Feature The Ingelfinger Rule: Franz Ingelfinger at the New England Journal of Medicine 1967-77

Jennifer Toy current article addresses these questions. sity football at Yale, hosted touch-football games at staff picnics each fall (he usually Where do we obtain our facts as well as Before the Editor ensured the outcome by selecting all the our theories? Both are being published Ingelfinger stood just over 6 feet tall and big, fast residents for his team), and took daily, in the medical journals that we had a lean, rugged frame. By his late 20s, his children traveling around the world.5 read. Medical journals help to shape he had noticeably receding light brown In his later years, he dug, fertilized, and our medical knowledge by supporting hair, and behind his large, wire-rimmed pruned in his Ipswich garden, never losing a theory, or by challenging a theory glasses he had the quick, analytic eye of the spirit of rivalry. In the summer under with facts, or by deliberately pointing a perfectionist. His critical tongue elicited his direction, the children and grandchil- to new theories. Who decides what we dren would cultivate personal “competi- read? The editors. Ingelfinger’s ... influence tive gardens”, each vying to grow the most Jan P Vandenbroucke1 acorn squash and tomatoes (personal com- on scientific publication munication, Julie Ingelfinger, 15 October In 1969, the New England Journal of 2001). Medicine instituted the Ingelfinger rule, an remains When he became editor of the New embargo designed to keep scientific find- England Journal of Medicine in 1967, ings out of the media until peer-reviewed incontrovertible. Ingelfinger was one of America’s leading and published in the Journal. The rule’s gastroenterologists, at the pinnacle of aca- founder and namesake, the famed New demic gastroenterology and chief of a large England Journal editor Franz Joseph fear from his 50-some medical fellows (and and thriving clinical service. Colleagues Ingelfinger (1910-80), stated that no two children). Those who knew him inti- credited him with “converting gastroenter- article he printed should be published else- mately as a friend, colleague, or teacher ology from a field of dogma and witchcraft where beforehand and, furthermore, that a spoke of a greater-than-life personality to a scientific quantitative discipline”.5 scientific claim should always be validated who could make cowards of grown men That year, he was on the brink of a career before dissemination to the public. Thus, and produce residents whose devotion, one change that would broaden his legacy and the rule prohibited scientific authors from former student wrote, “is best described as establish the Ingelfinger name in medicine releasing data to the mass media before the idolatrous”.2 When he was aggravated, as a whole, as well as in scientific publish- Journal’s date of publication. irritated, or frustrated, he had a peculiar ing. But in the preceding 3 decades, he had Although 25 years have passed since inclination to lean over and bite down on worked hard to rise through the ranks of Ingelfinger’s decade-long editorship ended the upper arm of his shirtsleeve, on his tie, his specialty. in 1977, his influence on scientific publica- or on his handkerchief.3 Born in Dresden, Germany, in 1910, tion remains incontrovertible. The rule he He preferred small quarters, at one Franz Ingelfinger was the only child established and formalized is now, in one time crowding himself and three secre- of Eleanor Holden and Joseph Franz form or another, a recognized protocol for taries into the hustle and bustle of a tiny Ingelfinger. His mother was a Yankee most peer-reviewed medical and scientific office—thriving on the inverse relation- schoolteacher who taught English lit- journals. Who was Ingelfinger, and what ship between working space and accom- erature, Latin, and mathematics (and was he like? How did the Ingelfinger rule plishment, which he believed rested on the continued to teach until she was 81 years emerge, and how did Ingelfinger’s concep- “enhanced flow of communication forced old).5 As Franz would be, Eleanor was tion of it evolve throughout the 1970s? The by physical constraints”.4 Throughout his strong-minded and without tolerance life he was an active, vigorous man. At his for fools. She was raised in Swampscott, JENNIFER TOY graduated in the history of country house in Ipswich, Massachusetts, Massachusetts, and, after graduating from science from Harvard College in March he rose every morning at 4 AM to write in Smith College, entered graduate studies 2002. She now studies landscape architecture his chapel-like office—and when the rest at the University of Göttingen. There she in Chicago. The current article is derived of the household finally stirred to life, he met and wed Joseph Franz Ingelfinger, an from a chapter of her senior thesis, Behind filled the house with the aroma of his spe- instructor in bacteriology and a scholarly the Story: Journal Governance in the cial pancakes, which were paper-thin and man devoted to the study of classics.5 In Production of Science News, 1969-2002. crispy around the edges. He played var- 1920, when Franz was 10, the family left

Science Editor • November - December 2002 • Vol 25 • No 6 • 195 Feature The Ingelfinger Rule continued postwar Germany and returned to Eleanor’s was Abbott.”5 Abbott, whose career was wider worlds of medicine and journalism, hometown of Swampscott, where she cut short when he died a few years after even after his death, for his innovative and taught at the Shore Country Day School Ingelfinger studied with him, became autocratic editorship at the New England and Joseph established a general practice the namesake of Franz’s son, Joe Abbott Journal of Medicine. His love of controversy as a physician. Joseph’s care, like his son’s Ingelfinger. and competition would add much to its later would, made a lasting impression For the next 30 years, Ingelfinger reputation and circulation. He sought to on his patients. As recently as 1995, the served as chief of gastroenterology at the broaden the scope of the journal with Ingelfinger family still received phone calls Evans Memorial Department of Clinical “special articles” about social and ethical from Joseph’s old patients asking to speak Research of the Boston University Medical aspects of medical care. He introduced to their former doctor and not knowing Center and produced over 50 fellows in the now-famous literary talents of Lewis that he had died in the 1950s. And to this training. Over half the “Fingerlings”, as Thomas, a physician and essayist, under day, the family continues to receive inqui- they came to call themselves, remained the title “Notes of a Biology Watcher” ries from Franz’s patients. in full-time clinical investigation, and and added a monthly Washington column, After study at Phillips Academy many came to direct their own GI units “Medicine and Public Affairs”, penned by Andover, Franz majored in English at Yale, in medical schools across the country. In Dan Greenberg. Twenty stable years of engaged in a broad liberal-arts program, 1961, Ingelfinger took on the additional editorship under his predecessor, Joseph and graduated Phi Beta Kappa. Originally responsibility of transforming the formerly Garland, had increased the New England he planned to enter the business world. dilapidated Boston University Medical Journal’s circulation from 20,000 in 1947 However, in 1932, his senior year and the to 100,000 in 1967—and by 1977, when pit of the Depression, Franz faced dwin- Ingelfinger ended his 10-year term, that dling job opportunities on Wall Street and “Teaching, above all”, he figure had risen to 175,000. hastily completed the necessary require- At age 57, Ingelfinger took reign, unify- ments for entrance to medical school. At stated, “is the task of the ing his policies under a vision that, like Harvard Medical School, he earned elec- that of his former career as a gastroenter- tion to Alpha Omega Alpha and began all-purpose medical ologist, was founded on the education of a career devoted to clinical research and the medical community. “Teaching, above teaching in gastroenterology. The initial journal.” all”, he stated, “is the task of the all-pur- reasoning behind this career decision was pose medical journal.”6 Challenging the characteristically Ingelfinger: He wanted journal to serve a new purpose as a medical to break new ground, and “nobody else Service at Boston City Hospital into one school without walls, he strove to emulate was doing it.” More specifically, Franz’s of national repute. the symbiotic relationship between the interest was ignited in the laboratory of As his career developed, Ingelfinger took teacher (now author), student (now read- T Grier Miller, a consummate clinician, on editorial responsibilities. He served on er), and dean (now editor), whereby they and William Osler Abbott, a creative the editorial board of the New England furthered collective medical knowledge. investigator with a “knack for designing Journal of Medicine. He chaired the edito- double-lumened tubes that could be placed rial board of Gastroenterology, edited the Education anywhere in the intestinal tract”.5 (The section on digestive diseases of the Year and the Ingelfinger Rule two are remembered as the inventors of the Book of Medicine, and was a two-time mem- The crux of Ingelfinger’s editorial philoso- Miller-Abbott small intestinal tube.) In ber of the editorial board of the Journal of phy rested in the belief that fresh contents their laboratory, which Ingelfinger called Clinical Investigation. And he edited a suc- made an indispensable contribution to a “the small bowel capital of the world”, he cessful book called Controversies in Internal journal’s teaching goals. “Without original blossomed under the Miller-Abbott tute- Medicine. In 1967, Ingelfinger took com- articles”, he wrote, “our printed efforts lage and learned the techniques available mand of the New England Journal with would become nonviable, gutless shells.” for studying the gut. In 1941, he married extensive editorial experience and quickly Ingelfinger admitted he had no evidence to a New York art designer, Sarah Shurcliff, crystallized a solid vision for his editor- support this belief, yet he argued on intu- with whom he had two children, Joe and ship. ition that originality engaged the reader: Lisa. “The reader’s appetite is less dulled by the Abbott became Ingelfinger’s dear friend. A New Career flavor of predigestion, and his self-esteem “If any one person”, Arnold Relman, Had Ingelfinger died in the middle 1960s, is sustained by the fact that his cerebral Franz’s successor as editor of the New he would have been remembered solely as exposure to the new is direct, not through England Journal, wrote, “can be said to an authoritative clinician and formidable a dialyzing membrane.”6 have had a decisive influence on a mind academic. Instead, he lived for another Considering the tumult gripping actual as independent as Franz Ingelfinger’s, it 15 years and came to be renowned in the university campuses in 1970—catalyzed

196 • Science Editor • November - December 2002 • Vol 25 • No 6 Feature The Ingelfinger Rule continued by the growing critique of science and its shift from Ingelfinger’s idealistic image as for medical news, Ingelfinger argued, neces- service to corporations and the military— editor-dean to the more practical view of sitated dependence on the journal as a reli- Ingelfinger’s notion of the New England himself as an editor-journalist. Faced with able purveyor of news. “We have to face the Journal as a pure realm for the flow of infor- the operational challenges of competition, facts”, wrote Ingelfinger. “We have on our mation, overseen by a benevolent dean and he moderated his educational vision with hands an organ [the New England Journal] free of politics and social protest, in some a savvy business approach. He began to that has become a prominent public figure, ways presents a striking utopian vision of view medical news as territory over which with the trials as well as perquisites of such the governance of scientific knowledge. the New England Journal had to compete a position.”8 As a popular source of medical Driving this ideal, however, was an authori- for control with many other media outlets. information and a role model, Ingelfinger tarianism that, as part of his personality, Wrote Ingelfinger, reasoned, the New England Journal held a powered much of his work. Over the 10 growing responsibility to filter the informa- years of his editorship, Ingelfinger actively when territory is in dispute, it is always tion disseminated to the public. sought to establish and maintain the juris- hard to draw a sharp boundary, and the However, Ingelfinger realized that to diction of the journal. In turn, from the very more precise a boundary, the greater the simply craft a competitive machine was not beginning he vehemently opposed what he opportunity for unhappy repercussions. enough to protect the journal’s influence saw as unruly, ungovernable practices in [But] if the Journal did not try to keep from diffusion. To this end, he fueled the medical journalism. physicians up to date but rather pub- journal’s prestige by also tearing down the lished only after everything was cut and credibility and authority of other sources Let us insist that policies of pure lais- dried and ready to go into a textbook, of medical news. A limitation of the mass sez-faire have no place in our complex our periodical would inevitably decline media, he warned, was that “although they society, and that all who put the word in importance, status and readership.8 pride themselves on reporting accurately, of medicine on paper—whether lit- there is no assurance that what they report terateurs or journalists—must for the Although his commitment to the educa- is accurate in the first place.”8 The New common good recognize and observe tional function of the journal remained England Journal, he said, must actively pre- certain rules of conduct.7 constant throughout his term, this defense vent “exaggeration and misrepresentation” of the rule reflects a clear conceptual from getting out to the mass media and To Ingelfinger’s alarm, however, rising development of the journal’s role in sci- thus the public: numbers of journals, prior publication in ence communication. The reality of com- free trade publications, and the general petition had in fact tempered his original One effect of the escalating public post-WWII proliferation of science cov- maxim that “teaching, above all, is the interest in medical news is that gener- erage in the media presented a dangerous task of the all-purpose medical journal” al medical journals that are reliable and threat to the journal’s capacity to print to a recognition that the pursuit and have maintained their newsworthiness original content and thus to its ability to dissemination of news is “a big, very big are increasingly cited [emphasis mine]. educate. business”.8 These journals thus eventually trans- In response, in 1969, 2 years into his edi- mit research findings to the public as torship, Ingelfinger formalized the policy In Control of a Public Organ well as to the health-care professions. that became known as the Ingelfinger rule. The Ingelfinger rule undoubtedly sup- To help prevent exaggeration and Almost immediately, prospective authors ported the New England Journal’s survival misinterpretation by the lay press and began receiving letters politely prohibit- in a competitive market, as well as the by the public, general medical journals ing them from speaking with reporters economic necessity to maintain and must evaluate submissions in a broader until after publication. If the author chose increase circulation. But also underlying than traditional context.8 to ignore this rule, or even if results were Ingelfinger’s rationale was his view of the published elsewhere unbeknownst to him journal’s public responsibility. In the early The Ingelfinger rule articulated Ingelfinger’s or her, the journal would reject the paper. 1970s, the opinion that the public had the definition of accuracy by weeding out the Such controls as the Ingelfinger rule thus right to know about laboratory work—even sensationalized ballyhoo of journalistic served the “common good” by setting before a scientist deemed his or her project medical stories from proper medical litera- the groundwork for “certain rules of con- complete—was gaining momentum.9 As ture. The rule created a formal dependence duct”—conduct, in Ingelfinger’s mind, evidenced by discussions at meetings and of the lay press on medical literature for best defined and administered by the New letters to editors, many doctors perceived information; it supported the notion that England Journal of Medicine. this movement as a threat to their profession the only medical research information and an encroachment on what they wished communicated to the public should be that A Very Big Business to maintain as specialized knowledge. Thus, published in a journal and thus approved by The middle 1970s marked a conceptual broad-based public interest in and demand peer review.

Science Editor • November - December 2002 • Vol 25 • No 6 • 197 HeaderFeature The Ingelfinger Rule continued

In conclusion, the Ingelfinger rule tions.8 Gastroenterology 1981;80:1062-6. represented a response to two changes in 3. Hoffman NY. Franz Ingelfinger, MD: a redoubtable science communication in the 1970s. First, Such was the vision Ingelfinger took with character. JAMA 1980;243:409-11, 414. competition forced the medical journal to him to his death when in 1980 he passed 4. Ingelfinger FJ. Acceptance of the George M Kober develop a way to protect its newsworthi- away after a 5-year bout with esophageal Medal. Trans Assoc Am Physicians 1979;92:51-3. ness. Second, the increasing sentiment cancer. The shifts in his perception of 5. Relman AS. Presentation of the George M Kober that “the public has a right to know” and the medical journal from a university-like Medal to Franz J Ingelfinger. Trans Assoc Am the backlash to this attitude in the scientif- “campus” to a “big business” and finally to a Physicians 1979;92:40-50. ic community meant, for Ingelfinger, that “public organ” reflected how he dealt with 6. Ingelfinger FJ. To impart the precepts and the the medical journal must take on greater concerns in medical journalism coming to instruction. Lancet 1968;2(7571):766-7. responsibility (and develop rules) to con- a head during this time. In response, he 7. Ingelfinger FJ. Medical literature: the campus with- trol public well-being. Wrote Ingelfinger, developed and upheld the Ingelfinger rule out tumult. Science 1970;169:831-7. and through his far-reaching vision for the 8. Ingelfinger FJ. The general medical journal: for We must recognize that the ideas pro- New England Journal of Medicine developed readers or repositories? N Engl J Med 1977;296: mulgated within our covers not only a clear, authoritative role for the general 1258-64. will be seen by knowledgeable profes- medical journal that still echoes true in 9. Culliton B. Dual publication: “Ingelfinger rule” sionals but also may be the source of science communication today. debated by scientists and press. Science 1972;176: secondary news stories that may elicit 1403-5. inappropriate public or legislative reac- References tions. Somehow, we must try to be 1. Vandenbroucke JP. Medical journals and the shap- both trustworthy and newsworthy—a ing of medical knowledge. Lancet 1998;352:2001-6. balancing act of redoubtable propor- 2. Levitt MD. Franz J Ingelfinger: the man.

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