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Editorials

Innovations in publishing BMJ research

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a3123 (Published 29 December 2008) Cite this as: BMJ 2008;337:a3123

Can journal abstracts alone be used for clinical decision making?

The Medline abstract, originally intended only as an indexing tool, has become the sole information source for many. It has its advantages -- easy to read, structured and informative, and it is now available almost everywhere through mobile phones and other wireless handheld devices. It can even be retrieved by text messaging or e-mail.

Wireless networks, so pervasive worldwide, raise the possibility that it might be useful in the practice of evidence-based medicine. Are journal abstracts alone adequate for clinical decision-making? Is it better to use abstracts from current clinical journals to guide clinical decisions than not to have any guide at all?

Clinicians and medical librarians are wary because evidence-based medicine (EBM) calls for a comprehensive review and critical assessment of full-text journal articles and, together with information from the patient and laboratory tests, develop a guide to patient management [1]. But, it is not easy to practice -- many clinicians, because of lack of time, access to full-text articles and expertise in critical appraisal skills, rely solely on abstracts for clinical decisions [2-3].

Could abstracts alone be used instead? Will multiple abstracts from highly regarded clinical journals comprise a ‘consensus’ opinion to provide the clinician the confidence to make a treatment decision or diagnostic approach? Concurring abstracts might provide validation needed for formulating a management strategy. If clinicians are unable to make use of clinical research they could miss out on research that can potentially benefit their patients.

Clinical evidence has to be easily accessible to be most useful -- if it is not convenient, clinicians will not use it even if the need is high [4]. The more effort is required to use it, the less likely it will be used [5-7]. In a recent survey of 1900 U.S. physicians, Manhattan Research found that nearly 50% of US physicians use Wikipedia for professional health and medical information purposes, especially condition information [8]. Yet, only about 10% created new entries or edited existing information. Convenience trumps need and knowledge all the time.

Most highly accessed journals today use structured abstracts. Since the adoption of the IMRAD (Introduction, Methods, Results and Discussion) format, abstracts like BMJ’s pico have become more systematic, detailed, and informative to the point of becoming ‘mini papers’ [9]. Sometimes, the abstract does not accurately represent or completely summarize the article [10]. However, many of the errors were minor and unlikely to lead to serious misinterpretation. A journal-based effort to improve abstract quality seemed to be effective [11]. A more recent review of BMJ, CMAJ and JAMA showed that the conclusions in 27 articles had a mean quality score of 100%, meaning that were consistent with the results [12]. Could several concurring abstracts from distinct journals provide a “consensus” clinical bottom line? Will this compensate for the deficiencies in abstracts and provide the clinician greater confidence?

The availability of open access journal articles is on the rise. Today, full-text versions of research papers of many highly read journals are immediately available or within a year of publication. Additionally, some organizations and publishers provide totally free, or low cost, online access to biomedical journals for readers in developing countries. [13-15]. Furthermore, papers generated through research funded by the NIH, other government agencies and participating organizations, are now required by law to be deposited in PubMed Central.

Nevertheless, access to online full-text articles is still a challenge in developing countries: the lack of Internet access, low bandwidth and shortage of computers for reading and printing journal articles are still making full-text access difficult. Most healthcare workers in developing countries use public computers like Internet cafes and libraries. [16]. Many countries (more than 70) with GNI (gross national income) per capita that do not qualify for free access are eligible for reduced subscription, but for most, the cost is still unaffordable. Moreover, these programs are intended for government and non-profit health care organizations only -– physicians practicing independently or in a group cannot avail of these programs.

We recently asked some physicians practicing mostly in developing countries whether Medline abstracts are adequate for clinical decisions: 28% (15/54)categorically stated they are. Forty three percent (23/54) said no, but that they had no access to full-text journals and another 28% also said no, but they had no time to read full-text articles. One respondent did not use Medline abstracts at all. This preliminary study confirms access issues in these countries, but also the potential value for abstracts if these could be made available easily through their existing infrastructure.

Wireless communications is a success story far exceeding the UN’s goal of 50% coverage by 2015. GSMA reports that there are now more than four billion connections worldwide with more than 80% of the world’s population accessible by mobile phones [17]. Among U.S. physicians, 64% now use smartphones [18]. Furthermore, mobile phones are getting better -- processes previously associated only with desktop or laptop computers are now in smartphones. The mobile phone, available in countries with minimal Internet access or low bandwidth and poor computer resources enables healthcare personnel to access the Internet. It creates an environment where updated medical information such as Medline journal abstracts is accessible. An added benefit is that expert consultation through camera phones is possible.

For example, a search for randomized controlled trials using the PICO strategy (http://pubmedhh.nlm.nih.gov/nlme/pico/piconew.html) P “postpartum haemorrhage”; I “misoprostol”; C “placebo”; O “low resource area” will retrieve an abstract of a three-year clinical trial [19].

Even though EBM teaches that full-text journals be reviewed, with more informative abstracts such as above, Medline abstracts alone might be a useful tool for making clinical decisions especially in places where no other resource is available. If journal abstracts are accepted as ‘current evidence’ suitable for evidence-based practice, then all who are involved in the publication process -- authors, journal reviewers and editors, need to ensure that the abstract is indeed an accurate summary of the full paper.

References:

1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996;312: 71-2.

2. Read MEDLINE abstracts with a pinch of salt. Lancet 2006, 368(9545): 1394.

3. Barry HC, Ebell MH, Shaughnessy AF, Slawson DC, Nietzke F. Family physicians' use of medical abstracts to guide decision making: style or substance? J Am Board Fam Pract 2001;14:437-42.

4. Sackett DL, Straus SE.Finding and applying evidence during clinical rounds: the "evidence cart".
 JAMA; 1998 Oct 21 ; 280(15):1336-8.

5. Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract 1994;39:489-99.

6. Slawson DC, Shaughnessy AF.Obtaining useful information from expert based sources. BMJ 1997;314:947-9.

7. Smith R. What clinical information do doctors need? BMJ 1996;313:1062-8.

8. Docs look to Wikipedia for condition info: Manhattan Research. Ben Comer April 21, 2009. http://www.mmm-online.com/Docs-look-to-Wikipedia-for-condition-info-Manh...

9. Editorial - Innovations in publishing BMJ research. BMJ 2008; 337: a3123

10. Pitkin RM, Branagan MA, Burmeister LF. Accuracy of data in abstracts of published research articles. JAMA 1999;281:1110-1.

11. Winker MA. The need for concrete improvement in abstract quality (editorial). JAMA 1999;281:1129-30.

12. Wong HL, Truong D, Mahamed A, Davidian C, Rana Z, Einarson TR.
Quality of structured abstracts of original research articles in the British Medical Journal, the Canadian Medical Association Journal and the Journal of the American Medical Association: a 10-year follow-up study.
 Curr Med Res Opin; 2005 Apr ; 21(4):467-73.

13. http://journals.bmj.com/subscriptions/countries.shtml

14. Access to Research Initiative (HINARI) http://www.who.int/hinari/eligibility/en/

15. Full-text e-journals. http://www.healthnet.org/essential-links/fulltext-e-journals.html

16. Villafuerte-Gálvez J, Curioso WH, Gayoso O (2007) Biomedical Journals and Global Poverty: Is HINARI a Step Backwards? PLoS Med 4(6): e220 doi:10.1371/journal.pmed.0040220

17. Mobile World Celebrates Four Billion Connections. http://www.gsmworld.com/newsroom/press-releases/2009/2521.htm

18. What Percentage of U.S. Physicians Use a Smart Phone? http://www.ihealthbeat.org/Data-Points/2009/What-Percentage-of-US-Physic...

19. Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial.
Derman RJ, Kodkany BS, Goudar SS, Geller SE, Naik VA, Bellad MB, Patted SS, Patel A, Edlavitch SA, Hartwell T, Chakraborty H, Moss N.
Lancet; 2006 Oct 7; 368(9543):1248-53.

The views and opinions of authors expressed herein do not necessarily state or reflect those of the National Library of Medicine, National Institutes of Health or the US Department of Health and Human Services.

Acknowledgements: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Library of Medicine (NLM), and Lister Hill National Center for Biomedical Communications (LHNCBC).

Competing interests: None declared

Competing interests: No competing interests

11 June 2009
Paul Fontelo
Research physician
Alvin A. Marcelo National Telehealth Center, University of the Philippines, Manila, Philippines
National Library of Medicine, Bethesda MD 20894