Correspondence
The Internet and the Journal
N Engl J Med 1995; 333:1077-1080October 19, 1995
- Article
To the Editor:
The editorial “The Internet and the Journal” (June 22 issue)1 addresses the pros and cons of electronic “publishing” of articles on the Internet. You mentioned abstracts in passing, but the specter of electronic publishing of abstracts raises even more serious questions.
Any flaws in the proposal for electronic publication of articles would be magnified enormously for electronic abstract publication. The selection process for abstracts already has demonstrable shortcomings. One study found that abstracts frequently were never published, and if they were it was only after a long interval. The number of citations of abstracts (a measure of interest in their content) was not a predictor of subsequent successful publication.2 Subsequent analyses have expanded these observations.3 Negative abstract results were published less often as papers,4 and even when publication did result, long delays were common.5
The electronic publication of data in an abstract, even when they are published later as an article, can lead to the acceptance of flawed or preliminary information by the medical community long before the data have been subjected to critical peer review. The risk of disseminating this unvalidated information is obvious.
5 ReferencesPhilip D. Lief, M.D.
Albert Einstein College of Medicine, Bronx, NY 10461-23731
Kassirer JP ,Angell M . The Internet and the Journal. N Engl J Med 1995;332:1709-1710
Full Text | Web of Science | Medline2
Goldman L ,Loscalzo A . Fate of cardiology research originally published in abstract form. N Engl J Med 1980;303:255-259
Full Text | Web of Science | Medline3
Meranze J ,Ellison N ,Greenhow DE . Publications resulting from anesthesia meeting abstracts. Anesth Analg 1982;61:445-448
CrossRef | Web of Science | Medline4
Yentis SM ,Campbell FA ,Lerman J . Publication of abstracts presented at anaesthesia meetings. Can J Anaesth 1993;40:632-634
CrossRef | Web of Science | Medline5
De Bellefeuille C ,Morrison CA ,Tannock IF . The fate of abstracts submitted to a cancer meeting: factors which influence presentation and subsequent publication. Ann Oncol 1992;3:187-191
Web of Science | Medline
To the Editor:
. . . Without hyperbole, it can be argued that mass access to electronic data transfer presents an order of change in communications that ranks with the development of the automatic printing press. Like that of the wide availability of cheaply printed books and gazettes, the impact of the Internet won't be clearly understood until our use of it has evolved further.
The limited distribution of the results of a medical investigation, whether in part or whole, can easily expand through redistribution. Although it is a point of professional etiquette that no correspondence can be recirculated on electronic mailing lists or posted on bulletin boards without the express permission of the author, it is difficult to enforce professional etiquette. Moreover, anyone with access to one of the electronic gateways to the Internet has access to most of the electronic information storage available on the Internet. Discussion groups are open-ended. No matter how esoteric the specialty orientation, nonspecialists often browse the lists or message data bases. They may include medical journalists, concerned patients, and sensationalists. The more controversial or newsworthy the information, the more likely it is to be promulgated rapidly and indiscriminately. . . .
Charles B. Watson, M.D.
University of Connecticut School of Medicine, Farmington, CT 06032To the Editor:
In your thought-provoking editorial on the potential dangers of medical publication on the Internet, you and Dr. Angell raise some cogent and important questions. However, your assertion that information published on the Internet is intrinsically susceptible to alteration by the recipient is untrue. World Wide Web and other Internet documents are uploaded by the author or authors and stored on a “server” computer, and are then available for viewing or downloading by the end user. There is no mechanism for altering the document's contents on the server by unauthorized parties.
Regarding the concern that nonmedical personnel will misinterpret Internet medical information, this phenomenon already occurs with information from libraries, newspapers, radio, and television and is not unique to the Internet nor sufficient reason to throw out the baby with the bath water in advocating the widespread restriction of Internet medical publication.
Although your emphasis on the principles of peer review and preserving the integrity of original papers is unarguable, your supposition that these principles are intrinsically threatened by Internet technology is unsupported. Appropriately used, these technologies offer the potential to maintain the high standards of traditional medical publication and add to it the efficiency of the electronic world. Our task is to ensure that it is employed responsibly.
Lory D. Wiviott, M.D
2100 Webster St., Suite 326, San Francisco, CA 94115To the Editor:
Just as the word “publishing” has taken on new meaning, so, perhaps, has the word “meeting.” You and Dr. Angell state that “posting a manuscript, including its figures and tables, on a host computer to which anyone on the Internet can gain access will constitute prior publication.” In a previous editorial,1 however, Dr. Angell and you stated that you would exempt all presentations at scientific meetings from the policy of considering a manuscript for publication only if its substance has not been submitted or reported elsewhere (the Ingelfinger Rule). An important issue in terms of the Internet is, what constitutes a “meeting”?
Recently, we and our colleagues created an interactive poster session on the Internet entitled “PosterNet.” When PosterNet is operational, computer users will be able to register from any location in the world at no charge to add a poster to the session, gain access to a poster, make comments about a poster to which the authors can respond, and read the previous comments of other viewers and responses from the authors. Although the current demonstration contains posters that were presented previously at a scientific meeting, we anticipate that investigators may place on PosterNet posters that have not been presented previously.
We believe that the editors should consider presentations at a virtual meeting on the Internet that requires registration by participants to be like presentations at any other meeting. We also believe that the editors should not consider posters such as those currently demonstrated on PosterNet to be “manuscripts” or to be “prior publications.” Such a policy will preserve the advantages of peer-reviewed publication without placing unwieldy and potentially chilling restrictions on communications among investigators.
1 ReferencesJerry D. Gardner, M.D.
Rick A. Barbarash, Pharm.D.
Saint Louis University Health Science Center, St. Louis, MO 631041
Angell M ,Kassirer JP . The Ingelfinger rule revisited. N Engl J Med 1991;325:1371-1373
Full Text | Web of Science | Medline
To the Editor:
We laud your message and share your view that posting a manuscript on a publicly available Internet host computer qualifies as prior publication. Implicit in your message is acceptance of the Internet as a venue for publication of original manuscripts, a step we feel to be inevitable.1 What particularly intrigued us, however, was the statement “medicine is not physics.” This statement aptly summarizes our first-hand experience in establishing a cancer-information resource on the Internet. We discovered that Internet publishing tests the fine line between free speech, academic freedom, and responsible dissemination of clinically relevant information.
We were surprised to be confronted by such challenges when we introduced an Internet-based resource for cancer information (http://www.oncolink.upenn.edu/) last year. A dispute ensued with the medical physicist who helped us launch the service and edit its contents. The issue was whether to post any manuscript without review or to mandate a review process. The physicist vehemently refused to agree to prior review, citing academic freedom and free speech as his reasons. The dispute was taken to a higher level within our university and culminated in the reaffirmation of the review process.
Subsequently, we received strongly negative reactions. Many electronic-mail messages took the physicist's position, favoring the open posting of manuscripts. The story found its way into the lay press,2 and there, too, the tone was negative. Few nonmedical Internet users acknowledged the need for our cautious approach.
We relate these events for two reasons. First, we anticipate that others in our profession may find themselves in a similar position, especially given the relative novelty of the Internet as a means of distributing medical information. Indeed, within a day of the publication of your editorial, your views were sharply criticized by Internet users on public Internet bulletin boards.
Second, the risks involved in distributing medical information over the Internet may be obvious to physicians but not to others. The Internet has traditionally provided a venue for “open” communications, where ideas, no matter how far-fetched, have been shared. Medicine is not well suited to this, and those outside the medical profession may object to our traditional peer-review mechanisms. The Internet should not be used as a means of circumventing such processes. We are advocating responsible distribution of medical information, not censorship.
2 ReferencesJoel W. Goldwein, M.D.
Ivor Benjamin, M.D.
University of Pennsylvania Medical Center, Philadelphia, PA 19104-42831
Goldwein JW ,Benjamin I . Internet-based medical information: time to take charge. Ann Intern Med 1995;123:152-153
Web of Science | Medline2
Goodman H. Power struggle cuts Penn's on-line cancer link. Philadelphia Inquirer. December 14, 1994:1.
To the Editor:
We agree with the conclusions you and Dr. Angell drew in your editorial. One year ago, we created Asmanet, an electronic forum for physicians interested in asthma. Our experience is still limited, but we would like to share an example.
Some weeks ago, a woman was hospitalized with a pneumonia due to dapsone, which had been prescribed for urticaria. It was the first time such a case had been encountered. We sent a description of the case to the members of Asmanet — a limited number of colleagues but many more than a dozen or two. Within 24 hours we received interesting reactions from experts, as well as references.
Asmanet is a moderated forum; that is, we have editorial responsibility for its contents. In our opinion, exchanging such case reports on the Net would increase information available to professionals. The Internet could be a fantastic tool, but Asmanet or any other forum on the Net will not replace peer-reviewed journals. Yet it will add something new.
Philippe Godard
Michel Godard
Hôpital Universitaire Arnaud de Villeneuve, 34295 Montpellier, FranceTo the Editor:
Your interesting discussion relates that “physicists” have long circulated preprints by electronic mail. There exists a wide range of fields or cultures in physics — physics is not monolithic (any more, one supposes, than is medicine). This January, at the American Physical Society Units meeting (composed of representatives of each of the units of the society), the electronic circulation of papers was discussed at some length. Before the advent of the Internet, it was not uncommon for large physics groups to send out several hundred copies of their papers before publication. Opinions expressed at the meeting ranged from those of the Los Alamos people (typically high-energy physicists) espousing free Internet circulation of papers, and hinting that referees are redundant, to those of many who think as do you and Dr. Angell and the Journal.
Your editorial states, “But medicine is not physics.” Surely physicians and physicists share, in addition to the original meaning of the names, an overwhelming desire to present their work as accurately as is humanly possible, including discussions of known limitations in their work. To this end, the peer-review system has evolved; it can certainly be improved upon, yet it is an essential part of the modern scientific method. For, in effect, all papers are equal, but some are more equal than others. It is these latter, which have the imprimatur and imprint of careful and rigorous reviewing, that will have the greatest weight and impact by far.
As an end user of medicine, I appreciate that medical research has a social responsibility to get it right. I would personally feel more comfortable if all research were done as well as possible, whatever its (often unforeseen) ultimate use. So, I suspect (and hope) that good people will still give the most attention to rigorously refereed work, be it presented to them by any of the solid-state methods in use — computer-monitor screen, optical compact disc, magnetic floppy disc — or the printed page.
Leonard Finegold
Drexel University, Philadelphia, PA 19104To the Editor:
You and Dr. Angell present a limited and somewhat pessimistic view of the relation between medical journals and the emerging electronic resources of the Internet and World Wide Web. To be sure, the current hodgepodge of unedited hypotheses, comments, and conjecture found at most medical Web sites cannot serve as a basis for informed clinical decision making. To reject the medium because of its content, however, is unwarranted.
If we agree that the method of peer review best ensures the quality and importance of published material, then the key issue becomes how to translate that process to the Internet. Ideally, if the most respected journals were to convert to primary electronic publishing, several benefits would accrue. First, the enormous savings from eliminating the costs of printing, shipping, and delivering the physical mass of the journal would allow lower costs per issue, decreased environmental impact, and decreased storage-space requirements. Subscribers would pay for the service of peer review in a more direct fashion. As more journals come on-line, the ability to access directly an article's references (or the author himself or herself) would allow a more critical reading of the literature, complete with the opportunity for direct response.
Because of the exponential accumulation of information, we are ever more dependent on the prudent editing and manuscript review that the Journal offers. Nevertheless, we would be imprudent to ignore the numerous advantages of converting to a primary electronic medium.
Michael Pignone, M.D.
University of California, San Francisco, San Francisco, CA 94143Author/Editor Response
The editors reply:
We believe that peer review is essential to maintaining the quality of the information that journals provide, and our policy is designed to preserve the integrity of this process. Because they appreciate that posters and abstracts presented at medical meetings are preliminary, most physicians wait until a report has been subjected to peer review and published before deciding about its applicability to their practices. If abstracts, posters, or preprints were made available on the Internet, they could be seen by anyone, as Dr. Watson points out. although people misinterpret medical information now, as Dr. Wiviott states, the amount of such information available could be multiplied infinitely if the Internet were used for preliminary reports. We think it likely that the public would end up more confused than ever.
We have always been willing to review manuscripts that had been presented first at medical meetings, but we have asked authors not to submit their figures and tables to reporters, so that peer review could take its course.1 Like preprints, any poster incorporated into a host computer with free access by anyone on the Internet (such as those on PosterNet) will be considered previously published, and we will not review for publication any manuscripts based on such posters. Because figures and tables are a necessary ingredient of posters in published CD-ROM collections, manuscripts based on the data in these collections will also be excluded from review.
Although experience with World Wide Web sites and Usenet groups is fragmentary, the Oncolink and Asmanet experiences illustrate some of the issues that have been anticipated for the time when medical care is adapted to an electronic medium.2 As Drs. Goldwein and Benjamin learned and as our June 22 editorial pointed out, attitudes toward information differ considerably among scientists in different domains and — as Mr. Finegold reports — even within those domains. The Asmanet experience shows that rapid communication among cadres of practitioners can have considerable promise; nevertheless, the particular case related by Godard and Godard only suggests the hypothesis that the drug and pneumonia are causally related, nothing more.
We have no quarrel with the point made by Dr. Wiviott and Dr. Pignone that peer review can be implemented entirely electronically and that manuscripts that have undergone peer review and been accepted for publication could be released rapidly by electronic means. Although the number of papers for which the immediate health of the public requires such rapid dissemination is small, it is only a matter of time before many journals will be able to publish such papers electronically immediately after acceptance and final editing.
Finally, we did not claim that a recipient could change the content of information downloaded from the Internet (though a clever hacker undoubtedly could), only that the person who submitted the document to a file server could replace it with a different draft.
2 ReferencesJerome P. Kassirer, M.D.
Marcia Angell, M.D.1
Angell M ,Kassirer JP . The Ingelfinger rule revisited. N Engl J Med 1991;325:1371-1373
Full Text | Web of Science | Medline2
Kassirer JP . The next transformation in the delivery of health care. N Engl J Med 1995;332:52-54
Full Text | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Angel A. Hernandez-Borges, Pablo Macias-Cervi, M. Asuncion Gaspar-Guardado, M. Luisa Torres-Alvarez de Arcaya, Ana Ruiz-Rabaza, Carlos Ormazabal-Ramos. (1999) Assessing the Relative Quality of Anesthesiology and Critical Care Medicine Internet Mailing Lists. Anesthesia & Analgesia 89:2, 520-525
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