Professor of Medicine, University of California, San Diego

Reforming Scientific and Medical Publishing Via the Internet

I am optimistic that the ascendance of open access postings of articles to the internet will transform scientific and medical publishing; and that a number of profound problems—some particular to medical publishing—will be assuaged as a result.

Currently, it can be impossible to gauge the true balance of risks and benefits of medical treatments from a reading of the literature. Frighteningly, this is true too for those doctors who ground their clinical decisions upon a reading of it. I will review some aspects of the problem; and then relay grounds for possible optimism.

First, as is probably true in all fields, bias occurs in favor of existing orthodoxy. This is arguably more troubling in medicine since the orthodoxy is in turn influenced, as has been learned, by the profusion of articles favorable to their products that are ghostwritten by the pharmaceutical industry, or by the for-profit MECCs (Medical Education and Communication Companies) that industry hires for this purpose. These companies in turn pay physicians and pharmacists—including favorably disposed "thought leaders" whom they seek to succor —to be the listed authors, extinguishing any appearance of connection to industry for the favorable views propounded. This provides the appearance that many independent parties are in agreement in their favorable representations of the evidence. Crisply said, advertising is published as though it were science.

These problems are exacerbated by bias arising from direct conflict of interest. Conflict of interest is endemic in medical research; and articles about a class of drug have been shown to be dramatically more likely to be favorable when authored by persons with ties to industry than when authored by persons without such conflicts. Conflicts for authors thus appear to foster submission of industry-favorable articles. Conflicts for reviewers may also foster rejection of industry-unfavorable ones. (As elsewhere, reviewers are drawn from the pool of authors.) Moreover, reviewers are seldom tasked to disclose conflicts, and they remain anonymous, precluding repercussions for biased reviews.

These factors are aggravated, possibly dwarfed, by pharmaceutical company influence on medical publishing—further aligning medical publishing with medical advertising. Medical journals are not the independent arbiters of article quality one might wish. They are businesses and derive their revenue from pharmaceutical company advertising, and from sales to industry of glossy reprints of industry-favorable articles, at inflated prices. For some medical journals, profits reportedly number in the millions, providing high stakes.

At least three former Editors in Chief of major US and British medical journals have penned books decrying the inimical impact of industry influence on medicine. One has to ask why, in medical journals, advertising is accepted (just because it is available for the taking); and whether the journal's bottom line is a proper consideration in dictating what is published, in settings where lives are on the line.

So, whence the optimism? One means to propel optimism is to suggest a tactic that might enable its fruition. Briefly, I suggest that papers be published on the Internet, reviews be submitted by named reviewers; and that others rate (and review) the reviews. Both papers and reviewers receive ratings that are updated on an ongoing basis. While this won't protect against biased submissions, it will protect against biased rejections—and at least enable a voice for original or contrary perspectives.

It is probable that more bad science will be released. However the system provides a means for improving poor quality work; and avoiding having to view what remains substandard.

More importantly, more good science may be published—and perhaps, more great science. As Nobelist Sydney Brenner (who famously authored an article entitled "Moron peer review") has observed, many of his co-Nobelists' prize winning work was initially rejected through the review process.

Transformative work by its nature may defy conventional wisdom. One might be drawn to wonder: is there other work that would have revolutionized science and merited a Prize, that languishes unpublished? And that does so because authors at some point ceased to persevere in submission efforts after some number of rejections, or finally deemed the effort to publish futile?

Hark back to the many great discoveries of which we have heard that were initially ridiculed: H. pylori as a contributor to ulcers; handwashing as a means to reduce puerperal fever; the sun as the center around which the earth revolves, to name a few. What might this imply for the possibility that major discoveries may be pilloried into nonpublication by peer review? There is no means to estimate the fraction of Nobel-caliber efforts that achieve publication, as the denominator remains unknowable.

Indeed, the benefits of a new, Internet-based approach may be particularly great for the most important work: work that challenges existing orthodoxy; work that defines a new field and fits no existing journal; work that crosses boundaries to other disciplines—with their own often arbitrary conventions and in-groups; or that demands knowledge from two or more disciplines; science that is ahead of its time, that entails many advances at once or that founds new work on an understanding of relevant material that others do not yet have. Or, too, work that runs counter to vested interest groups—particularly but hardly exclusively in the arena of medicine, where the potent impact of industry influence on information has been the subject of increasing alarm—and where disparities between literature and truth may cost patients' lives.

An instance from mathematics supports the premise that current convention, requiring articles to be published in peer-reviewed journal venues, may inhibit promulgation of at least some of the very most important work. The Poincaré conjecture—a holy grail in mathematics—was recently proved by a Russian mathematician who posted his work on the Internet but refused the bother of submitting his work to a journal. Other cases can be adduced favoring the proposition that some among persons capable of propelling major advances—which often entails rejecting conventions in science—are also constitutionally inclined to reject the conventions, petty obstacles and distractions that attend the current model of scientific publishing. And perhaps they do so with justifiable contempt.

Surely many will defend the current system—not least those who fare well within it, and who benefit disproportionately from it. And surely there will be problems to overcome in the new system. Orthodoxy, in-groups, and interest groups will continue to influence the literature. Those who serve these masters will likely submit negative reviews of articles (and of reviewers) who do not toe the respective party lines. But at least now the contrarian positions will achieve release, reviewers can be held accountable for biased reviews, and unacknowledged conflicts can be exposed in instances when others know of them.

In short, I am optimistic that online publishing, with a review-the-reviewer system akin to that proposed here, will provide more voice and venue for science that may now have the highest need—and the lowest prospect—of being aired.