Why do we publish? As the editor-in-chief of a medical journal, I struggle a lot with this question. After more than 200 years, peer-reviewed journals have clearly established themselves as medicine’s best arbitrator of truth. They are, or at least ideally should be, at the center of everything we practice in our clinics. Yet somehow we physicians, even those of us in academia, are blind to many of the important roles that journals serve in medicine today.
Within academia, where most of the heavy lifting is done inside many medical journals, the prevailing view is that peer-reviewed journals exist to validate and curate cutting-edge clinical science – often the very science generated by fellow academics. This function is indisputable. Nowadays no significant drug or medical procedure enters the mainstream of medical practice without having passed under the critical lens of the NEJM, Lancet, JAMA or any of another 100 “high impact” journals. These journals contain the most groundbreaking randomized trials that generate so much attention within medicine’s ranks, and even sometimes the mainstream media. Yet ultimately this societal function explains only a modest portion of all the articles published in a universe of thousands of other journals. To many high priests of medical academia, these “other” journals represent a toxic stew of vanity, misleading anecdotes and second rate thinking, all of which pollutes “their” otherwise pristine science. Is that truly the case, and if so, why then is so much time and effort expended to fill so many pages of so many journals that ultimately serve no purpose, or even worse, just leads to a misunderstanding of the important medical literature?
Having personally lived the vast majority of my scholarly life in “low impact” journals, I believe the prevailing viewpoint of academia too often chokes on its sense of self-importance. The vast majority of clinical practice, especially in the surgical specialties, does not lend itself to the structured scientific trials that find their way into major journals. Most of what physicians do every day (I refer to it as “small science”) is grounded in art and nuance. Still, before it can be generally accepted, there is an important need to examine even art critically, and ideally without bias, which is ultimately the only important function of peer review. Meanwhile in the enormous and fast-changing world of medical publications, review articles serve a very significant educational function. In my field of surgery, technical reports, having passed a measure of peer review, provide a basis for evolving one’s surgical technique. Moreover, I particularly enjoy reading “unoriginal” peer-reviewed articles that merely validate the findings of earlier publications. After all, isn’t replication at the heart of science? Even the lowly peer-reviewed case report, the object of so much academic derision, serves a valuable function; there has probably never been a significant medical breakthrough that did not begin as a simple anecdotal clinical observation published in some “low impact” journal. Now for a scary thought: could it be that as we go deeper into a world of precision medicine, the only truly valid clinical study will be N=1 case reports? We hear a constant lament that negative studies fail to get published and this is true. However this should not come as a surprise when academia and high impact journals give so little respect to anything other than big expensive weighty studies.
So why do we publish? We as physicians publish in all journals simply to communicate with one another in the most rigorous manner possible. Given the life and death importance of our work, peer review functions as that little extra, unique check and balance on the stories we tell before they enter the mainstream of our discourse. In an artful endeavor like medicine, absolute truths are few and far between. Therefore we physicians are compelled to perpetually chase ever-elusive sets of truths, and as we do, ALL peer-reviewed medical journals stand ready to serve.