Editorial   |    
The Millennium Enigma: More is Less
J Bone Joint Surg Am, 1999 Nov 01;81(11):1509-10
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Throughout its history, The Journal of Bone and Joint Surgery has maintained a high standard of peer review and an extensive editorial process in order to ensure that each article that is published in The Journal is clear and accurate so that it will be of the most use to the reader. One would anticipate that this past emphasis on excellence, subsequent success, and ongoing commitment to the same principles would ensure the future success of The Journal. Regrettably, because of the changes that have taken place in the last decade, such an assumption may be flawed.
Among the major developments that have taken place over the last decade are the advances in the arena of electronic publication and the expansion of such publication to the Internet. These developments have been accompanied by another drastic change, the evolution of the so-called Generation X, a generation of individuals who have metamorphosed from seekers of information to samplers of information. The members of this generation of computer-literate individuals increasingly derive their information from the screen, not the printed page. These individuals believe that all of the information that they need is available in electronic form and that all they have to do to get that information is to search for it on their computer. Little thought is given to the source of the information or to whether the information is valid. Rather, the reader wants all of the available information on a given subject, wants it now, and wants it summarized. It is as if the reader is saying, "Just give me the facts; don't make me think." Regrettably, without peer review, the so-called facts may not be facts at all.
Authors have reacted to this demand for knowledge by stating that anything that they write is worthy of consumption and that the process of peer review delays, and even prevents, publication of material that is timely, relevant, and important. This notion has led to the development of Web sites that provide material immediately, with little, if any, peer review. Thus, readers have been inundated with masses of data that have not been subjected to peer review and therefore must decide for themselves what is true. Unfortunately, any material, whether it be true or false, acquires a nuance of truth simply by appearing on the printed page or on the screen. Even sophisticated readers may be swayed by what they see in print, even if it may not be entirely true.
In effect, we have become a generation of so-called chitchat scientists. To be sure, it is worthwhile to obtain the opinion of a well respected colleague who is known to be a leader in his or her field. However, I fail to see the point of obtaining an opinion from a member of an on-line chatroom. By accepting such an opinion, we devalue the science of medicine. I liken this search for information in orthopaedic chatrooms to the current common phenomenon of the man-on-the-street interview on television, in which a TV commentator selects people off the street to give opinions regarding complex issues. The individuals who are interviewed frequently do not understand the question but generally give an answer anyway. Regrettably, we are approaching the same level of ignorance in the medical sciences by tolerating, and in some instances even endorsing, medical publications, both in print and in electronic form, from which adequate peer review is absent. One can only wonder why a reader would want access to worthless data or why a scientist would want information to be published without adequate review.
Thus, we approach the millennium with an ever-expanding base of medical knowledge but an equally expanding concern that the available knowledge may not all be accurate. That is the millennium enigma—there is more information but less factual knowledge. If no gatekeeper is present, a surfeit of knowledge, both true and false, will flood the Internet. Looking for a fact regarding a particular problem will soon become like reaching into a fishbowl full of so-called facts and hoping to select a true fact, rather than a false one, from the mix.
It is apparent from the level of acceptance of manuscripts for The Journal of Bone and Joint Surgery (currently less than 15 percent) that much of the material that is submitted for publication contains fatal flaws and should not be published. An article that is submitted for publication in The Journal may be rejected because the study is inherently flawed with regard to the selection of patients or the acquisition of data, because of the paucity of data supplied, because of a lack of follow-up, or even because the conclusions do not logically follow from the data presented. Such rejections are made following an in-depth peer-review process, with the clear understanding that the reader will use the material published in The Journal to manage patients. Surely, it is improper to consider managing patients on the basis of knowledge that has not been shown to be accurate.
The reader of an article published in The Journal of Bone and Joint Surgery can be assured that the material has undergone adequate peer review and that the material presented is clear and accurate. When this is the case, the reader can use the information to manage patients.
Thus, authors and readers must recognize that a scientific journal must have adequate peer review and must serve as a gatekeeper to the information highway by allowing only peer-reviewed material that is as accurate as possible to be placed on the Internet.
As the millennium approaches, and with it the completion of my term as Editor, I am confident that The Journal of Bone and Joint Surgery will continue to serve this function while developing strategies to address the explosion of non-peer-reviewed material in print form and on the Internet.
Henry R. Cowell, M.D., Ph.D.

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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