The Medical Journal Meets the Internet
First Monday

The Medical Journal Meets the Internet by Charles Curran

Medical journal publishing over the Internet affords major time and cost savings and conserves resources. The time savings allow more rapid incorporation of major advances into the practice of medicine. The Internet permits additional enhancements of medical journal articles that cannot be done in conventional print media. Electronic publishing also makes it feasible to publish negative studies which will enable more accurate appraisals of new drugs and new techniques.


Development of Electronic Medical Journals
The Internet Brings Significant Advantages
Disadvantages of Medical Journals on the Internet
Challenges Faced in Converting to Internet Publication
The Problem of Negative Study Results
The Internet Could Change the Peer Review Process




The Internet is capable of dramatically shortening all steps between the creation of a medical manuscript and its subsequent publication (Smith, 2001). This paper critically evaluates each component of medical journal publishing which has been or might be changed by the Internet. The use of the Internet makes it possible to massively reduce the duration of time from first submission of a clinical study report to its eventual publication and dramatically decrease publication costs. Just as important, the Internet can bring breakthrough medical advances to the attention of the practicing physician much sooner. As shown below, electronic publication can also enrich the depth of information that accompanies reports by permitting enhancements that cannot be provided using conventional print media.



Development of Electronic Medical Journals

The first electronic journals of any kind appeared in the late 1980s and since they preceded both the widespread use of hypertext formats or development of the World Wide Web, simple text-only formats were used. The first peer reviewed medical e-journal was the Online Journal of Current Clinical Trials, launched in 1992 (James, 1992). This was followed by the rapid introduction of several additional medical e-journals in a variety of specialties and subspecialties. Their number appears to be increasing rapidly. New publications are constantly appearing in many languages. Examples of some titles are shown in Table 1 below.


Table 1: Examples of Medical E-Journals

Name of Journal
Electronic Journal of Hand Surgery
Electronic Journal of Oncology
Electronic Journal of Pathology and Histology
Hypertension Dialysis & Clinical Nephrology
International Electronic Journal of Health Education
International Journal of Surgery & Specialistic Medicine


Table 2 provides examples of journals that are now available in both e-journal and conventional print formats.


Table 2: Examples of Medical Journals Available in Both E-Journal and Conventional Print Formats

Name of Journal
British Medical Journal
Journal of Clinical Investigation
Emerging Infectious Diseases
Journal of Clinical Microbiology




The Internet Brings Significant Advantages

Early steps in the current process of peer review used by most printed medical journals consist of initial review by the editor, submission of manuscripts to peer reviewers, receipt of reviewer comments, return of manuscript to authors for their revision and receipt of revised manuscripts (Roberts, 2001). Peer reviewers are typically unpaid health care professionals. They volunteer their time to assist editors of medical journals by carefully reading and critiquing submitted medical manuscripts, and by recommending to editors whether that manuscript should be published. The typical peer review is conducted anonymously.

In most of the major general medical journals and specialty medical journals, the majority of submitted manuscripts are rejected for publication, generally as a result of high editorial standards. Those that do get accepted have their acceptance almost always contingent upon the authors making revisions recommended by the editor. Review of the proofs of the final about-to-be-published article accounts for a further back-and-forth cycle between editor and author. During the process of manuscript review, except for physicians who performed the clinical study and the staff involved in manuscript peer review, the study results are unknown to the general medical community. The primary components of manuscript review are illustrated in Figure 1 below.


Figure 1: Reviewing and Publishing New Medical Journal Articles


Peer review appears cumbersome, but is a time-tested, highly regarded process for closely scrutinizing new medical information to assure the medical community that safeguards have been taken to increase the likelihood that the new medical information is valid, of high quality and medically relevant. It has been used in one form or another by learned medical societies for over 300 years (Lock, 1986). Peer review is a major criterion used in judging whether a medical journal publishes credible and useful information. The busy physician generally has little time for non-peer reviewed journals, commonly called "throwaway journals".

Whenever conventional mail is used in any step in the peer review process, transit time can be the major factor contributing to delay. Particularly if the journal is published at less than monthly intervals, the lag time between submission of a manuscript and the subsequent publication can be over a year (Dimsdale, 2001). Electronic publication reduces the time to publication by essentially eliminating transit times during the evaluation and revision of submitted manuscripts (Fletcher and Fletcher, 1998). Additionally, the cost of production and distribution is dramatically reduced (Anonymous, 2001).

Both the academic and health care communities have been severely constrained in maintaining access to newly-published information. New journal titles continually appear while subscription costs spiral upward. As an example, one of the subspecialty titles of the Journal of Comparative Physiology has a current annual subscription rate of $US3,881 and journals with annual subscriptions over $US1,000 are becoming more common. Many medical libraries, especially state-supported libraries, face the threat of reduced funding; selective cancellation of journal subscriptions, especially those in foreign languages or subspecialty-specific journals, is a common response. Electronic journals offer the opportunity to dramatically lower publishing cost (Donovan, 1998; Odlyzko, 1997) while at the same time reducing journal storage volume in libraries and increasing the breadth of access to new information.

The electronic medium offers additional advantages. An early report outlined features such as the ability to electronically publish articles days after acceptance, enabling the reader to search each article for selected words or strings of words, to alter text size for ease or convenience in reading, to navigate quickly between tables and figures, and to jump quickly from any reference number in the text to its respective citation (James, 1992). Additional advantages include the ability to incorporate audio or video clips and databases into an e-journal publication as well as to append the original data on which the paper is based (such as case report forms, chest X-rays, brain scans, recorded heart sounds and detailed clinical laboratory data), and to provide hypertext links (Markovitz, 1998; Smith, 2001). In stark distinction to print media, there is essentially no limit on length of electronic journal articles (Fletcher, 1998). The reduced access costs of e-journals allow physicians in developing countries access to articles that were not previously available (Jacobson, 1998).

In addition to the inherent advantages in producing articles, e-journals offer convenient and rapid access and downloading of articles of interest. If the popularity of e-journals continues to grow, the need for photocopying articles could be greatly reduced.



Disadvantages of Medical Journals on the Internet

Unlike print journals, electronic journal use is dependent on simultaneous availability of dependable electricity, telephone system, computer, local network, appropriate software and access to the Internet (Morris, 2001). Although these components are taken for granted in first world countries, access to one or more of these is a major problem in large areas of many third world countries.

Some may argue that the Internet journal user is less likely to "browse", i.e., become coincidentally exposed to related or unrelated knowledge which adds to the physician's personal store of knowledge and therefore the physician's breadth of knowledge. Also, in print, it is obvious to the reader whenever an article is part of a series of related articles and this may not be as clear in the electronic medium.

Finally, eye strain in reading articles on computer terminals is still greater than in reading printed journals although this can be overcome by printing any electronic journal articles that demand careful review or by enlarging the image.



Challenges Faced in Converting to Internet Publication

Issues which print media publishers must face when using the Internet to supplement or replace paper-based journals include: pricing, security, adapting page layout to electronic page format, copyright issues, degree of availability of back issues, and accessibility problems due to peaks in Internet traffic, broken links or crashed servers (Smith, 2001; Machovec, 1997). The archival stability of this format over time has yet to be tested (Dimsdale, 2001).



The Problem of Negative Study Results

In conventional print media, a considerable bias exists against publishing clinical studies in which the results were negative (indicating that the drug or treatment under study had no effect) or which failed to attain statistical significance when compared to another drug or treatment (in clinical studies, "not statistically significant" means a failure to statistically demonstrate that there was a less than one-in-20 chance the results were due just to chance). This bias, called publication bias, is pervasive and persistent (Song et al., 2000). Although at first glance it would seem reasonable not to publish studies with disappointing outcomes, there are two important reasons to publish such studies, described below.

A relatively recent technique used to evaluate results across medical studies has been meta-analysis. Using sophisticated statistical techniques, the results of comparable studies are combined. This is a powerful tool to more accurately appraise the real worth of a particular drug or a new diagnostic or treatment technique. The value of meta-analysis is hampered whenever studies having negative or statistically insignificant findings are not available to incorporate into the analysis. Internet publication of these negative or statistically insignificant studies will permit their incorporation into meta-analyses. Perhaps just as important, publishing these studies will directly alert clinicians to measures that are not clinically useful and may avoid unnecessary duplication of clinical studies already demonstrated to be ineffective. Publication bias exists largely because of publishing cost concerns which publication of these studies over the Internet would greatly reduce (Song et al., 1999).



The Internet Could Change the Peer Review Process

Although an early prediction was made that the rise of electronic journals would be accompanied by the demise of the peer review process (Judson, 1994), later authors suggested that the peer review process would be replaced by a more open, democratic process (LaPorte et al., 1995). However, one proposed replacement, that of ratings by readers or counts of number of times a report is accessed, deprives manuscripts of potential improvement through the rigor of the peer review process (Pitkin, 1995).

In a study to determine the potential utility of open (non-anonymous) peer review over the Internet, 56 manuscripts and reviewers' comments were posted on the Internet. Readers were invited to e-mail their comments; seven articles (12.5 percent) were changed by the authors in response to outside comments (Bingham et al., 1998). However, one shortcoming of democratic e-journal peer review is the lack of systematic maintenance of the range of knowledge and skill to maintain a high quality reviewing process (Gellert, 1995). Electronic journal peer review may subvert publication quality to populist appeal (Gellert, 1995).

Harnad (2001a) argued for an electronic peer review process mirroring that of print media journals, and Peters (2000) offered suggestions for insuring that electronic journals maintain an effective peer review process by paying for peer review and editing through subscription, pay-per-view charges or site licenses. Harnad (2001b) suggested the funding of peer review by page charges to the author and/or the author's institution. The latter procedure is a widely-accepted practice in experimental science journals. Eliminating peer review would increase the risk of early release of reports containing misleading and inadequately evaluated information (Relman, 1999). This in turn could compromise medical practice, patient safety and public policy; however, physicians are generally suspicious of medical reports which lack the safeguards of peer review.

It appears that all of the components of peer review as currently practiced can be handled over the Internet. On 13 April 2002, the British Medical Journal, a prestigious publication available both online and in conventional print formats, began a pilot trial for reviewing manuscripts of critical importance. This "fast track" publication of articles concerning major clinical events permits an author to submit a manuscript electronically, track the article's progress during its peer review, and peer reviewers to send their reviews electronically and be able to determine electronically what final editorial decisions were made on papers reviewed by them (Anonymous, 2002). If successful, this journal is planning to make the procedure standard for the submission and review of all manuscripts.




Medical publishing over the Internet reduces both the time between medical discovery and also the clinical application of these advances and the development of research based on the new findings. This medium also conserves the use of paper and drastically reduces storage space for medical information and makes efficient searching tools available for finding information on selected topics. Health care professionals who live in remote areas, or who lack sufficient monetary resources to keep informed about new medical findings and important new medical discoveries have improved access to medical information that would otherwise be difficult to obtain.

Electronic medical journals and health newsletters also facilitate consumer access to information. This is increasingly important as consumers begin to educate themselves about their health conditions and available options for medical treatment.

In spite of these obvious advantages, adoption of electronic journals has been slower than one might expect. This appears due to two factors. First, because most medical societies that publish journals use commercial publishers, an adequate means of paying for electronic publication costs must be developed, although as indicated above, several means have been suggested. Secondly, there are a number of physicians who have not yet become either adept or comfortable using the Internet to gain medical information. This will likely change over time as increasing numbers of physicians yield to the peer pressure of their medical colleges who are obtaining rapid and useful information over the Internet.




Publishing medical study results over the Internet affords major time and cost savings over the entire process of manuscript submission, review, revision and publication, conserves resources and permits incorporation of enhancing information in publications (by adding useful raw data such as X-ray images and scans) which improve their clinical value. Reductions in the elapsed time between submission and publication of an article permits major medical advances to be recognized and utilized in medical practice more rapidly. Electronic publishing also makes it feasible to publish negative studies that will enable critical reviews of new drugs and new techniques to become more accurate. End of article


About the Author

Charles Curran, Ph.D. is Director of Professional Affairs, Forest Pharmaceuticals, Inc. in St. Louis, Missouri. This department responds to inquiries from physicians and other health care professionals and from consumers concerning a wide variety of drugs and diseases. Over the past two decades, he has been responsible for the clinical development of new drugs and for drug information activities in several other pharmaceutical companies.



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Editorial history

Paper received 24 April 2002; accepted 10 May 2002.

Contents Index

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The Medical Journal Meets the Internet by Charles Curran
First Monday, volume 7, number 6 (June 2002),

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