Peer Review and the Internet
In March, 2000, Steven King’s novella, Riding
the Bullet, was published exclusively online by Simon and
Schuster, Inc. The entire sixty-six-page work was edited, proofed,
designed, and marketed within two weeks. Four hundred thousand copies
were downloaded in forty-eight hours. The Christian Science
Monitor reported on May 18, 2000, that, "...while
other industries rush towards the Internet, the 1.2 trillion dollar health-care
industry (of which we are a small part) inches cautiously forward."1 But we are moving
forward. In an insightful article recently published in Science
Editor, Conway stated, "The Journal industry is
in the midst of a transition of unparalleled significance—from distribution
in print to a finite number of paying customers, to dissemination
electronically to an unlimited number of users, some of whom pay,
some of whom do not."2What
does this mean for The Journal of Bone and Joint Surgery and
other scientific and medical journals? It certainly means many challenges;
but with these challenges, many opportunities will be created. While
the publishing world is changing substantially, high-quality medical
and scientific journals continue to deliver two key elements that
are very valuable and, indeed, irreplaceable. Through the peer-review
process, the journals provide quality improvement through a process
of critiquing and editing all scientific manuscripts submitted to
them, then they apply the "Good Housekeeping Seal of Approval" to
those that pass muster, and, finally, disseminate the new and relevant
information to both the research scientist and the clinician.
The peer-review editorial process (criticized by many because
of its laborious nature) has several valuable steps. It:
• Screens all submitted material,
• Selects only the high-quality scientific studies,
• Works with the authors to edit these studies for scientific
accuracy and clarity, and
• Validates the final product.
The need for someone, or some organization, to perform this important
function will become even greater as the ease of presenting raw
data increases with the growth of the Internet. As Hurwitz et al.
have pointed out, it is essential that we move away from the simple
accumulation of data and compilation of information in the medical
literature. Rather, we must acquire knowledge and, indeed, use that
knowledge to improve our diagnostic and clinical skills in the treatment
of orthopaedic conditions3. This
process of moving upward from data creation through the acquisition
of knowledge to practical understanding has been, and will continue
to be, greatly facilitated by the peer-review process.
Today, if you have your own web site (and who doesn’t?),
you can "publish" the results of your research. That "information" can
be disseminated to a very wide audience, particularly as search
engines become increasingly capable of identifying information in
a specific subject area that has been randomly placed in cyberspace.
Each and every one of us can do this, and, indeed, many individuals
have, saturating the electronic spaces with raw data or information
that may or may not be accurate, much less useful, to our scientific
pursuits or the care of our patients.
Now, some will argue that this new way of delivering information
is advantageous and, indeed, the high-energy physicists have created
a purely electronic journal, based in Los Alamos, New Mexico, that
allows immediate access to a researcher’s work4. Their so-called "preprints" are
put up on the network, where everyone can critique them online,
creating a quasi-peer-review process. Supporters of such electronic
journals praise the great benefits of the virtually immediate dissemination
of data and the openness of this kind of peer-review process5. Personally, I would much prefer
to have my research critiqued by fair and objective observers—experts
in the field—not just anyone with access to a computer
terminal. Furthermore, the random placement of new information on
the Internet allows the user to assume too easily that it is valid
information and the product of a rigorous enterprise. Obviously,
this is not always the case. How do you sort out and select the
quality work? I think this can only happen with a thorough review
process conducted by experts in the field.
Even if you accept a more open and dynamic review process, there
is still no way for the individual reader to sort through, prioritize,
and accurately assess the quality of the information. A two-pronged
problem is created:
• A vast array of information becomes available, and
one can search far and wide without finding anything of real value.
We are overwhelmed by "info-garbage"6.
• Furthermore, although there is this vast sea of information,
it is often so shallow that once you find a potentially useful place
to dive in to explore a specific subject area, you are very likely
to strike your head on the bottom even before your shoulders hit
the water! This is because huge amounts of information are randomly
distributed into cyberspace, but the information is not well catalogued
or qualitatively evaluated to facilitate the acquisition of its
useful and relevant elements. It is here that the peer-review and
editorial processes can and will continue to be of substantial value
by:
• Sorting the valuable from the valueless,
• Identifying important wells of information on specific
subjects, and
• Directing the busy clinician or scientist to all of
the high-quality, useful information in an efficient and effective
way.
These services of peer review and timely and efficient delivery
of quality information will continue to be valued in the marketplace.
Conway, in her article, also stated that librarians (and you
can read that as journals) "have changed from keepers of
the information" to "finders of the information." I
would add that journals and librarians are not only the finders
of the information, but can be the finders of quality information2. It is the pursuit of this goal that
will maintain high-quality peer-reviewed journals as viable
players in the marketplace.
The Challenge for Peer-Reviewed Journals
in the Electronic World
The younger generation, already so adept at acquiring information
electronically, demands a more exciting, timely, and dynamic interface,
rather than just words, pictures, and tables on the printed page.
Thus, with growth of the Internet, the print medium will be used
less and less, and subscriptions will dwindle. Advertisers will
lose interest in buying space in the print journals as readership
decreases. Thus, the only two sources of revenue so dearly needed
to support the peer-review process (subscriptions and advertising)
will continue to shrink while costs of production (especially printing
and distribution) will continue to rise.
Along with these threats to the printed word come opportunities:
• The electronic transmission of material can facilitate
the editorial process, accelerating the peer-review process, and
making it more broadly based.
• Space in the new electronic journal format will be
unlimited, creating the opportunity to publish many more articles,
and with each article, extensive databases so that the raw data
from the experiments can be published without any substantial increase
in cost.
• The dynamic nature of the electronic interface also
allows many new innovations in the publishing arena:
• Video supplements can be produced and actual video
demonstrations of surgical techniques and other procedures can be
accessed with a click of the mouse, allowing clear and lucid instruction.
• An interactive forum can be created, in which a very
robust, dynamic interaction between the author of the manuscript
and the readers can occur, including a chat room where authors and
readers can, within hours of publication, discuss the material presented
in the manuscript.
• This medium creates an opportunity for commentary
by many experts, with immediate access to the article, who can put
the information in perspective, citing both positive and negative
aspects about the scientific work.
• An enhanced capability for literature search can allow
the presented article to be
linked to an entire database of supportive references all of
which can be readily accessed by the reader.
• Finally, a cataloguing system can be created for the
reader to place articles of his or her choice (and all of their
attached references) into an easily accessible personal electronic
file to be tapped at a later date.
If we do all of this, and indeed it is all eminently doable,
only one problem is left to solve: How do we pay for it? We should
note that the Encyclopedia Britannica Corporation now publishes
the encyclopedia electronically, allowing complete and free access
to anyone who reaches their web site. Their sales force has disappeared,
and now they rely entirely upon advertising in the electronic format
to sustain their publication efforts. There are many possible ways
to fund this exciting new adventure:
• Because there is an intrinsic value to peer review,
it is my feeling that many individuals will always subscribe to
journals. The value-added features of electronic publication
as described above will attract and retain subscribers to the electronic
format.
• Everyone is exploring different ways to encourage
advertisers to underwrite electronic publishing. Banner ads have
been modestly successful, but their specific impact in the marketplace
has been difficult to measure.
• The orthopaedic industry may well appreciate the intrinsic
value of the high-quality peer-review process and agree to provide
underwriting for a respected online journal, in exchange for which
they might receive Public Broadcasting System-type recognition.
• To obtain the valuable high-quality peer review, authors
may pay a modest sum per submitted article to underwrite this service
provided by the journals7.
• Finally, very specific electronic linkages between
journal articles and commercial web sites are relatively easy to
create, but they tread upon the ethical guidelines for electronic
publishing recently established by the American Medical Association8.
General advertising, in a "Yellow-Pages" format,
through a journal link to a commercial advertiser, seems to be acceptable,
but a more direct tie to a specific product mentioned in a scientific
article challenges those guidelines. Is it ethical for an article
in The Journal of Bone and Joint Surgery on the
XYZ total hip replacement to have a direct hyperlink to the XYZ
company web site, where, with the click of a button, the reader
of the article (and the user) can see a company advertisement, review
a video of the surgical technique for implanting the total hip,
and scan the product catalog to select the size and style of prosthesis
for his patient?
Commercial enterprises might be willing to pay substantial
sums for such a direct link between the scientific article and their
promotional material, but such a linkage threatens the independence
and credibility of peer-reviewed publications. When we
move in this direction, we must, at all costs avoid the danger of commercial
interests influencing the selection of specific articles.
Regardless of what methods we use to fund this important enterprise,
peer review must remain independent and untainted by the interests
of specific funding sources.
Indeed, the paradigm of scientific publishing is shifting, but
the transition is by no means complete and, in my estimation, will
be measured in years, not days or weeks. Certainly, the older generation,
who read all the Hardy Boys and Nancy Drew mysteries as kids, will
still want to receive journals in a print format, at least for the
foreseeable future. The same may not be true, however, of the generation
raised on Nintendo and Donkey Kong. Regardless of the medium, as
long as this or any other journal provides high-quality peer review
and easy access to useful new information, it will continue to have
an important place in our profession.