Selection of articles for ACP Journal Club according to content
ACP J Club. 1992 Nov-Dec;117:A18. doi:10.7326/ACPJC-1992-117-3-A18
We accepted Dr. Pater's offer to comment on the content of ACP Journal Club to air the views of subspecialists in internal medicine who have inquired about the lack of depth of coverage of their field. As Dr. Pater knows and has documented, we are selective about the articles that we abstract or cite in ACP Journal Club. This selection process is, however, more complicated than a focus on specific content: It involves both study methods and content. Our selection criteria are stated in each issue in our Purpose and Procedure section. For methods, the criteria are explicit (e.g., “Studies of prevention or treatment must [include] random allocation of participants to comparison groups”) and can be reproducibly applied. For content, the criterion is simply “… disorders managed by internists.” The application of this criterion may not be as reproducible as those for methods, because the boundaries of “internal medicine” are not well defined and continue to evolve and, possibly, because we, the editors, are conditioned by our own training and preferences. This latter possibility is worth considering, and readers may wish to comment after reading the following explanation of how we apply our criteria.
The content of ACP Journal Club is determined by the strongest studies available on the cause, course, diagnosis, therapy or prevention, or quality of care and economics of adult medical disorders in the 35 to 40 journals we review for each issue. Only a small proportion of the articles published in any journal passes our criteria, and there is no guarantee that the subject matter of these articles will match the prevalence or impact of the disorders in the community; rather, they reflect the prevalence of scientifically sound studies published in the literature during the period of review. As any internist can attest, “things are happening” in the management of cardiovascular disorders, with a remarkable number of positive trials documenting the incremental value of a burgeoning array of new treatments. This explanation is the most important for the preponderance of articles on cardiovascular disorders shown in Dr. Pater's table.
However, another important determinant of the content of studies we select stems from our position on the target audience for ACP Journal Club, namely, internists, and stemming from this, our notions of what an internist is and does. The notions go like this. An internist sees patients with a broad range of problems, not delimited by any organ system. Because of the breadth of knowledge required to handle this range of problems, an internist will probably not do invasive procedures requiring high levels of skill and frequent practice, such as biopsies, endoscopies, or catheterization of major organs. Nevertheless, an internist will need to know the proven, important modalities of diagnosis and treatment for all of the organ systems. Thus, an internist should know that endoscopic injection for bleeding duodenal ulcers, added to histamine-antagonist therapy, reduces the risk for rebleeding and the need for emergency surgery when compared with histamine-antagonist therapy alone (1), so that he or she can arrange for appropriate referral. An internist, in this view, would be less interested in knowing of the greater convenience but equivalent therapeutic results with endoscopic method A compared with method B, although gastroenterologists might be very interested.
The situation is more difficult for oncology, and we purposely treat this field somewhat differently. Most of the treatments are toxic and complicated, and, as a matter of policy, we do not include studies of most cancer treatments because we feel that physicians with a special interest in oncology ought to be selecting and administering these treatments. Internists do, however, need to know about the prevention and early detection of cancer, comparisons of the major modalities of therapy that produce clinically important differences in outcome (so that efficient referral can be arranged), and the best care of terminally ill patients. Thus, we do include articles on such topics—if they meet our scientific criteria.
How, then, does ACP Journal Club serve the subspecialists of internal medicine? Although subspecialists may have given up on keeping up with all of internal medicine, they treat patients who have complex medical problems that frequently extend beyond the scope of their expertise. We have received many grateful letters from subspecialists who feel that ACP Journal Club provides a way for them to keep in touch with the major advances in all fields of internal medicine, permitting more efficient consultation and organization of care for patients with complicated disorders.
We agree with subspecialists who feel that ACP Journal Club lacks depth in their field and invite interested groups to form their own subspecialty publications.
This is an explanation of how we have been operating, not an apology or a decree. If you have strong views (positive or negative) on the content we cover, please send us a letter. Be sure to state whether you are a generalist or a subspecialist if you indicate that we ought to be covering a given topic in greater depth. It would be very helpful if you could send articles that illustrate your view … and that meet our scientific criteria.
R. Brian Haynes, MD, PhD
Hamilton, Ontario, Canada