HMS Beagle: As someone known for not shying from controversial topics, how do you define the place for controversy in the scientific publishing field?

George Lundberg: Science grinds slowly. It is rare that any one study or any one report in even the best peer-reviewed scientific journal represents "truth." There is a new "truth" almost every day in some fields, as different research projects come down using different methodologies, different databases, different subjects, and often greatly different results. Controversy is inherent in the field of biomedical research.

This is difficult. It would be nice if it were clean and simple every time. Unfortunately, that's not the way it seems to work, at least not at this point in this century. If a person is going to publish articles in biomedical research - not to mention the application aspects and the public health aspects - one has to assume controversy will be part of it.

Trying to sort out the controversy is part of an editor's job at a peer-reviewed journal, so that readers get the best information possible rather than wasting their time on chaff. A good editor of a good high-profile medical journal should try to provide readers with information that is as trustworthy as possible, skillfully using the best peer-reviewers, reading between the lines as needed, and sorting out conflicts of interest, financial or otherwise. The result should be a clear and concise article written by the real authors - all of whom must be identified and none of whom must be guests or ghosts - so that the reader has as much trust as possible in a given article.

The better journals will balance or extend or explain with editorials major research papers that are likely to be controversial. Editorials in a publication should express the position of the journal, not the position of the publisher, not the position of any politician (unless the editor is trying to be a politician, which is always possible). Editorials should be used freely with research papers that may be controversial, either to accentuate or to balance and explain an article, or to disagree with the methodology or the findings or the conclusions.

HMSB: Why would you publish something if you disagree with its methodology or its conclusions?

GL: I would prefer never to do the latter, but some editors do choose to do that because of the importance of the subject or the belief by others that the methodology is appropriate. The editor can cover himself or herself by doing a counter-editorial.

HMSB: Would you consider the therapeutic-touch article, which was controversial for using a nine-year-old girl both as investigator and coauthor, a case in point?

GL: Not at all. The therapeutic-touch article was extremely well done, beautifully crafted in its design, so elegant that our statistical editor thought it was just wonderful at first glance. Although it was a candidate for an editorial if one wished to accentuate it, we thought that therapeutic touch - which of course is about therapeutic non-touch - was best left to stand on its own. It was controversial enough.

It's good to pique the reader's attention in a variety of ways. One way is to throw in papers like the therapeutic-touch piece from time to time to surprise people. Editors are also there to try to make their journals successful. Success means readers who come back again and again, because they're happy with what's there.

To be lively, medical journals should also take on controversial public-health and policy issues, partly because readers enjoy this and partly because they are so important.

HMSB: You said "medical journals." What about other scientific journals?

GL: Scientific journals other than medical journals have every right to take on controversy, even to take an aggressive editorial stance, for example, on cold fusion or life on Mars. It's beyond me to suggest exactly what they should do. But I would emphasize that in public health - where the people's welfare is so much at stake, and where there's often so much money on the other side of issues involving the public's health - a courageous journal editor ought to enter these debates on behalf of patients and the public, in advance of the profession itself.

It is helpful for any major medical publication, and probably any science publication as well, to have a mission statement or a set of goals and objectives. Without such, the inquisitive or cynical reader will wonder what a publication's all about, and whether the owners and the editors have even figured it out themselves. In publishing a mission statement so readers and authors can see it, one tends to attract writers and authors through that mission statement. One also puts a management control on oneself as the editor. You had better do what the mission statement says.

The publisher should approve the mission statement, although the editors should probably create it in a cooperative process. If the editor, editorial board, and editorial staff develop a mission statement that includes addressing controversy, and if the publisher or owner agrees with that, the editor should feel free to act accordingly. If the publisher is unwilling to approve that kind of mission statement, then the editor had better be careful.

HMSB: Did you have such a mission statement at JAMA?

GL: I created a set of goals for JAMA in 1982. The previous mission statement was very broad and general, a rather motherhood-and-apple-pie kind of statement. Different levels of hierarchy approved and updated the 1982 mission statement at different times, but the fundamental goals didn't change a great deal. We followed that mission statement, which worked very nicely for my 17 years.

HMSB: Did you feel that the action that led to your departure from JAMA deviated from those goals? Were the goals specific enough to have addressed that?

GL: There was nothing that we did in the last several months of my employment at the AMA that was any different from what we had been doing for years, which was completely within the confines of the approved set of objectives and goals.

HMSB: Are those goals public?

GL: Sure, you can get them off the Web. You can get them in JAMA. Editorials in 1982, 1987, 1993, 1998, all deal with them. You can find the set of objectives most recently in an editorial published in JAMA on February 3, 1999, which was the first available issue after the cessation of my employment. The entire editorial staff, editorial board and all the Archives journal editors coauthored and signed a common editorial, affirming their editorial integrity and independence and criticizing the AMA for having caused me to leave. The set of objectives is in that editorial.

HMSB: Do you feel that what you will be doing at Medscape with regard to controversial issues will be different from what you did at JAMA?

GL: Medscape has made its name and its reputation, properly, by being a clinical site. It's good clinical information up-to-date and delivered in a friendly way, to help doctors take better care of patients. Now, when there are clinical controversies, they're there in Medscape: what drug do you use, what surgery do you use, what hearing aid do you use, etc. It's not deliberately spawned controversy; it's clinical controversy, and Medscape has dealt with that very well.

My first job as a physician is to do no harm, and my first job in Medscape is not to do anything to hurt it, but to make it better. I've seen too many people go into organizations and screw them up immediately, destroying the good things along with what they perceive to be bad. I intend to come in very gently, make my presence obvious, listen carefully and talk to a few people, and systematically figure out what's really good and should be kept and enhanced, what's good but not as good as it could be and how we can make it better, and what's really not very good and can't be made better and ought to be eliminated.

I have said, and I don't mind your repeating, that I intend to begin to create editorials on general medical topics, some of which will be clinical and some of which will be public-health and policy-oriented. There's no doubt that some of them will be controversial. I will do this because some things just need to be said, and said in a publishing environment that is without political or, I believe, commercial spin. One can do that on Medscape when one would have a harder time doing it in some other venues. That statement can stand on its own. We'll be careful and pick our topics well, pick our spots, and utilize a variety of people to do it, not just me. Editorials will always be signed, but they'll express the position of Medscape. That's new. That's not been done on Medscape.

Second, I expect that we will add new sections to Medscape, including health-services research and public policy. Those aren't there now and certainly should be. We have a section on managed care, and we'll enhance that as well.

Third, after I get the Chicago office fully set up and operating, and after we have created an overarching international editorial board for the whole site who will be advisory to me, if that board and the owners of Medscape agree, we will probably try to create the first Web-only general medical journal.

I haven't done it yet, but people are already sending me stuff and, yes, there are authors who are already angry with me for not putting it in. But I never told anybody that we would have one now, only that we're going to have one sometime. That's the funniest part of the whole thing so far. It tells me that there are authors there who want their stuff on a Web-only publication.

HMSB: Why?

GL: They want quick publication. They want the visibility of a million readers, which is fantastic. They want the panache that Medscape already has, and I want the credibility that I bring reflected in their publication, because they know we're going to get attention. When we at Medscape start putting controversial editorials on the Internet and start publishing general medical articles, we will get major press coverage with it (and the author's going to know that) over and above people coming to the Internet to see that text.

HMSB: Obviously public-health issues impact the public. How does the role of the public press differ in reporting controversy?

GL: We at JAMA, and now we at Medscape, consider public journalists to be our friends and colleagues. We believe that patients should take charge of their health. To do that, they have to have information from the better medical meetings and journals.

In print publications, there are two problems in achieving this: There's a lag time which is substantial, and there's a distribution problem. Print biomedical publications generally don't go to millions or hundreds of millions of people. They only go to hundreds or thousands (or, rarely, hundreds of thousands) of people, most of whom are professionals. So in order to get a multiplier effect of information at JAMA, we cooperated with the public media - radio, television, magazines, and newspapers - free of charge.

On the Internet, one has a somewhat different situation. The general public has access, and the better Internet sites are free. At Medscape, I have to wear the hat of physician-scientist, but also the hat of journal editor and, in a sense, also of public journalist, because the public has free access to Medscape (as it did to the AMA site).

When we built the AMA Web site in 1995, we conceived it as a site for professionals, and so we stated. We were quite surprised early on, in the first month or two, to note that 60% or 70% of the people who appeared were not physicians or allied health professionals but the general public. We kept track for several months as people registered on the AMA site. The percentage of new registrants from the general public increased. When we stopped tracking, registration was running at about 70% non-physician or medical professional. So we learned unequivocally that patients like to come to the doctors' site and read doctor stuff.

HMSB: What impact did that have on your judgment about the way you needed to handle controversial topics? Did you temper what you did?

GL: You had to think about it even more carefully. One has to assume that the knowledge base the public brings will be varied. On the other hand, I don't see that as awesome. People have always been able to go to libraries to read medical journals or medical books. The take-home message is whatever they wish. In a free country with a free press, people can get access to whatever they want. Our whole approach has been to try to be as clear and accurate as possible, and then to encourage readers to use whatever medium they can to get useful information.

Several years ago for an editorial subtitle I coined a phrase: Caveant lector et viewor. Caveant is the plural of caveat. Lector is reader. Viewor is a Latin word I created, because it sounded good, for somebody who looked at a screen. The main criticisms I got were from people who thought I had misspelled caveat and language purists who didn't like my creating a new word in a dead language. But an editor can do what he or she wants. I like it a lot. So the reader and the viewer had best beware.

They should consider the source, go with brand-name identification when possible, hope that those trusted sources don't let them down in a new medium, and hope that the old reliables like Mayo Clinic and Harvard and the CDC and the National Institutes of Health and, I guess, the American Medical Association, and the newer authorities (led by Medscape, by far), will give them true and honest information to the best of their ability - and not spin it for their own marketing purposes.

Everybody needs to be aware that somebody is trying to sell them something at all times - and maybe they're offering something that's in the reader's best interests, and maybe they're not. People have to be very alert to that.

HMSB: That raises another issue: Advertising on the Web is a different animal from what it is in a medical journal. Have you begun to establish new policies for how you will use advertising on Medscape?

GL: We use as much advertising as possible. It's our principal source of revenue, because we give away information free, and we intend to continue to do that, so we want as much advertising as possible.

However, I take issue with your statement that it's all that new. Some elements of it are new, others aren't. When JAMA was founded in 1883, among the many reasons the committee report gave for its founding was to generate revenue for the American Medical Association. JAMA has run ads in every issue since July 1883. The nature of the ads has changed and the kind of products has changed and how it's done has changed, but the principle of giving advertising to people is there.

The main principle is people should be able to tell the difference between an ad and a non-ad. It's an editor's job, working with the publisher in any medium, to assure ethically that the average person can tell the difference, and they're not hoodwinked.

We set the rules for this in JAMA, in April 1997. An editorial states the basic rules about how the medical Internet should work, including the advertising element, to help the patient to protect him or herself. And the International Committee of Medical Editors published an editorial on June 11, 1997, in JAMA, with its statement about how the Internet should work. It's a very crisp and clean statement, it's still perfectly applicable, and it basically says you have to clearly separate editorial from advertising. One must disclose sources of financial support, one must disclose authorship, one must attribute information to its proper source, and one must post on the Internet the date you put something up. Most health sites don't have any of that.

I coined the phrase Internet payola for the practice of paying another company to have people routed to your site without disclosing the fact. The ethical thing to do, if a site routes anybody anywhere, is to let people know they're leaving the site, and to tell them whether you were paid to send them away.

When one refers a person from one medical site to another, to me it's the same as a physician referring a patient to another doctor. You're vouching for the validity of that other source. If the referring physician doesn't believe the other doctor will do a good job, they shouldn't send them there. An Internet site really, ideally, has the same responsibility. But there isn't any way to regulate the Internet. It has to be self-regulation, and viewers have to regulate it pretty much themselves, because there are no boundaries, geographic or political. It can't be regulated.

George D. Lundberg is editor in chief of Medscape. He is also a senior fellow at the Institute for Health Services Research and Policy Studies at Northwestern University and adjunct professor of health policy at Harvard School of Public Health.

Caleb Brown is an illustrator and biologist living in Montana. By day he drives a delivery van, and by night he draws pictures with his computer.

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Endlinks

Breakthrough? The Science and Politics of Medical Journalism - downloadable files of talks presented at a conference focused on medicine and the media. From the The Lancet, 21stC, and the Horace W. Goldsmith Foundation at the Columbia University Graduate School of Journalism, New York.

JAMA and Editorial Independence - Journal of the American Medical Association editorial addressing Lundberg's dismissal.

George D. Lundberg Ousted as JAMA Editor - JAMA's own initial news article on the dismissal.

Storming the Barricades - New Scientist explores the impact of the Internet on peer review.

Related HMS Beagle articles:

• The Future of Medical Publishing - Cutting Edge debate.
• Great Feuds in Science: Ten of the Liveliest Disputes Ever - review of Hal Hellman's book.