The internet has fundamentally changed the way we understand and interact with the world: not just as physicians, but in our daily lives; however medicine (especially academic medicine) still lives in the dark ages. The ways of old are starting to show signs of wear, that this is beginning to change. And as things in the age of information move at an ever more-rapid pace, I think the changes will be here before we know it. I, for one, welcome our new data overlords.
The medical journal was initially created as a forum: a way to publicly share information with your colleagues, and get credit for the discovery. Say you wanted to tell the world of a new surgical technique. Or a new drug that you’ve discovered to help your patients. You could discuss it with a few colleagues in the hospital. But if you think you’re really onto something — something that really might be great and really might help not just your patients, but everyone’s — you’ve got to spread the word. And that’s how the journals started. Not with research, but with physician opinions and approaches and case reports and “Hey look what I found out”s. If you go back to the early publications of the New England Journal of Medicine — which now allows you to search from their archives from 1812 on – you can see some pretty cool stuff. Punch in your favorite subject and you’re transported back in time to when physicians like you were still trying to figure out what the hell was going on with this patient, instead of the biochemical cytokine pathway of today. It’s pretty incredible.
So here’s my first point: look how we share information today (and honestly, we’re just getting started): Twitter, Facebook, emails, blogs, text messages, Google, Wikipedia. Sure sure, we still share some very important information through medical journals, but they simply can’t keep up. Hundreds of new medical journals are launched every year, for everyone’s own sub-sub-specialty out there. Yet the hunger for publication and knowledge continues to grow. Let’s just consider the case report, for example. Imagine you’re staffing a hospital in the late 70s/early 80s in New York, or San Francisco, or Los Angeles, and you find these small crops of patients with really, really weird infections. You scratch your head, dig in a little deeper, and publish what you’re finding in the New England Journal of Medicine in the December 10, 1981 edition. Four months later, several replies are published: it’s marijuana use; no no, it’s the amyl nitrates that the gay men are using; of course not, it’s the CMV they’ve been exposed to; no, you’re wrong, this is something entirely new we’ve never seen before. It’s an absolutely fascinating read of the natural course of HIV’s research pattern, but one that I imagine would be very different today (and will be different when the next HIV/AIDS-like disease hits):
Okay okay, so fine, that’s just case reports. And medicine and science and the scientific method evolved, and It Was Good, and then medical journals became the place to publish research. Big trials. Lots of money. Which brings me to my second, unforunate point: peer review is not all it’s cracked up to be. Some concerning data (ironically, yes, published in the journals):
- Association of Funding and Conclusions in Randomized Drug Trials, JAMA 2003: if your randomized trial was funded by Pharma, it was 5.3 times more likely to recommend the experimental drug than if it was funded by a non-profit organization.
- Undisclosed Changes in Outcomes in Randomized Controlled Trials: An Observational Study, Annals of Family Medicine, 2009: In 31% of randomized controlled trials, the primary outcome had been changed (without disclosure) after the trial had been submitted to the clinicaltrials.gov database.
- Females may be less likely to get papers accepted.
- When you blind reviewers to information about the author, they are less biased in their acceptance of abstracts.
Now, I’m not saying that peer review should be discarded, or that journals should cease to exist, or that we should throw the baby out with the bathwater. I am, saying, however, that I think there’s room for another option, using the internet, social networks, and crowdsourcing. (NB: In this topic I am building on existing ideas from Chris Nickson/LITFL’s Time to Publish Then Filter? and The Wisdom of Crown Review which also references these BMJ and Annals of EM opinion pieces.) I agree with Chris: I don’t know exactly what form this should take, but something like an academic Twitter (Trip Database’s TILT?) might not be a bad start. I hate to make this all a popularity contest (mostly because I lost those so vigorously in high school), but the cream typically rises to the top when something is put to the crowds. (But sadly, not always. Okay, at least, the academic crowds.)
Or perhaps it’s meta-reviews of the data. It’s online Critical Care Journal Clubs, or it’s a rating system to articles with ratings from colleagues you like and trust (and who know the literature better than you) like Leon Gussow’s 5/5 Skull and Crossbones at his Toxicology blog. Or podcasts reviewing a single topic. I’m not sure if it’s centralized. Who knows. Someone will build it and get it right (maybe me?) and we’ll go from there.
And all these great online links and resources lead me to my final point: “academic” works cannot and should not be limited to the length of one’s search in Pubmed as author. Yes yes, I’m suggesting the beginning of an academic new world order, and should be burned at the stake for such heresy (especially since I’m going into academics). But “publish or perish” should not simply mean “get your name in a journal.” Academics is the pursuit of knowledge, the pursuit of teaching and education. Case in point: Rob Reardon, narrator of so many of those fantastic ultrasound videos that I’m forever loving, is a well-published article in the journal world as well. But I guarantee you this: the amount of education that Rob has produced on his website — and that people have learned from — already exceeds the amount of whole-world educational impact of his Pubmed career. It’s simply exposure from the internet versus exposure through one journal.
Like-minded people (frequently education-minded, tech-oriented like myself) are doing this all over the web. They’re frequently (but not always) affiliated with some sort of academic place — be it an official medical school or simply an area where residents rotate — and do it because they enjoy it. And none of it would make it into a journal article. It’s too short, or too fast, or too digital, or simply too practical — but yet clearly useful. And it should be valid and appropriate academic work, recognized by our peers. (Let the crowds do the peer-reviewing of these publications if they like. Don’t like one of Rob’s videos, or disagree with him on something he says? Leave a comment or send a message on Twitter for all the world to see.)
There is a huge, huge volume of really high-quality learning on the web, especially in Emergency Medicine (much of which I’ve documented here), and it’s only becoming better.
Journals are here to stay — and I welcome them. They provide an important resource to develop and publish research and trials, and are still the biggest forum available to spread one’s medical ideas. But at the same time, there is content and ideas and a wealth of knowledge and information-sharing going on that is occuring not in sequence — but in parallel with them. Information that is simply out of the realm and scope of the journals and old-fashioned peer review. We are starting to develop the tools to share this information, and I look forward to where the next 10 years take us. (Hopefully to at least a modicum of technologic advancement in the snail’s pace at which medicine frequently changes.)