A Conversation with Dr. George Lundberg, Special Advisor to Cureus

Dr. George LundbergCureus: You’ve spent time as Editor-in-Chief of JAMA as well as a host of other academic journals. What are your thoughts on the current state of medical journal publishing?

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.

We’re extending the deadline for competition articles!

Good news for all the innovative neurosurgeons out there! Summer is a busy time of year - with holidays, vacations, the new residency year, and the long hours demanded by the neurosurgery profession, we know that your time is scarce. That’s why we’ve elected to extend the entry deadline for our Intraoperative Fluorescence Publishing Competition!

We’ve had more than a few potential authors express concern regarding their ability to submit research before July 28th. After considering their requests, as well as the effects an extension would have on the competition, we’ve decided to push the article submission deadline back to Monday, July 28th. That’s a whole extra month to gather your research, write your article and submit it to Cureus. All of the upcoming dates are listed below:

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As a reminder, you can visit the competition page to find out more about the competition. Questions? Just leave a comment below or email us at info@cureus.com and we’ll get back to you right away. We can’t wait to see all the exciting new research submitted over the next six weeks. Good luck!

 

Cureus Team Building: Crawfishing in Pescadero Creek

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9S2A5710Our team has been hard at work creating the best possible experience for the Cureus community, and while hard work is its own reward, we were lucky enough to escape the office recently for a day of good old-fashioned team building. How did the fine folks at Cureus elect to spend the day? Hunting for crayfish (aka crawfish aka crawdads) of course!

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The gang packed up nets, bacon (for bait!) and picnic lunches before heading down the coast to Pescadero, California. Home to the appropriately-named Pescadero Creek, Pescadero is a wonderfully secluded and picturesque town just a few short miles from the Pacific coast. It was here, along the muddy banks of the Pescadero Creek, that the Cureus team went to work, baiting and trapping crawfish with the same verve and zeal normally reserved for design, development and customer support.

IMG_7151Utilizing skilled techniques passed down through generations of Barrettos (Chris Barretto, Cureus VP of Engineering), we set bait with mouthwatering raw bacon and proceeded to wait, and wait, and wait and finally poke and prod the delightfully plentiful crawfish into our awaiting nets. It was messy business, and there were more than a few cuts, spills and even one unfortunate crawfish attack, resulting in a well-deserved wound to the finger. But just as with web design and editorial duties, these trials eventually gave way to well-earned rewards. The final tally? 55 crawfish, 8 dirty but happy Cureus team members and 1 very nice dinner

IMG_7150The team made it back to work the next day, all in one piece and now the march continues as we work to bring you the very best medical journal on the web. We’re very excited about our recent channels and competition, and we’ll be ready to announce new features very soon. Thanks again for your continued support. Don’t forget to contact us with suggestions, criticism and the like!

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The Cureus Team toasts to a job well done before sitting down to enjoy the day’s catch.

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Crawfish!

Does Peer Review = Better Science?

It is widely assumed that the peer review process improves the article that is eventually published. This concept is taken largely as an article of faith except for one miniscule question posed to a range of published international academics as part of a large survey in 2009; in this survey, 91% of respondents, none of whom were medical professionals, agreed with the idea that the revisions made to their article as a result of the conventional peer review process improved the end product. Of note, most of this subjective sense of manuscript improvement was felt by authors to be within the discussion section. The response to this one question represents the only evidence of which I am aware that demonstrates peer review resulting in better published papers.

Obviously one cannot simply dismiss the findings in the above study out of hand. However, it seems to be worth asking whether or not peer review has the same advantages outlined in the above survey when considered in the rich world of observational studies that describes so much of medical publishing. Moreover, is an improvement in a article’s discussion section significant enough to warrant all the added time and effort on the part of the very busy physician authors who write most medical articles and who represent some of the busiest individuals on our planet?

As an editor of a journal myself (Cureus) I cannot help but ask these questions. I also pose this line of inquiry now, however, due to a recent discussion with a colleague who is a very senior and internationally respected neurosurgeon. He is about to publish an article in a well-known neurosurgery journal having now jumped through the usual reviewer hoops requiring several revisions and months of effort. I asked this colleague whether his article was any better after all this effort. His simple response: “NO!” In fact, in my own academic career, which involves more than 150 peer-reviewed articles, I find it difficult to recall a single instance where I felt the final published article was meaningfully improved through the peer review process.

Oh, I jumped through plenty of hoops, like routinely needing to add additional references so that my paper would cite the reviewer’s own publications, but sadly I have found far too much of the peer review process to be merely an exercise in power and vanity. With so many diseases so poorly treated, and so much clinical research that needs to (or could) be published, is all this inefficiency justifiable? It is for this very reason that we at Cureus emphasize a much more efficient post-publication “peer review” process, or as we term it, SIQ (Scholarly Impact Quotient). I would very much like to hear from any readers of this blog who have published in conventional peer-reviewed journals  - did the review  process improve the ultimate published article?

Finding a Doctor

Finding the right doctor is a challenge for everyone. Believe it or not, even physicians are challenged.

I love to ask all types of patients and referring doctors how they go about finding a good doctor. After a confused stare and a lot of stammering I get a series of answers. In the case of physicians making a referral it generally boils down to the old tried and true three “A’s”: “Available,” “Affable” and “Ability.” I am embarrassed to acknowledge that this little list describes the thoughts of referring doctors in DESCENDING order of importance! Although “ability” is often judged through the lens of medical education and any prior firsthand results that were witnessed, many (most?) times the final choice is dictated by vague rumors or even gossip. The only exception to this practice is when referring physicians have access to, and opt to actually read, outcome studies published by the potential specialist in question.

Ultimately, if there is a ground truth in the referral business, as exemplified when physicians themselves need a great doctor, the decision is based on peer-reviewed publications. It’s clear that subjecting one’s clinical outcomes to the peer review process remains society’s single best tool for revealing physician competency, and as medicine becomes more specialized, this is ever truer.

How do patients go about this same decision when trying to locate the right specialist for them? Sometimes the choice has, for better or worse, been removed by insurance plan networks or geographical constraints. However, when true life or death decision making is involved, there is oftentimes some flexibility within the system, and in such cases patients are much more determined to find excellence; if the risk of dying or ending up disabled at the hands of one doctor is 2-3X greater than another, only the most desperate or unsophisticated patients would ignore such knowledge. This notion is nice in theory, but where can a patient access such information? When it comes to finding the best doctor, the typical resources that patients can use to make their decision are little better than throwing darts at a dartboard!

Yes, patients can check to see if their physicians have been sued in the malpractice lottery or if the physician has complied with some mindless government-collected quality metrics. Yes, they can rely on rumors, innuendo, ZocDoc, Angie’s list, glossy advertising pages in airline magazines etc., however, do any of these measures reflect the type of competency that truly matters when selecting a doctor, the consequences of which involve life and death? Not from my perspective. In my opinion, the single best tool for assessing a specific doctor’s ability continues to be the same resource used by smart referring physicians: published, peer-reviewed outcome studies.

Historically, patients have not had access to the peer-reviewed medical literature. Fixing this situation is one of the primary rationales for Cureus’ existence. In the modern world of internet connectivity, I would think such validated health information should be a virtual human right. By the same token, I think the onus should be on ALL physicians to contribute to the medical literature, and in doing so, demonstrate their competency within a peer-reviewed environment. If you really are a good specialist, then prove it in some tangible way! Billboards, magazine ads, fancy brochures or websites, broadcast advertising and sundry PR campaigns are not evidence of your competence.

Once upon a time it was not easy to publish in the medical literature, but Cureus is doing its best to remove publication barriers to the greatest extent possible. Therefore, it is time that ALL physicians, (yes, including you guys in private practice), prove some of your skills through a validated process like publishing in journals. Going forward it will be my provocative advice to all patients in need of complex healthcare to trust no physician who has not demonstrated some competency within the peer-reviewed medical literature!! In turn I urge all physicians to use Cureus to demonstrate your hard-earned knowledge to the world, including the lessons imparted to you through patient complications, which will be the topic of a future blog by me.

The VA’s Revelation: No Surprise to the Physicians in the Trenches

In a classic movie line from Casablanca, the anything but naive Captain Renault proclaims “I’m shocked, shocked to find that gambling is going on in here”, shortly before being handed a wad of money (his winnings) by a casino worker.

And so when I hear politicians proclaim to be “shocked” about the atrocious treatment of veterans within the Veterans Affairs hospital system, my only response is that I am more than shocked that they are shocked! The type of care that has engendered such public and congressional outrage was the norm throughout my 7-year tour of duty as a staff neurosurgeon almost 2 decades ago inside a flagship VA hospital. With rare exception (spinal cord injury, rehab for brain trauma), patient care inside the VA system I knew, was totally second rate with customer service on par with the California Department of Vehicles. As a young and newly minted neurosurgeon, I yearned to practice the kind of high quality care I delivered as a resident, but the opposing bureaucratic forces within the VA system were omniscient. Throughout so much of my VA experience I felt like a sordid part of an uncaring bureaucracy and wanted more than anything else to move onto a better job, which in time is what happened. One particular event more than any now shapes my perspective of the VA.

Aspiring to be a young Turk neurosurgeon delivering state-of-the-art care for malignant brain tumors, I implemented, after a lot of sweat and tears, an immune therapy program inside my VA hospital, which at the time was quite an avant-garde approach to this dreadful disease. Despite some interesting preliminary results in a Phase 1 study, a few patients had problems with brain swelling. However, the VA hospital I was in had no equipment for monitoring intracranial pressure (ICP). To remedy this shortcoming I filed the appropriate paperwork to request an ICP monitoring device as part of the capital budget process. Despite a considerable effort my plea fell on deaf ears.

Months later, within a day of the government’s fiscal year being closed, I got a frantic call from the chief of staff’s office informing me that there were unspent funds in the VA system and I had a few hours to get my request for an ICP monitor into the system….which of course I did.  But to no avail, I did not get my device and I was forced to manage my patients much like a third world country neurosurgeon. The following year I again submitted my request through the capital budgeting process, and low and behold, when that failed again, I got a second panicked call in the whee hours of the fiscal year suggesting yet another hurried opportunity to procure the object of my desire before the VA funds disappeared into some fiscal black hole. Yet it was Deja vu all over again and the funds were never to come my way. Believe it or not this cycle repeated itself a third year, and soon I would be yet another three-time VA loser in the budget cycle.

Not long after this farce had ended, I found deliverance at the university mother ship. Now free of my VA purgatory, I felt only eternal gratitude. About a year later, while in the middle of an operation, my pager went off and I instructed the circulating nurse to answer it. With the phone put to my ear, I heard a voice on the line tell me he was the manager of the loading dock of the VA hospital and he had just received a shipment for me: a Camino ICP monitor.  Almost 10 years later I do wonder if my $30,000 unused monitor isn’t still sitting somewhere on that loading dock…..along with a long line of neglected military veterans.

Yes it is true that the recent “shocking” revelations about the VA system are almost 2 decades removed from my personal experience. As a simple physician in the trenches, I cannot say for sure how best to care for today’s military veterans. However my experience suggests that a radical decentralization might improve both morale and the quality of care.

Cureus Channels: A Window into Your Organization

It’s a new age for medicine, and for medical journals, too. The advent of many exciting, cutting-edge medical techniques is mirrored by the rise in popularity of online journals. While the traditional print journals are led by stalwarts such as New England Journal of Medicine, JAMA and Nature, the recent explosion of online journals makes it more difficult than ever to stick out from the crowd.

Perhaps you’re a physician or researcher who’s looking to publish your work; as anyone who’s published before knows, there are a multitude of factors that influence such a decision. What can the hundreds of different online journals do to convince you that they’re the right place to publish?

Cureus channels offer a wholly unique opportunity to medical schools, departments and professional societies that have opted not to produce a journal of their own. Creating a journal is an expensive and complicated endeavor; however, there are myriad benefits to having your group’s members published in the same place, perhaps covering the same general topic area.

Some groups will create their own journals, and for those societies with ample cash and an extensive queue of articles ready to be published, perhaps that’s the right choice. But what about everyone else? Maybe your school doesn’t have a few million dollars to spare, or maybe your society is a small, but growing group with a steadily increasing stream of articles.

SMISS Channel

The SMISS Channel

A Cureus channel could be the answer. Offering the chance to gather all of your school or society’s clinical and research activities in one place, a Cureus channel is a unique branded page that increases your visibility by assisting in clinical research publication and promotion to broad professional and patient communities. Cureus is currently hosting channels for the Canadian Association of Radiation Oncology, the International Pediatric Simulation Society, the Society for Minimally Invasive Spine Surgery, and ZEISS.

Each organization appoints a channel editor to oversee submissions and encourage fellow members to contribute, but the foundational editorial work is all handled by Cureus. Think of a channel as a window into your organization, a place to see what your colleagues or fellow students are up to, all while exchanging valuable research and information in your field of expertise. We’ve launched four channels so far, with several more on the way. Get in touch with us today if you’d like to explore whether or not a channel is right for you.