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How Annals has responded to a period of rapid change

The departing Editor talks about the influence of evidence-based medicine and electronic publishing

From the June 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Deborah Gesensway

Six and a half years ago, when Frank Davidoff, FACP, became Editor of Annals of Internal Medicine, evidence-based medicine was a new concept for many clinicians, Internet publishing seemed futuristic and many wondered whether general medical journals would survive in an increasingly specialized health care environment.

As Dr. Davidoff steps down early in July and turns leadership of the 74-year-old journal to Harold C. Sox, MACP, the world of medical publishing looks quite different, although many of the general issues remain.

In a recent interview, Dr. Davidoff shared his thoughts on the legacy he leaves after steering Annals through a period of great change. In terms of content and form, Annals is a different journal than the one he inherited.

Dr. Davidoff says that medical journals not only keep physicians up to date on the latest medical research, but also foster a sense of community.

Q: How has the content of Annals changed since 1995?

A: Evidence-based medicine was just starting to take off at that time. The standard for evidence—what is considered adequate evidence—is more rigorous.

In terms of editing a medical journal, this has meant that our standards for what we find interesting and acceptable have changed. And this has increased the importance of statistical review.

Q:Annals has a reputation for being somewhat rigid, pickier than most when it comes to statistical review. Is that fair?

A: We have developed this reputation because our statisticians—three core reviewers and seven backup statisticians—carefully go through every original research paper once we become seriously interested in it. They write detailed comments in addition to those of the peer reviewers, and authors must take all comments into account when they write revisions.

Although our statisticians try to be as constructive and user-friendly as possible, authors don’t always appreciate this level of review. At the same time, it’s essential because evidence-based medicine depends on the evidence being right. A lot of the statistical issues are highly technical, but they can make an enormous difference in how clinicians should interpret evidence.

An obvious example is the issue of clustering. Increasingly, trials are done in many different institutions. Unless the randomization is done properly, the effects of being in one institution compared to another may be quite substantial because each institution functions differently.

What might look like the effect of a drug or a treatment may actually be attributable to the fact that the patients were clustered within certain institutions. There are statistical ways of dealing with this, and a certain amount of our statisticians’ time is spent telling authors, “Well, you didn’t take clustering into account here.”

Q: Annals also has the reputation for being more clinically oriented than some of the other major medical journals. Why?

A: We have received a fair number of complaints from researchers that Annals tends to favor the clinically interesting paper, even if it is a little less rigorous, over one that may be more rigorous but clinically less interesting.

That’s probably true, but I don’t believe the two are mutually exclusive. I have tried to shift the focus toward clinical practice-type information that can be used at the bedside, but without losing rigor and relevance.

At the same time, we have run very technical articles about statistical issues. We have even invited an occasional article on statistical best practices because we feel an obligation to have our clinician-readers understand what is going on in research and how it is relevant to their practices.

Good clinical material in the journal stimulates researchers to do further research. We are explicit about that; we ask authors to discuss implications for both practice and future research, whenever that’s appropriate.

Q: Why do you think clinicians read a medical journal like Annals?

A: When I talk to readers, the things they like most in Annals are the reviews, updates and guidelines. People read journals because they clearly feel the need to keep up.

But medical journals also operate at another level, one of professional identity.

The practice of medicine is very isolating. It’s true that physicians see people all day, but when they are in a room with a patient, they are on their own. A journal is an instrument of social cohesion, which I believe is important. At some level, when physicians receive Annals, they know that 100,000 other internists are reading the same thing at the same time, which fosters a sense of belonging to a shared profession.

Q: Is that the reason why you have expanded the “On Being a Doctor” feature to now include essays, poetry and photographs?

A: Medicine is a social act, a fact that is very easily lost in the pages of clinical journals. There are many dimensions of medical practice that you can’t capture in a randomized trial. I think of medicine in terms of mix and balance.

In addition to their intrinsic value of teaching something about medicine, these sections draw people into the journal. The content of Annals is very dense, very hard to get into. I suspect very few people open Annals and first read the abstract and then the full text of the lead article. They work their way in. I have very little doubt that that’s why they frequently read “On Being a Doctor” first.

Q: Why are you now adding “Patient Summaries” in the journal? Isn’t Annals supposed to be for doctors?

A: The idea was brought up by the Internet. We realized that a lot of people with no medical training are interested in our content, but it is difficult to read. We also think that our physician readers have trouble getting into some of the articles because the information we publish, particularly in original articles, is often quite technical and relates to areas they are unfamiliar with.

The patient summaries are a quick take on the article, a way for physicians to find out what the article is about so that they then may be willing to read the whole thing. We also are hearing that housestaff find them particularly helpful.

Q: The Internet raises the issue of whether print journals have a future at all. During your tenure as editor, Annals.org was started. Will electronic publishing replace paper?

A: I believe that’s a false dichotomy. The history of information technologies has shown us that a new one does not completely replace the previous one. You use them all, but you use them differently.

Electronic journals are great for some things, but they don’t replace the print journal. The electronic version gets it out fast. It’s more convenient for many people. It’s searchable. There are links. We’ve looked for the best uses and the best balances of functions and purposes for the print journal and the electronic journal.

Q: When we look back on your tenure as editor, what do you want your legacy to be?

A: I don’t think I’ll be remembered as doing anything drastically new or different. I tried to build further on the excellence of a general journal, move it ahead scientifically and make it more appealing and accessible. I think generalism and general journals are threatened. In my view, that trend is destructive because it fragments the profession. The ability to take a broad view in medicine is crucial.

The debate about problems with patient safety is a good example. Everybody has been focusing on his or her own little piece of clinical care. Very few out there are taking the broad view, the system perspective.

Deborah Gesensway is a freelance writer in Glenside, Pa.

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