Medical News : Journals Struggle to Keep Pace
When federal health officials at a September press conference openly discussed the promise of an experimental AIDS drug called AZT, they not only violated the traditional rules for scientific communication but also underscored the changing ways in which doctors and the public sometimes learn of important medical developments.
Usually, major research findings are kept scrupulously under wraps until they have been rigorously reviewed by independent scientists and then announced in a medical journal.
Increasingly, however, the journals are no longer performing this gatekeeping role. With their tedious peer review process, the journals often simply cannot keep up with the quickening pace of medical research in fields such as acquired immune deficiency syndrome.
AIDS Developments Cited
“There are so many new AIDS developments . . . that doctors would sometimes be weeks to months behind the time if they had to wait for the journals,” conceded Dr. Arnold S. Relman, editor of the prestigious New England Journal of Medicine.
But as the news media increasingly become a significant conduit for medical news on topics ranging from artificial hearts to to test-tube babies, journal editors such as Relman say their publications are “more important than ever” as sources of “conservatively stated, factual information” that help separate genuine progress from poor research and sheer hype.
Speedier Review Process
To keep up, the journals are speeding the review process for key articles on AIDS and other topics, sometimes publishing articles within weeks of submission by researchers. Copies of such articles are sped to the independent reviewers by overnight mail, who in turn are asked to read the manuscript immediately and then telephone their evaluation to journal editors. This process can reduce by months the delay in publishing the new findings.
The intense public interest in AIDS, heart disease, cancer and other medical topics today reflects the increased pace of medical advances, improved science education and the greater importance of medical progress for everyday life.
“There has been an astounding increase in the way that the general public has been informed and has come very properly to expect information about medicine,” said Dr. Drummond Rennie, senior contributing editor of the Journal of the American Medical Assn.
Leading Journals
In addition to the Journal of the American Medical Assn. and the New England Journal, the other leading journals include Science, the Annals of Internal Medicine, and the British publications Lancet and Nature.
Stories based on reports in these journals appear much more frequently in newspapers and on television today than they did a decade ago, in part because many reporters consider the journals to be authoritative sources of information.
At the same time, news media coverage of some medical meetings, such as American Medical Assn. conventions, has declined, in part because presentations at such meetings often do not break new ground or may primarily be of interest to practitioners and researchers in the field, not the public at large.
But some say journal articles are receiving more attention than they deserve.
“There is awful lot of medical news being spoon-fed to the press by major journals,” said Jay A. Winsten, the director of the center for health communication at the Harvard School of Public Health. Winsten said the “spoon-feeding” leads to disjointed coverage by reporters and discourages in-depth stories that put new developments into perspective.
On AIDS and other subjects, the journals are increasingly considering the likely reaction of the general public, as well as the medical community, in selecting and editing articles. An example is the widely publicized study by Dr. Brian MacMahon of the Harvard School of Public Health, suggesting an association between heavy coffee drinking and cancer of the pancreas. The study was published by the New England Journal of Medicine in 1981; since then, it has never been confirmed, even in further studies by MacMahon and his colleagues.
‘On the Fence’
Relman said he was “on the fence” about publishing the article, fearing that it might alarm the public and upset the world coffee market.
In deciding to publish the study, Relman recalled that journal editors 30 years earlier had to take the lead in publishing the first evidence linking cigarette smoking and lung cancer.
“The (coffee) study was preliminary and provocative, but it was not obviously fatally flawed,” Relman said, adding that the assertion “needed the widest possible medical audience to stimulate immediate efforts to confirm or disprove it.” Indeed, it is almost a monthly occurrence for conflicting research findings to be published on other topics as well, such as the possible association between birth control pills and cancer.
Medical publications base their claims of preeminence on the accuracy of a process called peer review, the pre-publication evaluation of manuscripts by journal editors and often two, three or more outside experts.
“A professional journal is distinguished from other publications by virtue of peer review,” wrote Dr. George D. Lundberg, editor of the Journal of the American Medical Assn., in an editorial in June. “Few, if any, other methods of disseminating information can equally challenge such a process.”
Many journal editors try to maintain control over the dissemination of research findings by adhering in varying degrees to the so-called “Ingelfinger Rule,” named after Dr. Franz Ingelfinger, a former editor of the New England Journal. This rule ordinarily prohibits publication of research that has already received extensive publicity.
Seen as Impediment
But such a policy is not meant to impede researchers from presenting their findings at scientific meetings or interfering with press coverage of such meetings, according to Relman and others. Still, many researchers and reporters believe that it often does.
“The Ingelfinger rule has been widely misunderstood as a complete embargo,” said Dr. John C. Bailar, the New England Journal’s statistical consultant and president-elect of the Council of Biology Editors, whose members represent more than 500 biomedical journals.
Increasingly, the journals in recent years are making exceptions to such rules, although there are no set policies for doing so.
For example, in October the New England Journal published a report on infant heart transplants by Dr. Leonard Bailey, the cardiac surgeon at Loma Linda Medical Center, even though his pioneering work in the field has been widely publicized.
Sometimes, as the AZT announcement in September demonstrated, waiting for a journal article to be published may delay knowledge of important medical developments and impede open discussion of research progress. After determining that AIDS patients receiving the experimental drug were surviving longer than those receiving a placebo, federal health officials and Burroughs-Welcome, the drug’s manufacturer, immediately took steps to make it more widely available.
“In view of the urgency of the information, it would have been unreasonable for us to expect the authorities to withhold it from doctors and the public,” Relman said in an interview.
‘Reviewed on It Merits’
Despite the publicity, he added, a scientific article on the AZT trials will be “reviewed on its merits,” not rejected immediately as might have been the case five years ago.
A critic of the muzzling policies of the journals is Dr. Lawrence K. Altman, the medical correspondent of the New York Times. He feels that the peer review system sometimes threatens the quality of medical information by exaggerating the accuracy and the importance of the journals.
“Doctors have come to consider some medical journals as bibles,” Altman said in a talk at the National Library of Medicine in Bethesda, Md., in February.
“In many ways, peer review is a self-serving phrase that is often misused to provide a more scientific appearance to what in other forms of journalism is considered to be part of the normal editing process,” Altman said.
The weekly New England Journal, which like most of the leading medical journals does not pay its authors, gets 4,000 unsolicited manuscripts a year, more than double the number it received 20 years ago. The Journal of the American Medical Assn. receives about 3,500.
Most of the journals publish only 10 to 20% of such manuscripts, some after extensive editing and revisions that often takes close to a year or more to complete. In fast-developing fields, some research findings may be outdated by the time of publication.
The medical journals have not always controlled the release of information about landmark medical developments.
In 1846, the first use ever of a general anesthetic to put a patient to sleep during surgery was reported in the Boston newspapers the day after the operation took place at the Massachusetts General Hospital. This was a month before a scientific report appeared in the Boston Medical and Surgical Journal, the predecessor of the New England Journal. The anesthetic, the volatile gas ether, was soon widely used in operations.
In 1895, when the German physicist Wilhelm Roentgen discovered X-rays, he released the information to the press immediately, according to Daniel M. Fox, professor of humanities in medicine at the State University of New York at Stony Brook. Within the month, there were public demonstrations of “Roentgen ray” machines throughout the world.
Side-Effects Discovered
X-rays became widely used in medicine both to diagnose conditions, such as broken bones or pneumonia, and to treat a variety of illnesses, from acne to enlarged tonsils, despite scant evidence that such treatments were either safe or effective. Only in recent years have many physicians and the public realized the many side-effects of X-rays, such as the development of cancers, mostly as a result of scientific studies published in medical journals.
As recently as 1955, the success of the Salk polio vaccine, one of the most significant medical developments since World War II, was simultaneously announced to doctors and the public in a televised scientific meeting at the University of Michigan. The report was published the next month in the American Journal of Public Health.
But as the medical journals have become more important, many universities, drug companies and even some medical journals and doctors have begun to routinely issue press releases or arrange briefing sessions to compete for the attention of journalists.
The prototype for such public relations activities are the annual meetings that the American Cancer Society has organized since the late 1950s.
At first, the cancer society arranged for a handful of reporters to travel by train between research centers for several weeks each year. They would visit the laboratories of leading researchers and observe first hand some of the experiments in progress.
In 1959, the train tour was replaced by an annual meeting in March, usually held in a resort area of California or Florida. Other organizations, such as the American Medical Assn. and the American Heart Assn., now sponsor annual press seminars as well.
Such meetings are not only designed to allow leading scientists to brief reporters on their work. They also generate publicity for the sponsoring organization and are often timed to coincide with fund-raising drives. Extensive news releases and other background materials make it easier for reporters to write their stories.
Publicity an Objective
“Our objective is to get the name of the heart association before the American public,” said Howard Lewis, director of the organization’s health and science news division. “I don’t make any excuses for that.”
More researchers are also willing to explain their work to reporters at such meetings and in interviews, not only to inform the public, but also in the hope of getting a step up on their competitors. “It is a widely held belief among scientists than the right kind of publicity about their work can help their standing in their field and their prospects for obtaining additional research grants,” said Winsten of the Harvard School of Public Health.
The dangers of medicine by press conference are illustrated by several recent instances.
Last November, at a Paris press conference, French scientists told of “dramatic” improvements in a few AIDS patients treated with the drug cyclosporine for less than 10 days. But within months, the same researchers conceded at a cancer meeting in Los Angeles that they had raised false hopes because the treatment ultimately did not work.
Another example of misleading publicity is a 1978 press conference at which scientists at the City of Hope National Medical Center in Duarte and Genentech Inc. of South San Francisco announced that human insulin had been produced for the first time using recombinant DNA techniques.
Three months later, the scientific report of the discovery, published in the Proceedings of the National Academy of Sciences, revealed a significant fact that had been omitted at the press conference--the insulin that had been produced did not work. It took several more years of research to perfect the synthetic human insulin, which is now marketed worldwide.
Practice Subsides
There were other such instances of “gene cloning by press conference” that also tended to drive up stock prices. The practice has since subsided, in part because of the strong negative reactions in the scientific community to the first such announcements.
Genentech now would rather “err on the side of conservatism,” according to Susan Atkins, the company’s director of corporate communications, explaining that Genentech now believed that scientific developments should be reported through scientific journals and meetings and not by press release.
“The biotechnology industry doesn’t do itself any favors when it talks about scientific achievements as if they are products on the shelf to help human health care,” Atkins said in an interview.
The peer review system might have prevented such misleading announcements, but it is not foolproof.
An example is a 1983 report in the American Journal of Obstetrics and Gynecology purporting to prove that a tiny worm causes an often fatal disease called toxemia of pregnancy. Within months, British researchers, publishing in Lancet, showed that the “worm” was actually an artifact produced by the research process.
Other articles have been retracted because they were based on fabricated data, such as many studies conducted in the early 1980s by Dr. John R. Darsee at Emory University and Harvard University, including two which were published in the New England Journal. In October, a UC San Diego Medical Center committee concluded that cardiology researcher Dr. Robert Slutsky in a similar pattern of fraudulent research had falsified parts of 13 articles published during his 6 1/2 years at the school.
Despite such problems, experts on journals, such as Bailar of the Council of Biology editors, feel that both the average quality of science and the review process itself “have improved considerably” in recent years, spurred in part by the AIDS epidemic. Compared to 25 years ago, both scientists and journal editors “tend to be much more careful thinkers,” he said.
