George: Medical journal publishing has been in a state of flux for as long as I have worked in the field – since about 1973. But the scope and rapidity of change has varied greatly, partly for reasons of science, often for reasons of politics and economics, and especially for reasons of technology. Medical journal publishing is currently voluminous, widespread, diverse, fluid, vibrant, unpredictable, and risky for owners, publishers, editors, authors, readers, advertisers and the general public. The three most important elements are trust, truth and access. Of course the “internet changed everything.” The for-profit medical publishers (which includes the not-for-profit medical organizations that are also publishers) resisted the open access opportunities provided by the internet as long as they could, because they wanted to keep the money flowing, and old-style paper publishing provided the surest way to continue profiting. But almost all medical publishers have adapted to using some forms of open access, often in hybrid models. Enlightened trust is in short supply, mostly depending on brand name identification. Endorsement by application of the www.icmje.org policies can help. Truth is illusory, with the shortcomings of the “peer review process” (the only real method available) being elucidated by evidence in studies presented at quadrennial “Peer Review Congresses.” Access to a deluge of medical information is freely available online. Quality is highly variable. Predatory publishing practices are common with both rogue and established publishers. What is the poor publisher, author and reader to do? “Caveant emptor, aeger, auctor, et lector.” All that, plus an old phrase, “there is always room at the top.”
Cureus: Your career has spanned multiple organizations, universities and medical journals – what can you tell the Cureus community about The Lundberg Institute?
George: We founded The Lundberg Institute (TLI) in 2009 as a 501c3 not-for-profit charity to promote decision making shared by patients and physicians. We secured a stellar Board of Directors and an equally stellar Advisory Board. The defining credo is: “One patient; one physician; one moment; one decision. Let it be a shared decision, informed by the best evidence and considering cost.” The principal activity of TLI has been to sponsor and present an annual lecture in collaboration with The Commonwealth Club of California in San Francisco each Fall in 2011, 2012 and 2013, with 2014 coming up.
Cureus: You were called a “medical internet pioneer” back in 1995. Now, nearly 20 years later, how do you see the current relationship between the internet and medicine?
George: Completely intertwined and likely to become more interdependent. There are 4 basic elements in the practice of medicine. Some physicians cut on people, we call them surgeons; some physicians shoot ray guns at people, we call them radiologists or imagers; some physicians administer various kinds of chemicals and poisons to people, we call them internists, pediatricians and oncologists. All the rest of medical practice is information: seeking, collecting, processing, analyzing, interpreting, dispensing, acting on and following up. Use of the internet is central to most of that information handling. Of course, the old, hardware-rich, enterprise-based legacy EMRs that are being forced upon American physicians, to their great dismay, will be replaced by cloud-based, nimble, interoperative, searchable, and intuitive EMR/EHRs that actually will aid rather than impede the efficient and safe practice of medicine.
Cureus: What was it about Cureus that made you want to lend your voice as a senior advisor?
George: The dynamic and enthusiastic founders, owners, publishers and editors of Cureus, and its potential future. Cureus strikes me as very much like Medscape was in 1999, a publishing platform and identity with a unique name, run by visionaries. Medscape was privately held, for profit, and enjoyed a successful IPO during the dotcom boom. It was then acquired by Medicalogic, endured the dotcom bust, and was acquired by WebMD, its current owner. We began Medscape General Medicine (MedGenMed) in 1999 as an experiment in open access publishing, testing whether it was possible to create and maintain a primary source, peer reviewed, exclusively electronic, general medical journal entirely open access. We achieved MedGenMed listing in Medline/PubMed in 2000. Later we secured inclusion in PubMedCentral and also changed the name to The Medscape Journal of Medicine. In 2009, WebMD declared the 10-year experiment a success and closed down the journal. Coincidently, and of special interest to me, 2009 was the year of beginning for Cureus.
Cureus: At Cureus, we’re seeking to create a more democratic interconnected community of physicians, and especially non-academics, where research and clinical experience can be more easily shared, dissected and discussed, but which is independent of a specific organization. What are your thoughts on the importance of group organizations/societies in medicine? Just how important are they to doctors when it comes time to connect with peers?
George: Medical societies/associations/academies exist to serve their members, to help them gain certain benefits. There are hundreds, even thousands, in virtually all countries. They form communities and attempt to “speak with one voice,” believing that there is strength in numbers. Steven Lock has pointed out that when a group of physicians in a common discipline and within a common geographic area reaches 500, it will form an organization. And, by the time it reached 1,000, it will found a medical periodical publication of some form, often a journal. Of course, these organizations may also develop many other kinds of programs and products, to serve a range of purposes and audiences. I have written extensively about the American Medical Association since 1982, as it struggles to try to be “all things to all people” and in the process, has evolved into a membership organization for only a small minority of American physicians.
Cureus: What are your hopes for the future of medical journals and how does Cureus come into play? N=1?
George: Medical communication is as important for physicians (and the public) as oxygen is to human existence. But it takes on increasingly varied forms. The very definition of a “medical journal” may have been placed in question by the abundant other methods of ready communication that are now available largely because of the internet. I believe that this is a battle of communication forms that will be fought out in the marketplace. I believe that the three essentials, trust, truth, and access, will be joined by branding, speed, quality, tradition, and a reward system for participants as key determinants as the battles are waged. The value systems of the principal participants as motivation and personal satisfaction will weigh heavily. Economics matters; there will always be costs and someone will have to pay them.
The Cureus enterprise as a publishing platform with variable content has a strong likelihood of success. With the assumption that the principal audience for “Cureus” as a “medical journal” is English-reading physicians in all countries, a “Cureus Journal of Medicine” would have its best chance of success by combining the use of “the best” policies and practices of traditional (paper and electronic) medical journals so as to attempt to gain trust and truth via accepted processes, with the best features of the internet, speed and free access, and by cultivating that vast array of previously unpublished practicing physicians who have something important to share with their millions of peers (all practicing and academic physicians), and all other interested users of the internet in open access. Post-publication peer review has always been the most important form. Early branding for trust could be done, in part, by name recognition of Cureus leaders. There has always been a place for publication of focused observations, even of one case. Indeed, several of the JAMA Centennial Landmark Articles were case reports. Within the new scientific paradigm of personalized medicine and precision oncology, prompt reporting of N of 1 observations will become paramount. Even more so, the N of 1 Case Report can become (with proper privacy rules and informed consent) an open access living medical journal (record), with the unique potential of advancing both scientific knowledge and rapid learning communities. A Cureus Journal of Medicine could do exactly that.
Cureus: Any other thoughts you would like to share?
George: Good luck. Your efforts are worthwhile. Knowledge gained by physicians should be shared with their colleagues; it is a Hippocratic imperative.
Cureus: Thanks for taking the time, George.
George: Thank you.