The Academy Awards of Medical Science

Last week a friend of mine told me about watching a notable old movie at a film festival entitled “Sergeant York.” Besides being a story about WWI and starring Gary Cooper, I can’t say I know much about this film other than one interesting fact; it was also nominated for the Best Picture Academy Award in 1941. Of note, it did not win, losing out to “How Green is My Valley.” Now before you start to worry about me running off on a tangent here, I’ll get to my point. Two other movies were also nominated, but lost out, for the 1941 Best Picture Academy Award: “The Maltese Falcon” and “Citizen Kane.” Now through the lens of hindsight is there almost anyone alive today who would truly believe that the Academy Award voting process got the decision right back in ‘41?

To my way of thinking such a question is directly relevant to the world of peer-reviewed medical publishing. How often have important ideas in medicine struggled to get published within contemporary leading journals, only to have such ideas be recognized as true genius after the passage of time? Two weeks ago, my friend and mentor Tom Fogarty was honored by his induction into the National Inventors Hall of Fame by none other than President Barak Obama. Tom was recognized especially for his invention of the Fogarty Balloon Catheter, which through another lens of history has proven to be one of the most important medical devices ever created. Clearly once upon a time the reviewers of the scientific article written by a young Tom Fogarty to report his new discovery must have recognized the genius of his invention, right? Not at all! Tom’s 1965 article reporting how and why his new catheter might work was rejected three times before ultimately being accepted. Even today, Tom has no idea why so many (supposedly) open-minded and wise reviewers rebuffed this important article.

I don’t for a second believe that Cureus reviewers are innately smarter, or politically less biased, than the reviewers who rejected the original Fogarty balloon catheter paper. The Cureus review and publication process, however, does not put reviewers in a position to choose what is important or unimportant medical science. As long as the article in question represents a good faith effort (following peer review) to apply reasonable scientific standards, and is neither fraudulent nor clinically dangerous, Cureus will publish your article for free with no questions asked!

Cureus believes that good ideas available to the broad court of scientific critique will invariably be discovered over time and serve to advance medical science – “the cream will generally rise to the top.” Meanwhile wrong-headed scientific ideas can and will be discredited. Very importantly, we at Cureus also believe that SIQ, our unique post-publication peer-review process, can, through the democratic power of the many, serve to discern real and enduring scientific quality over time, not unlike like the once overlooked masterpiece “Citizen Kane”. It is our fervent hope that at some point in the future, after the passage of enough time, when we look back at Cureus’ growing library of medical articles, we will see that our SIQ system can accurately foretell the inductees into the National Inventor Hall of Fame or, for that matter, the winners of medical science Academy Awards.

Please don’t forget that all Cureus readers are invited to cast their SIQ ballots after each and every article they read!

Does the Journal Make the Author or Does the Author Make the Journal?

Last week I attended a grand rounds lecture at a major medical school given by an internationally-renowned, chaired professor at the peak of his academic career. Through our personal relationship, I know he also happens to be a man of great integrity. Nevertheless, this professor presented data during his lecture that he tried to publish in three different specialty journals but was ultimately rejected. Why? We will never know. In fact, I equate the traditional peer review process to the game of water polo; during a water polo meet the real action occurs beneath the water’s surface. Undeterred, the professor in question commented in the middle of his talk that he would now publish his article in Cureus. At that instant, I, as proud Editor-in-Chief of Cureus, felt a little like the guy who realizes he is not the first, or even second, choice of the teen who asks a girl to the prom. However, I quickly consoled myself; if ultimately I get to go to the prom with a beautiful girl, then where is the downside to that?

In reflecting on the experience of the above professor, I fully acknowledge the right of any journal to choose what gets published through its peer review processes. Nevertheless, this reminds me of how inefficient the “game” is – there is so much human effort required to reformat, resubmit and re-review a article. Once published, will this article be better for having survived this process? I for one am deeply skeptical. Meanwhile, if an acclaimed and politically connected academic has such problems getting his articles published, one can only imagine the difficulties that a less accomplished and, god forbid, non-academic (or even developing country) physician has in getting their ideas into the ocean of pubic discourse at many journals.

We at Cureus like to continuously, and quite provocatively, question why the medical community-at-large subjects itself to such abuse. My answer: being innately insecure, we academics engage in such self-flagellation merely for the perceived status derived from seeing one’s ideas published in luxury journals (a term I am stealing from 2013 Nobel laureate Randy Schekman) as well as the sloth embodied by most university promotion committees, who by virtue of their intellectual laziness, have chosen to make tenure decisions through journal impact factor. In response to this, I urge more physician authors to let their ideas speak for themselves by publishing in Cureus, a journal in which the process of getting published has never been easier. After all, does the journal make the scientific article, or do scientific articles make the journal?

Comments from an Invited Reviewer: How Cureus is Different

Here at Cureus we take author and reviewer satisfaction very seriously. We strive to respond to all questions, comments and complaints as soon we can, often within just a few hours. If you’re familiar with the Cureus mission, you know that constructing a publication process devoid of politics (and supporting the increased transparency that comes with it) are our primary goals.
With that in mind, we’d like to share a recent exchange between an anonymous Cureus peer-reviewer unhappy with the amount of time he received to review an article.

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Reviewer: Less than a week for an academic neurosurgeon to provide a review? Hmmmm.

Cureus: I was forwarded your recent email lament about the review period ending on a paper to which you were recently invited to comment. I wanted to reach out to you by email to firstly, thank you for responding, and secondly to explain a little bit more how the Cureus review process is designed to work, which as you perhaps noted is quite different than traditional journals.

As an academic neurosurgeon myself, I am all too aware that sometimes it can be impossible to find the time to review a manuscript just because one is just too darn busy. That is a given!! What happens in traditional journals routinely is that such busy academics plan to review a paper but for a range of reasons never get around to it. Therefore, the editor in chief and staff of most journals spend most of their time (and journal money) chasing down reviewers and as a result the process of review can last for months in many cases. We at Cureus have tried to do something quite different in our review process. We invite a number of reviewers to review but we fully expect most to be too busy and decline. If anyone is busy, it is quite ok to decline, our Cureus editorial team totally understands. However, the expectation is that a few of the invited reviewers will have both the time and the interest to perform a timely review……in fact, we are eventually hoping to achieve a review cycle of just a few days.

While this review cycle is better than nearly all other medical journals, it should be noted that NEJM does offer a turn around time in a week for some selected topics so this objective is not totally beyond current trends at the most selective journals. By resetting expectations for reviews, Cureus hopes to avoid the many month review cycles that are commonplace with JNS or Neurosurgery for example. The beauty of a faster review cycle is that the reviewed article remains fresh in everyone’s mind so that a lot of time is not wasted reacquainting oneself (both author and reviewers) with the article and any reviewer comments that emanate with each review cycle. Moreover, Cureus’ in-browser reviewing tool makes it easier than ever for a reviewer to comment on a paper and communicate their critique directly to the author. In the process hopefully everyone wins. The ultimate objective is to accelerate the process of publishing/documenting medical science, which I believe to be a net positive.

Clearly your first interaction with Cureus was less than ideal. I am hoping that after my explanation here you might give Cureus another try? In particular I would love you to perhaps even consider publishing your own article in our totally FREE open access journal, an experience first hand how a faster/easier review process can even make publishing peer reviewed papers FUN!!  I note that you are a DBS guy and by virtue of such you clearly must be comfortable with new ideas and technology. As Cureus seeks to innovate in the medical journal space, we especially welcome early adopters like yourself.

I am happy to answer any further questions should you have any or address any other concerns your might have.

Reviewer: Many thanks for your email and clarification. I do agree that the review process is often too lengthy, especially with the journals you mention. Sadly, even with the best will in the world, the pressures of clinical work and other academic deadlines do not make it feasible for me to provide a thorough review on a paper within a week of receiving the request.

That said, now that I understand the philosophy behind the Cureus review process and I do like the idea. It is a clean and workable solution, but I fear it may work against the clinical scientist, especially in the surgical field where time is more limited.

I do find publishing fun … especially the debate with constructive reviewers. I will think of Cureus if I have any suitable material in the coming months.

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A fair argument? What do you think?

Hear From the Co-Founder: Dr. Alexander Muacevic

alexander-muacevic_01Cureus: Tell us about your background – how did you decide to pursue a career in medicine? How did you settle on brain surgery?

Alex: I started my medical career at the University of Mainz and did my doctoral on surgical strategies for multiple intracranial aneurysms. I was always fascinated by the option to work at the very central part of human beings – the brain. I got the chance to participate in one of the best neurosurgery programs in our country at the University of Munich Hospitals and finished the residency program there in 2003.

Cureus: You’ve also worked as the Director of the European Cyberknife Center in Munich for the past 9 years. How did you get involved with Cyberknife radiosurgery? What’s a typical day like for you at the Cyberknife Center?

During my residency program I got more acquainted with the possibilities of brain radiosurgery and it was obvious to me that this kind of non-invasive and equally effective therapy for certain tumors has a big future perspective. I did an additional two years of training in radiation oncology and teamed up with my partner Berndt Wowra who already was an experienced brain radiosurgeon. During that time we learned about the new radiosurgery innovation called Cyberknife and decided to found a new center together with the University of Munich Hospitals to offer this kind of treatment option for the first time in Germany. My ambition was and is to establish radiosurgery as a full body treatment method for the whole body, not only the brain.

Cureus: And as if that wasn’t enough, you’re also a professor at the University of Munich! What can you tell us about your professorial experiences over the years?

Alex: During my residency I worked on several research projects to do a thesis for an additional medical degree which is similar to the Ph.D. in the U.S.. Since I continued to publish scientific contributions after my thesis, the University of Munich appointed me a full professor in 2013. I was fortunate to receive this title as this is something you can not apply for yourself.

Cureus: How did you get involved with Cureus? What attracted you to the concept of an open-access, free-to-publish medical journal?

Alex: I’ve known John Adler for many years and we were both very involved in a medical society called The Radiosurgery Society. Initially our idea was to establish a medical journal for this society but when we started to work on it we came to the conclusion that there is urgent demand for a new way for medical publications to take on the web capabilities of the 21st century. We started with a small group and called our platform Peeremed.com. It was obvious that we needed to step up and find a more professional group to pursue our dreams of a real powerful web 2.0 journal plattform for the upcoming publishing generation. We had contacted several groups in Germany, but as all of the big web innovations nowadays come out of Silicon Valley we worked on establishing the new company – Cureus.com – in the San Francisco Bay Area.

Cureus: Not only are you a co-founder of Cureus, but you’re also the Co-Editor-in-Chief – what does that entail? Describe your daily editorial duties.

Alex: My job is to manage the articles from submission to final publication. I need to make sure they fulfill the criteria of a scientific contribution in terms of data quality, and also bureaucratic aspects like disclosures and conflict of interest. Furthermore I manage the review process with our team to achieve fast and high-quality reviews for our authors.

Cureus: Peer-reviewed medical science has grown increasingly political of late, with accusations of reviewer and editorial bias. What are your thoughts on this? Why is Cureus different?

Alex: Cureus offers the most unbiased possibility for publishing scientific data, as the decisions of how and what to publish remain up to the author. The author himself is responsible for his data, he keeps his copyright and is evaluated by the scientific community-at-large similar to ratings at YouTube or Amazon. This is a huge difference from the conventional publication process where two or three so-called insiders decide what is published or rejected – a very biased and inadequate way to evaluate the academic work of your fellow researchers.

Cureus: Thanks so much for taking the time!

Alex: Thank you.

Publication Bias: Who is to Blame?

Publication bias occurs when a study’s results influence its probability of publication. This has been acknowledged already in 1959 (1). An article this past week in Newsweek rightfully laments the impact of such publication bias on the public health.

The Newsweek article implicates big bad pharma as the primary culprit in this process. But is it? Logic and human nature would surely suggest that marketing departments inside big corporations, where money is the primary incentive, are unlikely to go out of their way to publicize the negative effects of their pharmaceuticals or medical device. Therefore, I get this argument and I don’t disagree. Meanwhile there are clear cases where a pharmaceutical company threw its considerable weight around to squash negative studies. A case in point being the much-ballyhooed instance that happened in the mid 1990s – Knoll Pharmaceuticals threatened legal action against UCSF when an investigator sought to publish a negative study. But where is the evidence that such behavior by pharma is common? The PLoS article cited by Newsweek only demonstrates that many clinical trials (roughly half) go unpublished. Since big bad pharma is as beholden to academia as academia is to big pharma, I find it more than a little disingenuous to ascribe all of the publication bias to a pharma conspiracy.

Having been personally involved in scientific publishing over almost three decades, and having seen two clinical studies go unpublished, I believe that the primary culprit behind publication bias lies with academia itself. Why? For starters, medical academia controls most scientific journals as well as the incentives for most of the scholarly publishing of clinical trials, hence the interdependence with pharma. Moreover, it is a reality that academic promotion is a primary motivation for publishing journal articles. In this regard, a young academic scores few points in the chase for tenure by publishing negative studies, which just aren’t sexy in the eyes of promotion committees. Meanwhile, negative studies don’t score many points in the impact factor game played by so many big name “luxury” journals whose cachet is highly coveted by academic promotion committees. Given academia’s near stranglehold on both authors and journals, there are no incented physicians left to publish negative studies, hence the publication bias we all decry.

Meanwhile when it comes to publishing any scientific article, medical journals themselves have created ever-burgeoning barriers involving cost, process and time. The reality is that in a world where the rewards are so small, or in truth non-existent, it is just too painful for many physicians to publish any number of societally high-value observations such as negative studies. For example, look at the academic and journalistic bias (including PLoS) against case reports, arguably the only instance of publishing pure truth devoid of underpowered studies, misleading statistics and heterogeneous patient populations. So ultimately I argue that the same powers-to-be that bemoan the lack of more publishing are the very source of the problem, and active steps to mitigate publication bias across the academic literature are needed. Cureus, with its streamlined process for scientific publication, is quite happy to help remedy the challenge of publication bias!

  1. Sterling TD. Publication decision and their possible effects on interference drawn from tests of significance – or vice versa. J Am Stat Assoc 1959;54:30-34.

ZEISS/Cureus Competition Spotlight: 3rd Place Article

ZEISS recently partnered with Cureus to host a publishing competition focused on microscope-integrated intraoperative fluorescence. The competition attracted articles submitted from all over the world, with the final field of published articles standing at 10. While prizes have already been awarded, we wanted to take some time to recognize a few of the highest-scoring articles.

Today we’ll take a look at the 3rd place article, “Indocyanine Green Videoangiography and Intraoperative Catheter Digital Subtraction Angiography in the Treatment of Intracranial Aneurysms: A Consecutive Series of 235 Cases,” written by Archie Defillo, Mushtaq Qureshi and Eric Nussbaum. Receiving an SIQ score of 6.9, this deserving article could’ve easily finished in either of the top two spots.

Cureus Editor-in-Chief Dr. John Adler was impressed with the scope of the article, focusing on the fact that “this article represents one of the largest published clinical series reporting experience with intraoperative fluorescence microscopy.”

Co-Editor-in-Chief Dr. Alexander Muacevic was also pleased with the article: “Large patient series of Indocyanine Green Videoangiography and Intraoperative Catheter Digital Subtraction Angiography in the treatment of intracranial aneurysms with distinct results and suggestions for the daily clinical praxis. Interesting to read for all neurovascular surgeons.”

Perhaps the size of this study is a sign that we’ll soon see larger and larger undertakings in the research and reporting of intraoperative fluorescence. That’s it for our coverage of the ZEISS/Cureus Intraoperative Fluorescence Publishing Competition. You can find the complete list of published articles here. Contact us at info@cureus.com to learn more about hosting your own competition!

Ebola Wars

What’s it like right now to be on the front lines of treating Ebola victims in West Africa, or in the past few weeks, even here in the US? Given that this battle might be waged in my community tomorrow, it would be nice to know that we healthcare providers are getting smarter in humanity’s tectonic battle. The traditional peer-reviewed journals do a credible job of publishing the major studies for a disease like Ebola, even on an accelerated basis; in fact when it comes to hot subjects like Ebola, such journals cannot publish fast enough. It may well be, however, that this disease is not defeated by a big scientific breakthroughs or insights, but rather myriad little things. In fact that is the kind of stuff I want to learn about; which detailed little steps in terms of containment, infection control, tracing of contacts etc. seem to be working against this disease and which are not?

Clearly something wasn’t working correctly when two nurses caring for the first Ebola patient in the U.S. contracted the disease! Over the past week I have certainly received my daily dose of The New York Times and NBC TV reporting about what went wrong, however, I would like to read about the subject after it has been vetted by medical professionals via the peer review process. What, if anything, did the infectious disease unit, ICU or any other staff at Dallas Presbyterian learn in the past 2 weeks? It seems impossible to believe that absolutely nothing has been learned. Even if expert analysis of the problem is incomplete, they probably have some working hypotheses. Is training an issue? Are the wrong gowns being used? What about facial splash shields? There are dozens and dozens of small things being practiced by the medical teams caring for Ebola patients, some of which worked and some which might not have, yet for most of us, the best source of info is, frustratingly enough, the news media.

Clearly my “ask” will find its share of critics. It is rightfully argued that incomplete knowledge is misleading and potentially dangerous if misinterpreted. If the physicians on the front lines of the Ebola fight arrive at incorrect conclusions as a result of a rushed analysis and this information is passed on to the medical community via journals, patients could die. But such a paternalistic critique assumes that the physicians and nurses reading the early lessons of this war are incapable of understanding that such observations are preliminary. How can it not be better to learn from experienced healthcare providers via medical journals than it is to rely on mass media or alternatively, know nothing?

The current approach to disseminating knowledge about the Ebola fight seems to be through panels of “experts” like the CDC or Doctors without Borders or other Federal and State government organizations. This method of establishing protocols is, in an emergency, clearly necessary and needs to be done. Anyone who has ever participated on such committees, however, will tell you that political considerations invariably color recommendations, especially when quality information is scant. For this reason I believe that rapid communication via the peer-reviewed publication process can supplement expert guidelines and keep the “expert” community from straying into all too common political minefields. Moreover, even experts can wrongly interpret some procedure as being inconsequential when in fact it is the key to success. When it comes to publishing seemingly trivial information about a scary and fast moving disease like Ebola, I say simply, “bring it on.”

What if the secret to controlling Ebola is a specific technique for cleaning bedpans? And what if some low ranking nurse has stumbled upon the answer about how to do it right? What if, unsurprisingly, the big government experts are oblivious to this nurse’s unique insight? It might well take 100 years before such unglamorous information was to make it into Lancet or NEJM; there are just so many barriers to vetting and communicating this type of idea in the conventional medical journal world. It is into this void that Cureus would like to boldly step. In the Cureus world of publishing no medical idea submitted in scientific good faith is too humble to be vetted and rapidly and widely communicated through the peer review process. So I say, if clean bedpans could be the answer to eradicating Ebola, let’s hear your story. And once it is published, I trust the wider court of medical expertise will be there to either vet or discredit your idea through Cureus’ SIQ process. A great idea, no matter how humble the origins, is a terrible thing to waste during an epidemic like Ebola.

Although I am far away from the front lines of Ebola, I have been in the trenches of publishing in peer-reviewed medical journals for almost 30 years and I am doubtful that all important information is being documented at the rate at which it’s learned. Nevertheless, since I am not an infectious disease expert nor on the front lines of the current epidemic, I’d love to hear what experienced (with Ebola) physicians think about the hypothesis I have put forward here.