28 Practical Dermatology March 2008

he influence of “the literature” on daily medical ings from a Merck-sponsored study of rofecoxib, alleging that practice is incalculable. Through it, researchers manuscript authors suppressed evidence of cardiac effects caused share and pursue additional avenues of discovery, by the medication. Certainly peer reviewers can assess the infor- while clinicians uncover the latest information mation presented in a publication, but they cannot know what about new patient care strategies. Without pub- relevant information is not presented. Tlished studies documenting the efficacy of new drugs, physicians According to the International Committee of Medical would be hard-pressed to adopt them into practice. Every clini- Journal Editors (ICMJE), a peer-reviewed journal is “one that cian has at some point mined the literature for clues to the diag- submits most of its published research articles for outside nosis or management of a challenging case. The literature can review.” The group of general medical journal editors whose par- even influence insurance coverage decisions, as companies deter- ticipants meet annually and produce the Uniform Requirements mine broad policies and decide case-by-case coverage based on for Manuscripts (URM), acknowledges that, “The number and available published evidence. kind of manuscripts sent for review, the number of reviewers, the It is incumbent upon physicians to keep abreast of the litera- reviewing procedures, and the use made of the reviewers’ opin- ture relevant to their field of practice. Yet familiarity with med- ions may vary. In the interests of transparency, each journal ical journals may breed complacency; those who depend on should publicly disclose its policies in its instructions to these publications may take for granted the quality of informa- authors.” Among US journals, both the Journal of the American tion presented in the canon of the literature while unduly dis- Academy of Dermatology and Archives of Dermatology follow the missing other worthy sources of pertinent, quality information. ICMJE URM, which outlines policies for peer-review processes. To encourage a more thoughtful approach to the medical litera- Another group of editors, the World Association of ture, the following is a primer on peer-review, indexing, and Medical Editors (WAME, pronounced Whammy, estab- other elements of publication. lished in 1995), “is a voluntary association of editors from Peer Review. The concept of peer-review is intended to countries throughout the world who seek to foster interna- ensure the scientific rigor of a published research article. Peer tional cooperation among editors of peer-reviewed medical reviewers generally are charged with validating the research journals.” Archives of Dermatology, International Journal of methods employed, assessing the veracity of data and statistical Dermatology, Journal of the American Academy of analyses as presented, scrutinizing the integrity of the research Dermatology, and Photodermatology, Photoimmunology & from inception to data analysis, and identifying any potential Photomedicine are journal members of WAME. WAME biases that may invalidate or diminish the impact of findings. maintains that to be peer reviewed, “a journal should have Peer review is hardly fool-proof, as demonstrated by the 2005 obtained external reviews for the majority of manuscripts it Vioxx debacle, in which the New England Journal of Medicine publishes, including all original research and review articles. publicly acknowledged flaws in a 2000 published report of find- Some editors request peer review for other kinds of articles, 28 Practical Dermatology March 2008 such as opinion pieces (commentaries/editorials) and corre- define a ‘peer reviewed journal’ in clinical medicine,” accord- spondence.” The association adds that a manuscript should ing to one publication.3 have been reviewed by at least one external reviewer to be Selection of reviewers is itself an area of scrutiny, with some considered peer reviewed, though it is typical to have two noting that selection processes and reviewer qualifications are reviewers or more. often ill-defined.4 One investigation found no particular formal Ironically, within the literature there is relatively little training or experience that predicts reviewer performance.4 published regarding the impact of editorial peer-review.1 One author has suggested that “peer review” has sup- Study of the impact of peer review is difficult, due in large planted the scientific standard of “peer usage” as a method part to variability in peer review processes across journals. for evaluating scientific data. Peer review, a prospective vali- One review of peer review practices at well-known clinically- dation measure, is more rapid and less expensive than peer oriented journals compared to those at interdisciplinary and usage, a retrospective and largely more costly undertaking.5 specialty journals showed distinct editorial review practices The latter method is essential to pure science with its repli- for each type of journal, with less reliance on editorial peer cation of results or refutation of hypotheses, while the for- review in the former group.2 Variability in peer review mer may be suitable for applied science, (e.g. medical prac- processes, including extent of the review process, sequence of tice). However, the role of opinion and, consequently con- decision points in the process, blinding practices, acceptance flict of interest, may influence the usefulness of peer review. rates, and guidelines for reviewers, “make it difficult to Conflicts of interest (discussed below) may permit “damag- March 2008 Practical Dermatology 29 Medical Literature ing distortions” to become “‘locked-in’ to clinical practice WAME suggests that “all participants in the peer review and and health policy for considerable periods.”5 publication process” disclose all relationships that may present a Finally, it is worth noting that studies suggest that editorial potential conflict of interest. peer review may not provide much benefit as a means of ensur- Indexing. As its name implies, journal indexing refers sim- ing quality of biomedical research,1,6 but researchers maintain ply to the process of collecting journal information into one that “absence of evidence on efficacy and effectiveness cannot be database or “index.” Perhaps the index with which most physi- interpreted as evidence of absence.”1 cians are familiar is the National Library of Medicine’s Medline, Readers of the refereed literature would benefit from publi- searchable online via PubMed. On a technical level, Medline cation of each journal’s peer review processes so that the reader employs the Medical Subject Headings thesaurus to facilitate can critically assess them. This practice is encouraged by both electronic journal content searches. Medline has fully replaced WAME and ICMJE. A systematic review of English-language Index Medicus (properly titled Index Medicus/Cumulated Index journals listed in Index Medicus in 1994, however, revealed that Medicus (IM/CIM)), the last print publication of which was half did not publish clear statements about their peer review produced in 2004. practices.7 Index Medicus developed under Dr. John Shaw Billings Evidence-based Medicine. The notion of evidence-based (1838-1913), an army medical officer charged with organiz- medicine (EBM) has gained prominence, particularly in the ing the surgeon general’s reference library. Billings eagerly past decade, as a means for validating clinical care strategies. sought publications to add to the collection then undertook EBM has been adapted for use to “score” recommendations an effort to index the collection. Owing perhaps in some published in review articles and by working groups convened to measure to the nature of Index Medicus as a print publica- assess management of particular disease states. In some respects, tion, an application and review process was instituted for evidence-based rankings may be considered an alternative to journals that wished to be indexed. With time, the collection editorial peer-review for publications that are not research morphed from Billings’ collection of any and all publications reports. with medically relevant content to a more selective, though Evidence-based medicine (EBM), “is the conscientious, extensive, listing of qualifying materials. As more and more explicit and judicious use of current best evidence in making libraries, academics, and researchers came to depend on the decisions about the care of individual patients,” according to Index, inclusion was thought to signify the “merit” of a pub- Sackett.8 In practice, EBM requires a combination of clinical lication. As biomedical science has advanced and publication expertise with the best available external clinical evidence from has expanded, the number of Medline’s indexed journals has systematic research. Therefore, EBM does not supplant peer- swelled to approximately 5,000 worldwide journals in 37 review; peer-reviewed publications form a basis for much of the languages. The electronic nature of Medline presumably will “evidence.” “By best available external clinical evidence we facilitate further rapid growth. mean clinically relevant research, often from the basic sciences Currently, selection for Medline indexing is based largely on of medicine, but especially from patient centered clinical the recommendations of the Literature Selection Technical research into the accuracy and precision of diagnostic tests Review Committee,

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