Biomedical journals and the Internet

Elizabeth Leef Jacobson, MD; Michael Jacobson, MD, MPH

The World Wide Web, which greatly facilitates the distribution of information, poses a challenge to traditional forms of publishing, including printed biomedical journals. In a recent article (1), LaPorte and Hibbitts argue that the Internet is a publishing alternative "in many ways superior to traditional journal publication". Although in the near future medical journals are unlikely to be replaced by author-posted papers on the Web, journals will need to adapt to significant changes brought on by widespread access to the Internet.

Medical journals are complex entities with multiple functions.They act:

Each of these roles is subject to different influences from the emerging information super-highway.

Journals as distributors of medical news

Most medical developments reach the profession, the media and the public after appearing in one of the major journals. Journals have maintained control over the release of information primarily through the Ingelfinger rule (2). Developed by a former editor of the New England Journal of Medicine, the Ingelfinger rule stipulates that a journal will only print material not previously published elsewhere. Although presentations at medical meetings are exempt and the press can report on them, the rule remains an effective brake on non-journal reporting of medical developments (3). The Internet now threatens the journals' control over the release of medical news, a threat amplified by several concurrent factors.

On the Internet, information is a fluid commodity, passing between source and consumer with ease and speed. An interested person can search for and obtain information online and then electronically contact the source. In the medical domain, the traditional flow of medical news from researcher to the media to the public can be circumvented in a similar fashion. Such point-to-point flow is much harder for journals to control than the traditional path through the media. As the public avails itself of the Internet's capacities, the ability of medical journals to direct the dissemination of medical news will be reduced.

Other factors will accelerate this development. In a climate of decreased public support, biomedical research is being carried out in a competitive marketplace. Privately-funded researchers have a strong incentive to bring new developments rapidly before the public and are less likely to be swayed by the Ingelfinger rule. Finally, medical journals justify their control over the dissemination of medical news by pointing to the harm that can be done when un-reviewed material is prematurely and irresponsibly leaked to the public (2,4). The current trend away from medical paternalism greatly weakens this argument.

Just as the medical profession is losing autonomy in decision-making to the economic forces of managed care, medical journals will lose control over the dissemination of research developments as a result of these combined forces. Although the New England Journal of Medicine has stated that the Internet is a published medium and thus subject to the Ingelfinger rule (4), the British Medical Journal is already exploring the possibility of publishing "pre-prints" on the Internet prior to acceptance and publication (5). In the long run, the Internet will assume an important role in reporting and disseminating medical news and the journals will probably grant it a dispensation similar to that accorded medical meetings.

Journals as quality control

Quality control is another major function of biomedical journals. Prior to publication, the selection and editing of articles by peer review is designed to assure a measure of quality control over research methodology and presentation. After articles have been published, they are reviewed by the profession as a whole and critiqued, primarily through the medium of correspondence sections in journals.

Although the Internet will undermine the news function of journals, it will greatly enhance their importance as vehicles for peer-review. As the Ingelfinger rule is relaxed and new sources of medical information appear on-line, we will be confronted with masses of medical content of unclear provenance and quality. Professionals and the public will need reputable sources to separate the valid from the bogus. Reliable peer-review will be critical, and Journals are well-placed to perform this task. The rise of the Internet is likely to enhance the value of journal publication as an imprimatur of quality. Peer-review by Internet, as suggested by LaPorte (6), is appealing and democratic but will supplement, rather than supplant, peer review by the medical journals.

Post-publication peer review will also be enhanced by the facilities of the information super-highway, but in a different way. It is now possible for authors of articles, other experts and readers to engage in an on-line dialog after publication. Journal articles will evolve into foci for ongoing discussion of important topics. This could take place at a "site" organized by the journals themselves, or at independent sites (such as Journal Club).

Journals as medical libraries

Journals serve an important role as repositories of medical information. The aggregate of biomedical journals can be viewed as the accumulated knowledge of the field, more complete than any collection of textbooks and more up-to-date.

The role of journals as repositories of medical information will also be enhanced by the Internet. The main obstacle to using journals as a primary reference source has been the necessity to use a library in order to access articles. Pulling a textbook off a shelf is substantially easier. As databases of references such as MEDLINE migrate to the physician's desktop computer, and as abstracts and full-text become obtainable on-line, this situation will no longer pertain.

Until recently, MEDLINE access was quite costly. It is now available for free from multiple sources on the Internet. Similarly, the cost of full-text references on-line is high at present, but as the technology for "pay-per-page" becomes more developed and with rising competition, access to journal references will be accessible and affordable. The entire medical literature will soon be easily accessible from the desktop, and will, indirectly, enhance the value of biomedical journals as primary reference sources.

Journals as power brokers

Finally, medical journals and their editorial staffs are important components of the medical profession's infra-structure. In order to advance in academia, publication is crucial. Reward is meted out by those who wield the power of the press. Even if scientific merit is the prime criterion by which articles are judged, other factors obviously enter into play. Those who reach high positions in academia are often on the editorial boards of major journals and play an important role in editorial decision-making.

The role of journals as elements of the medical hierarchy will depend on their ultimate place in the medical information marketplace. The Internet magnifies the leverage that can be gained by having the right information at the right time. If biomedical journals retain an important position in the market of medical knowledge, their influence is likely to be enhanced in the future rather than threatened.

The journal of the future

In an article in Wired magazine (7), information guru Esther Dyson predicts that wide-spread connectivity will lead to a devaluation of intellectual property ownership. In her view, "content" will be largely free on the Internet, and will serve mainly as an enticement to marketable services. To take a concrete example, ownership (and sales of) the MEDLINE database is less important than providing a useful search engine for that database.

Taking the notion of service over content together with the considerations described above, we can see the outlines of the successful biomedical journal of the information age. The journal will exist in print and on-line. Subscribers will be able to access full-text for free, non-subscribers for a reasonable fee. Peer-review will remain one of the most valuable services provided by the journal. Letters to the editor will be replaced by an on-line dialog between study authors, readers and experts. Articles will become organic entities, growing as knowledge accumulates. Links will be provided to relevant sources of material elsewhere in the information space. The journal will retreat from its position of jealously guarding the copyright of its content and move towards becoming a service provider for all consumers of medical information.

April 21, 1997

Reader comments

Date: Mon, 28 Apr 1997
From: (Sergio Emanuel Kaiser)

Michael, there is an important point for us, doctors who live in poor countries:

After the spreading of the Internet, it became very easy for those who own a computer, to have free and fast access to Medline, as you have stated. However, if it turns into a matter of having access to the full texts of medical journals, we are still faced with lots of trouble. Here in Rio de Janeiro, for instance, one has to seek for desired articles in several different libraries, in order to obtain just part of the information one might eventually need. If one is persistent, then one can fax some specialized institutions that will try to get a few more papers which are hard to find. After 2-3 weeks, search will be 80% complete.

Even so, it is now much easier for us, thanks to the Internet, because just two years ago Medline searches were not only expensive, but also performed by library staff, according to some prespecified rules, bringing up lots of trash polluting important information while missing, on the other hand, some precious articles.

Once a "pay-per-paper" system becomes more cost-effective through the Internet, then the diffusion of medical knowledge from peer-reviewed journals to readers and researchers living in developing countries will be solid and fruitful.

The gap between the generation of such information and its applicability to our different environment might also be reduced, once the discussion of such matters could be stimulated through Journal Clubs and specialized forums, such as Satellife (htttp://

Date: Tue, 29 Apr 1997
From: Rangan V <>

I do agree that lots of doctors in the developing world are totally ignorant of the real value of accessing data bases via the Internet, and also consider owning a PC a luxury, only meant for accounting purposes.

Until & unless an effort is made to dispel these wrong ideas and make computers cheaper to the medical fraternity, especially those in rural areas --- all this talk of upgrading etc. becomes useless.

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1. LaPorte RE, Hibbitts B, Smith R, Horton R, Lundberg GD, Davidoff E. Rights, wrongs, and journals in the age of cyberspace. BMJ 1996;313:1609-12. Full text from the BMJ site.

2. Angell M, Kassirer JP. The Ingelfinger Rule revisited. N. Engl. J. Med. 1991; 325:1371-1373.

3. Altman LK. The Ingelfinger rule, embargoes, and journal peer review. Lancet 1996; 347:1382-86 and 1459-63. Abstract

4. Kassirer JP, Angell M. The Internet and the Journal. N Engl J Med 1995; 332:1709-10. Full text from the NEJM.

5. Delamothe T. Why we should allow authors to post preprints on the Internet. BMJ website. September, 1996.

6. LaPorte RE, Marler E, Akazawa S, Sauer F, Gamboa C, Shenton C, et al. The death of biomedical journals. BMJ 1995;310:1387-90. Full text from the BMJ site.

7. Dyson, E. Intellectual Value. Wired Magazine July,1995 pp 136 ff. Article text

Search Medline for "computer communications networks and publishing" from the NLM's PubMed database.

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