resistance among both medical publishers and researchers that is rooted in beliefs about how medical research should be published--and fears about how it might be misused by physicians and the public.
The peer review controversy
At the heart of this resistance are notions about peer review. Advocates of electronic publishing like Ronald E. LaPorte, PhD, an epidemiology professor at the University of Pittsburgh, would like the current system of academic publishing, including formal peer review boards, to disappear altogether. In its place, he envisions a more "democratic" system of peer review in which anyone who reads an electronic article can attach their comments. In such a system, physicians looking for the latest in medical research would judge the merits of an article--and whether it is worth reading--by reviewing their peers' comments. (Dr. LaPorte outlines such a proposal in "The death of biomedical journals," the British Medical Journal, 1995; 310:1387-90.)
Proponents of this approach say that all researchers and physicians--not just those appointed by medical journals--should have a chance to speak up about cutting-edge medical research. They complain that the current system of peer review relies too much on a relatively small number of reviewers, and that broadening the peer review process electronically would infuse it with new ideas and perspectives.
Mainstream medical publishers, however, insist that a more structured system of peer review is needed. Frank Davidoff, FACP, editor of the Annals of Internal Medicine, said that while direct electronic publishing may work in disciplines like physics where researchers deal with quantitative data that do not have the potential to directly affect patient care, medicine is a different story. "The closer you get to the bedside," he explained, "the less appropriate it is to do this kind of thing. It's too easy to get flaky ideas and incomplete or premature information out there that might hurt someone directly."
The issue of peer review has already emerged as a hot topic in the online world. OncoLink, an Internet resource for cancer patients run by the University of Pennsylvania, was shut down in 1994 when one of the service's editors repeatedly posted information on the Internet without having it reviewed by a physician panel. OncoLink quickly resumed service after establishing a formal peer review process, but the entire episode generated controversy in the Internet community, where peer review is often equated with censorship.
Joel W. Goldwein, MD, an associate professor of radiation oncology at the university and one of OncoLink's editors, argues that peer review is necessary in electronic medical publishing not just for patients, but for physicians as well. "Within medicine there are so many little niches and so many esoteric areas that we as physicians have to depend on experts to assure quality," he explained. "I could take all kinds of information and place it on the Internet. Without peer review, how can people really know what kind of quality is being posted unless they're experts?" Dr. Goldwein said he did not know how many articles OncoLink has declined to publish, but he noted that reviewers have rejected submissions because of fabricated references and outdated information.
Critics like Dr. LaPorte concede that the lack of structured peer review may mean that some shoddy research gets published online, but they argue that no competent physician treats patients based on one article. Much of mainstream medicine rejects that argument. Editors at the New England Journal of Medicine feel so strongly about the issue that they last year ruled that any article published on the Internet will not be considered for publication in the journal. Jerome P. Kassirer, MACP, the journal's editor-in-chief, explained the rationale "is to prevent people from publishing articles without peer review."
Faster and cheaper?
The debate does not stop with peer review. Print publishers and e-publishing advocates also disagree on the potential time and cost benefits of online publishing.
Supporters, for example, claim that by publishing medical research electronically, journals get the latest information to physicians more quickly. Most print journal editors, however, estimate that online publishing would probably shave only one or two months off their production time and not produce dramatic savings.
And when it comes to costs, electronic publishing supporters say that print publishers can save up to 75% of their operating costs by distributing journals electronically and reduce--or even eliminate--subscription charges. As proof, they point to electronic-only journals that operate on little more than a shoe string. For example, Alzheimer's Disease Review, one of the few electronic-only journals in medicine, will be e-mailed to subscribers free, primarily because of low start-up and operating costs. The journal, due out sometime this spring, will consist of review articles with state-of-the-art information on Alzheimer's disease and will be peer-reviewed by an international editorial board.
Reducing or eliminating subscription charges is an important goal of many online publications. Critics of print-based academic publishing complain that while print journal publishers get their articles written, reviewed and sometimes edited for free, they then sell them to the scholarly community in the form of journal subscriptions. Even after publishers have recouped their production costs, critics say, they continue to charge for electronic access to their material.
Publishers are skeptical about how much money could be saved by going online. They point out that electronic journals require staffing and in some instances additional technical as well as editorial personnel. Adding extra features to electronic journals, such as the ability to go to other journal articles by clicking on a highlighted word, can make electronic publishing more costly than print publishing, said Karen Hunter, vice president of strategic planning and development for journal publisher Reed Elsevier.
Most important, medical publishing is a big business, and few journals want to risk losing subscribers and lucrative advertising dollars by e-publishing. "We don't want to discourage people from looking at current issues of the journal," explained the Annals ' Dr. Davidoff, noting that subscriptions to the journal and ad sales based on those numbers generate a significant amount of ACP's revenue.
That does not mean that print publishers are ignoring electronic publishing altogether. As some libraries--many publishers' biggest customers--begin to turn to electronic subscriptions as an economic alternative to print subscriptions, publishers are taking notice.
And while there is considerable disagreement about the benefits, most major medical journals are also getting online. For example, the Annals offers full text of key articles from each issue and summaries of other articles on ACP's new Web site, ACP Online (http://www.acponline.org/journals/annals/annaltoc.htm). The New England Journal of Medicine also has a Web site (http://www.nejm.org) that offers abstracts of all recent articles and text of articles like book reviews and editorials.
Still, the mood in medical publishing seems to be one of caution. After all, print publishers say, physicians do not need more information, they need better information. "As anyone who has every done Medline searching knows, the big problem is screening out useless material," Dr. Davidoff said. "What we don't need is more second-rate information."
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