Research in the BMJ
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39273.529641.47 (Published 12 July 2007) Cite this as: BMJ 2007;335:0
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Fiona Godlee implies (Editor’s Choice 14 July) that the new-look BMJ
is better because most of the feedback from readers has been positive.
This is dangerous logic. The BMJ has always been regarded as a publication
that sets standards, not one that courts popularity.
In defending the journal's current approach to publishing research
she is on firmer ground. But perhaps the new "look" is not all good? In my
view there have been two undesirable changes to the printed journal in
recent times, namely more advertising and worse design.
Advertising in the paper copy has increased steadily in quantity and
intrusiveness over the last two decades. In recent issues the visual
preponderance of advertisements has made the journal look more like a
Christmas tree than a serious research publication.
As the BMJ editors should know, advertising and research are a
suspect combination. The sheer weight of advertising in the printed
journal sends a subliminal message that undermines the credibility of the
research content.
Secondly the design of the printed page has been updated using modern
technology, but the result has been to make it more difficult to read. A
glance at the journal of twenty years ago, with its excellent readability,
shows that in this area "progress" has not helped.
Competing interests:
None declared
Competing interests: No competing interests
Papers that change practices
Be not the first by whom the New are try’d,
Nor yet the last to lay the Old aside.
Alexander Pope, An Essay on Criticism
In her recent column1 the Editor of the BMJ wrote that the journal wants to publish “research that has the potential to change what [readers] do and how they think”. This policy needs careful scrutiny. It implies certain assumptions:
The assumptions
Assumption 1. That a single paper can change practice There are undoubtedly papers that have changed clinical practice or health-care outcomes in one way or another. The Lancet paper of Wakefield et al. on the relation between measles, mumps, and rubella (MMR) immunization, behavioural symptoms, and intestinal abnormalities2 rapidly changed public perception about MMR, which led to a change in public health. A paper on the use and adverse effects of minocycline in acne,3 with an accompanying editorial,4 probably immediately reduced prescribing of minocycline—the evidence is circumstantial but the time-course is convincing5; even so, others have recently felt it necessary to repeat this message,6 although they surprisingly failed to cite the earlier papers; it will be interesting to see if this new paper has a further effect. These two examples highlight one adverse change and one beneficial change. Neither was predictable.
In contrast, the original paper on apoptosis by Wyllie and his colleagues7 took many years to achieve recognition and to change what people understood about cell biology. Barry Marshall’s observations, starting in 1981, of the role of Helicobacter pylori in peptic ulceration8 undoubtedly changed practice, but only after several years and in the face of considerable resistance9; the association was not generally accepted until the early 1990s. In both of these cases, practice was changed, not by a single paper, but by the overwhelming force of evidence. I believe that there are many more examples of this than of the single paper that changes practice.
There are examples of reports of adverse drug reactions that have led rapidly to withdrawal of the drug from the market. For example, the first anecdotal reports of the oculomucocutaneous syndrome with practolol10 did just that in the 1970s. However, the number of drugs to which this has happened is very small by comparison with all reports.11 For each report of an adverse effect that has rapidly altered the fate of a drug there are hundreds that have not. There are very few “between-the-eyes” adverse effects that warrant immediate action.12 In most cases, when the use of a drug does change, it is because of accumulated evidence rather than a single paper. A good recent example is the prevention of osteonecrosis of the jaw associated with bisphosphonates—the first cases were detected in 2002 (barring a possible early case published in 199513), reports (now nearly 900 cases) started to appear in September 200314, proposals for preventive dental care emerged in 2005,15 and those proposals are now beginning to be implemented.
The BMJ has for some time run a series of fillers called “A paper that changed my practice” (currently 540 hits on bmj.com). There may have been some that changed it for the worse (examples please), but I cannot recall any such. It is natural for authors to recount beneficial examples. Nevertheless, a survey of this highly selected sample might be of interest—specifically, to discover how the insights gained from the papers cited have fared since they “changed my practice”.
Assumption 2. That it is desirable for a single paper to change practice Occasionally, an individual paper may be salutary in indicating that a treatment should be abandoned. A report of an adverse effect of intravenous diazoxide16 probably led directly to an important change in practice—the demise of the rapid lowering of blood pressure with diazoxide in accelerated hypertension; it reversed a change in practice that had been instituted by the first reports that diazoxide could lower the blood pressure with what appeared to be satisfactory rapidity. On the other hand, Wakefield’s paper,2 which rapidly reduced the uptake of MMR vaccine, certainly changed health care for the worse.
However, medical practice usually progresses gradually, by accretion of knowledge a little at a time. This is actually reflected in the Editor’s careful use in her column of the word “potential” (cited above). Adopting a new treatment immediately on the basis of a single publication (which I call whizz-kid medicine) is unlikely to be wise. Someone has to be first, but don't let it be you, unless you are an expert, one who understands the pathophysiology of the disease, the mechanism of action of the intervention, and how the two can be married to produce appropriate therapy.17 There are many examples of ineffective or harmful therapies that have entered practice in the absence of evidence about the balance of benefit and harm.18 A comparison of the speed of introduction of effective and ineffective therapies might be informative.
Practice changing is not always beneficial. Indeed, since it is likely that most research findings are false for most research designs and in most fields of research,19 papers that change practice are likely to do so for the worse, or at least not for the better.
Assumption 3. That editors and referees can recognize papers that have the potential to change practice I cannot raise any evidence to support or refute the third assumption. However, “prediction is very hard, especially about the future”, a dictum that has been attributed to sages as diverse as Mark Twain, Albert Einstein, Niels Bohr, and the baseball catcher Yogi Berra.20 I doubt if editors and referees can spot the paper that is really going to change practice, or even has the potential to. I doubt if they are even able to spot “research that has direct application in clinical practice, public health, or policy making”, to quote the Editor again. She writes that the BMJ's research channel is “a great mix of decision-changing research”. But how does she know that any of these papers will change decisions at all, and if any does whether such changes will be for the better or for the worse? Indeed, how can anyone charged with the selection of material for publication make reasoned decisions about the influence that an individual piece of work will have?
Take some examples of research that should, with hindsight, have changed practice immediately, but didn't (in addition to those I have mentioned above). James Lind’s observations on the use of citrus fruits in preventing scurvy took many years to be implemented by the Royal Navy.21 The first paper that suggested that rofecoxib (Vioxx) might cause an increased risk of cardiovascular disease had no effect until confirmatory data were published a few years later.22 The current doubts23 about the risk of myocardial infarction with rosiglitazone, in the wake of a recent paper in the New England Journal of Medicine,24 reflect the difficulties in interpreting any new set of data, even (?especially) a large meta-analysis. After all, we have been here before, with tolbutamide and the University Group Diabetes Program, as highlighted by two contrasting reports, 34 years apart.25,26
Changing practice
I think that there are three broad categories of ways in which a paper might change one’s practice.
Firstly, there is the paper that reminds or teaches individual doctors about something they should already know. In other words, education. I think that less of this kind of didactic material is now being published in the BMJ. The axing of the ABC series, for example, is regrettable. This way of changing practice may be more powerful than publishing original research.
Secondly, there is the research paper that changes practice in general. All my comments above relate to that.
Thirdly, there are policy papers, which can lead secondarily to changes in practice through the establishment of general principles. I know of no evidence about the influence of such papers (information please).
Along with others who have expressed concern about its decline,27 I am greatly in favour of promoting more clinical research, which has suffered in recent years under various coshes, including an overemphasis on genomics and proteomics and the treacherous research assessment exercises. However, I think that the policy that the BMJ is starting to espouse is not the right way to go about improving clinical research or its usefulness. Instead of having editors sitting round the table asking “Will this paper change what our readers do or think?” I would rather have them ask “Will our readers be interested in reading this paper?” We know that editorials, fillers, news items, and reviews score more hits on bmj.com than original research articles, which appear only occasionally in the top ten papers on the BMJ’s hit parade.28 Currently, papers on adverse effects of drugs are the most read research papers29; a modest aim would be to see more original papers in different disciplines feature in the hit parade than do at present.
And perhaps we should reflect on something that the stand-up poet, Luke Wright, has recently said: "Not everything has to change the world—sometimes it's just good to laugh."30
References
Competing interests:
None declared
Competing interests: Be not the first by whom the New are try’d,