The Value of “Small Science”

“Let me tell you about an interesting case.”

“I’m having trouble with a patient, can I get some advice?”

“Help, my patient is dying on me and I cannot for the life of me figure out what’s wrong.”

“While caring for this patient, I learned something kind of cool last week.”

Have you or a colleague uttered such things in the past few days, weeks or months? Throughout my own clinical practice in an academic setting these types of utterances happened on a daily basis, if not many times a day, albeit sometimes merely under my own breath.

It is a fact that we physicians, even the smartest among us, still have a lot to learn, and vice versa, have a lot to teach through such experiences. Our clinical practices are sometimes influenced (usually for the better) by prominent, well-funded, randomized clinical trials, but more often it is the humble practical knowledge learned from one another that separates the satisfactory from the great physician. In my chosen specialty of neurosurgery, I have observed that there is not two or three bits of knowledge that make for a great operation. Instead the best surgeons have a grab bag of literally thousands of largely undocumented tricks (patient selection, choice of instrument, anatomical insights, manual skills, techniques, etc.), which make for their success. Much of this knowledge continues to get acquired the old fashion way – via trial and error in the trenches of medicine. Amazingly, in a world of more than 5,000 medical journals we all too often find ourselves repeating one another’s mistakes and relearning lessons previously learned by others. Why is this?

I believe that the above situation stems in part from a medicine-wide failure to formally acknowledge the true value of practical knowledge, or what we at Cureus like to refer to as “small science.” In many ways this is illustrated by how most medical journals see their mission, especially those with a coveted high impact factor. For example, the Instructions for Authors section in JAMA is almost half the length (in words) of Joseph Conrad’s the Heart of Darkness. Filled with complex guidelines for statistical processes and data reporting, the focus is on academic researchers who themselves are focused on climbing the ranks of academia as much as they are the knowledge at stake. The complexity of such processes, and even the associated financial costs in open access journals, intimidates too many of the busiest practicing physicians who have amazing clinical experience and insights but lack the time and arcane knowledge of contemporary journal publishing processes. As an Editor-in-Chief of Cureus this strikes me as a tragedy; some of the most knowledgeable clinicians have no forum for passing on their hard-won insights.

Our mission at Cureus is to use technology and a new philosophy of post-publication peer review to strike a better balance between process and the more efficient reporting of valuable clinical science. Our goal is to make it easier than ever for busy physicians in the trenches of medical practice to document the important things they learn on a near continual basis. Ultimately if some clinical observation is important enough for an overworked physician to invest time in writing up, we at Cureus are delighted to help with the task.

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Measles, the Anti-Vaccine Crowd and the Peer-Reviewed Article Partially to Blame

A big measles outbreak in the US is generating considerable news of late. Much of the blame, rightfully so in my opinion, is centered on parents who have refused to vaccinate their children out of ill-founded paranoia. Most of their anti-vaccine “thinking,” if you can call it that, is grounded in muddled anti-science. However, one of the intellectual pillars of the anti-measles movement is rooted in peer-reviewed science. And not just any science, but none other than the acclaimed high impact journal Lancet. To my way of thinking this is a big part of the problem.

Andrew Wakefield’s much ballyhooed and eventually discredited 1998 Lancet article, concluded that childhood vaccines were a possible cause for autism. Parents of autistic children seized upon this possibility, especially A-list celebrity Jenny McCarthy, invoking the Wakefield article as proof of their fears. Unable to weigh the scientific merits for themselves, the fanatical anti-vaccine public at large ascribed considerable veracity and power to the Wakefield article in large part because of its publication in Lancet; although undoubtedly this article also reinforced a narrative they wanted to believe. Like most of its peers within the “luxury” journal domain, Lancet revels in every opportunity to burnish its reputation for publishing “important,” high quality science and in doing so, laughing all the way to the bank. It is impossible to believe that had the Wakefield article been published in the Burmese Journal of Gastroenterology it would have gotten nearly the same zealous respect it did in Lancet.

Don’t get me wrong. I don’t fault Lancet for publishing a bad paper; such risk is intrinsic to publishing a peer-reviewed journal. However I do take issue with the reputation Lancet seeks to foster around impact factor and by intimating that their peer review process results in a meaningfully more valid scientific publication; the Wakefield article being a perfect case in point of why this thinking is flawed. Any scientist with integrity knows that the proper perspective for approaching all scientific publications involves a substantial dose of skepticism until the findings within have been replicated, oftentimes more than once.

Despite its subsequent retraction, Wakefield anti-vaccine believers refuse to relent, claiming even today that allegations of scientific misconduct are a conspiracy at the highest levels of science. If the Wakefield article had instead been refuted by a democratic barrage of post-publication critique and scoring, ala SIQ, it would be much harder for the anti-vaccine fanatics to keep believing in discredited science. That said, as long as luxury journals are perceived as having a uniquely rigorous peer review system, and therefore uniquely truthful, the public health will be disserved as we are currently witnessing in this measles outbreak. We at Cureus continue to believe that there is a better process via more rigorous post-publication review, as implemented in our SIQ. Give it a chance – you’ll be surprised.

An Introduction to Cureus’ First Student Ambassador

The processes of peer-reviewed medical science have been around a very long time with the New England Journal of Medicine even passing its 200th anniversary last year. It, like many other old journals, has become venerated for the important science reported over the centuries, and in conjunction, there has evolved the aura of scholarly respect and status. In fact the prestige of a journal, perpetuated by medical school tenure processes, and as quantified by Impact Factor, is roughly proportional to the age of the journal. Roughly speaking, old journals are prestigious, while new journals tend not to be; academic medicine tends to be a very tradition-leaning and status-conscientious community! Despite its relative youth, Cureus’ leadership team also includes a number of senior academics, some of whom have five decades of medical publishing under their belts. Our advisor and former editor at JAMA, George Lundberg, is a perfect example; experience always has a lot to teach us all.

Despite medicine’s veneration of history, it cannot be denied that the future belongs to the young, and just possibly, they might choose to evolve peer-reviewed journalism in new directions. In the past decade, youthful exploits have truly transformed human culture and commerce, with Facebook, Google, Uber and AirBnB being only a few cases in point. In many ways the pace of social change seems to be accelerating on the backs of the young. To date, youthful exuberance has not been part of science, however, Cureus is hoping to change that. As we aspire to be a new concept in peer-reviewed medicine, we would like to introduce Cureus’ first medical student ambassador, Paul Windisch, from the University of Munich. Paul’s role at Cureus will be to help introduce our tools for publishing peer-reviewed science to a new generation of physicians and simultaneously provide our team with a deeper insight to the needs and aspirations of younger doctors.

When stepping into this new role, Paul was quick to encounter a little bit of skepticism among fellow students. Their concern was whether or not publishing an article in a newer journal like Cureus, and thereby not publishing in a more conventional journal, might negatively impact the career of an aspiring young academic; many professors have stressed the importance of publishing in the most highly-regarded journals. My counterargument is that by all means it’s good to publish in prestigious journals, but do not let that dissuade one from publishing in Cureus as well. To publish in Lancet or Nature or NEJM is a very time-consuming process with much of the effort being expended throughout the rationing process of responding to multiple rejections, each one eating up precious time that might have gone into publishing yet additional papers. The most successful scholarly careers in medicine tend to combine important papers in highly-regarded journals AND much more numerous peer reviewed articles in lesser-known journals. Quality (or at least the perception of such) is important, but so is the QUANTITY of one’s scholarly work as one seeks to become known and rise through the academic ranks. As the maxim “publish or perish” clearly implies, it is important to publish frequently as one seeks to build an academic reputation. Need I remind you, Cureus makes that process easier than ever. Just maybe when Cureus has enough of its own storied history in the future, the aura of our articles will bring the cachet of academic tradition as well!

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?

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.

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.