The Emerging Challenges of Medical Journal Editors

Podcast Transcript

Dr. James K. Stoller:

Hello and welcome to MedEd Thread, a Cleveland Clinic education podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello. Welcome to today's episode of MedEd Thread, an education podcast exploring the crucial role and emerging challenges of medical journal editors. I'm your host, Dr. Tony Tizzano, director of Student and Learner Health here at Cleveland Clinic in Cleveland, Ohio. Today, I am very pleased to have Dr. Brian Mandell, editor-in-chief of the Cleveland Clinic Journal of Medicine and professor and chair of Academic Medicine here to join us. Brian, welcome to today's podcast.

Dr. Brian Mandell:

Thanks, Tony. It's really nice to be doing this. I'm happy to spread the legend of what editors do and don't do to anybody who's listening.

Dr. Tony Tizzano:

Perfect. Well, along those lines, to get us started, if you could tell us a little bit about yourself, your educational background, what brought you to Cleveland and your role here at Cleveland Clinic.

Dr. Brian Mandell:

It's kind of a novella in and of itself, but I'll, I'll abbreviate that. So I started this sc- science medical career getting a PhD in physiology and biophysics with an interest in inflammatory diseases and cellular biology. That morphed into needing some knowledge of human biology, which I thought the best way to do that was to get an MD, which, which I did. Then once doing that, trained in internal medicine and then in rheumatology with that shared interest between rheumatology, internal medicine and my own curiosity in inflammation.

So I was at University of Pennsylvania for a number of years, was in industry doing drug development in the space of exploratory clinical pharmacology and inflammation. For a short period of time, I missed clinical medicine. I was going back to running a basic science lab and realized that I really enjoyed clinical medicine and education in clinical medicine the most, and then moved from Philadelphia to Cleveland with the uniqueness really of the, the medical center here at Cleveland Clinic. That within rheumatology space and involvement in medical education, residency training, fellowship training, and then general medical education brought me to the role of editor-in-chief of the Cleveland Clinic Journal of Medicine.

Dr. Tony Tizzano:

Well, you've had a fabulous trajectory and, you know, you only have to take a peek at your CV and have a postage scale at hand to weigh the volume of what you've done. So in today's segment, we'll explore the evolving role of medical journal editors in sustaining the integrity and relevance of medical publishing amidst an increasingly complex research landscape. So, Brian, if you could help us frame today's topic, providing the listeners with some context and sense of your role as editor of the Cleveland Clinic Journal of Medicine.

Dr. Brian Mandell:

Sure. First, I think you have to have a context of what the Cleveland Clinic Journal of Medicine was and is. It is not a typical medical scientific journal and that we no longer publish primary, original research. That ended about the time that I assumed the editorship, but really the driving force of that was from John Clough, another clinical rheumatologist who preceded me as editor in chief. We recognized that really the quality of research that anyone would publish in the Cleveland Clinic Journal of Medicine was not at the top tier of what is out there in academic medicine.

So why would we want to be publishing that in addition to clinical topics? Why not focus on what really our strength is as an institution and really focus on medical education and clinical practice and practicality. So we ended doing primary research and took over the role of a primary medical education journal with a focus on practicality, clinical relevance and accuracy of content, but trying to include in that really the personalized clinical expertise of our authors, which are... And we'll talk about this as we go through this discussion.

Anyway, not all Cleveland Clinic faculty. So the Cleveland Clinic Journal of Medicine is a unique journal in the sense that we publish reviews, conceptual topics, all of which are peer-reviewed by content experts and not doing research. So we're a little bit different than, you know, a typical medical journal that people tend to think about.

Dr. Tony Tizzano:

You know, you make a good point and I must say that when I come across a copy and look at the cover or look at it online and see a topic that I, as an OBGYN, it may be internal medicine, but it's put forth in such a manner that it's enticing to me and gives me just another little step towards understanding in a one direction that I may not be familiar with. So you've been doing this work for quite some time. How has the role evolved over the years?

Dr. Brian Mandell:

So I, I don't know that it has really changed in the major functions that the editor does. The fine points, you know, in day-to-day stuff has changed. Certainly the technology and support of what we do has changed, but the, the role of the editor of a journal like ours is really to focus on the content and really, in, in my mind that, again, I, I totally credit John Clough who came before me as the editor-in-chief o- of sharing this mission of looking at our papers really that they should be accurate, they should be very useful and they should really should be readable.

And I, I made the point before that we're different as a medical journal not doing primary research and in our publication, and there are other journals that do reviews as well. But I don't think there are many, and maybe none that really emphasize the same degree that, that we have over time of really the readability and digestibility of the information. Physicians often think that they write very well. We don't. We tend to be fairly verbose. We tend to be fairly lead-heavy in our writing style and we've really morphed the journal into having medical writers, and editors work with the authors to make our articles readable.

So they're really accessible. And I think that remains a primary moving force that motivates me as the journal editor to be sure that the content that we publish is really useful and readable. So as I, I look at the individual papers and I, and I do see all of them, the primary question I have for them and what I count on our peer reviewers to do is to address the issue of really can we get this message across in a useful way?

While many scientific publications are really for the authors to, you know, pad their CV, grow their academic careers, our mission for publication is really for the reader, not for the author. And I would say that occupies a good amount of, of my time to look at each paper in ways that we can emphasize the readability and emphasize the utility of, of the actual paper.

So that gets into, you know, how we can utilize our peer review process to get the best out of our peer reviewers and, and get them to understand that really is our goal. And I ask the peer reviewers, how can you make this paper better? What can you do to increase the utility of the educational message? And I say that really probably as much as anything else, takes the bulk of my time as editor-in-chief.

Dr. Tony Tizzano:

Yeah. I can really appreciate the importance of this more or less digestibility of the information. And I think that speaks to the popularity. So I imagine that you are confronted with an increasingly rapid pace of medical research that generates a constant stream of manuscripts that come to your table and each one hoping to be published. You know, how do you look at this huge number of papers coming your way and pick and choose?

Dr. Brian Mandell:

Yeah. So we- we're not inundated with thousands and thousands of papers because again, the nature of what we write is not for the author. Most medical authors when they're writing really are looking at how this is going to really enhance their own career. And I, and I don't say that critically. That's totally appropriate in an academic setting. So we are looking really for educationally useful manuscripts. So some of ours are about maybe 50% are solicited in terms of content and author, but even solicited ones are, are still totally peer-reviewed and none of them are just kind of gratis accepted.

50% just come in off of, you know, email submissions. So it's not a total, you know, boxcar of manuscripts every week that come in. But we do screen them initially as the topic appropriate for a general medicine focused in internal medicine audience. Is it... At, at first glance, is the manuscript actually written in a way that, that we think will translate well? I know we have medical writers who will help, you know, make it into a, a more polished product, but it's gotta be somewhere close to begin with.

So the first screen of those is, you know, really on topic. Is it, is it relevant to our readership? And is it in a format that we think we can work with the authors to, assuming it is accepted for publication, that it will be a useful contribution.

Dr. Tony Tizzano:

Excellent. So when you reflect on the body of work that you do and you look at challenges you might have, if any, what might they be?

Dr. Brian Mandell:

The challenge list is fairly long. The immediate one in the reality is really the challenge of getting quality peer reviewers. I am an internist, but I'm a subspecialist internist, so I don't do as much general internal medicine as I did once before. So there's no way that I can view myself as a content expert across the gamut of, of internal medicine. So I really do have to rely on peer reviewers to look at manuscripts for content expertise, make sure there's no bias built into this that I, you know, as someone not in that specific field might recognize.

So that's the main challenge I have is getting quality peer reviewers. Many will write a peer review correcting grammar, syntax, sentence structure. I, I don't need that. I have medical writers who are quite good at doing that, rephrasing a sentence where appropriate. So to get somebody who does a thoughtful review, not nitpicking, but looking really to enhance the educational message, that is far and away the major challenge. And as physicians get busier and busier in their day jobs, getting people to just do a peer review is challenge number one. Getting them to do a quality peer review is challenge number two to 55.

Dr. Tony Tizzano:

So that said, are there guidelines that you give to reviewers to, to kind of spell out what you're looking for?

Dr. Brian Mandell:

It turns out that, you know, physicians don't read any instructions whatsoever. They just don't. So we, we try very hard to say what we're looking for in a peer review and occasionally we get it. But usually we don't. And so we have to invite more peer reviewers and per article than, you know, when we actually need, A, because not all complete them, even though they've promised. You know, the check is in the mail is something we're very used to as a journal. So we have to ask for more reviews than, than we need and hope that they come through.

Sometimes we have to modify the peer review to make them useful to us and to the author. That's really the major challenge, Tony, that I, I would say that I face with. There are many incident kind of stories that come up with issues of occasionally of, you know, plagiarism or just bizarreness of articles and odd stories that come up, that are interesting for us to talk about in-house, but fortunately are not very common. It really does come down to peer review being the major challenge and then thinking about topics that I would like to see published.

You know, the easy ones are new class of drug that comes out, a major paper that comes out somewhere about a new utility of a drug or even sometimes a, a new disease or manifestation of disease that has become very apparent, and then trying to solicit to get in a timely manner an author to write for us about that. And that I would say is the second major challenge, and, and that's an enjoyable challenge that I have.

Dr. Tony Tizzano:

Yeah. Do you think that, that persons you're asking to be reviewers, is there protected time for doing that? Is that considered a noteworthy academic pursuit that physicians typically are given some time to do because to do a good job of it, imagine you've got to spend a bit of time with a paper.

Dr. Brian Mandell:

Yeah, it does take a while. I, I would say, you know, on, on a, on a standard length paper, you know, 20 to 30 minutes, if you know the topic is probably an appropriate amount of time to, you know, type your comments, read the paper, hopefully read the paper first before typing your comments is sufficient. For some that you may be a little bit outside your threshold of high energy knowledge, you may have to do some literature searching on it.

So, you know, protect the time. Well, you know, a huge percentage of physicians are now employed by medical systems. Certainly in academic people, that's even probably a larger number. So, no, I don't think people have protected time per se for this. At, at the clinic, people have very little protected time for other than defined tasks. So you're asking them to do this pretty much on their own time.

It is a recognized role that, you know, is very important in academic medicine, if not critically important in academic medicine. Do you get rewards for that? For in most universities for a promotion, you may be asked if you served on an editorial board. Some promotion committees will ask for, you know, journals that you've done peer reviews for. But for most, I, I would say it's critically important, but not certainly at the high end of something that's going to lead to your promotion from assistant to associate to full professor of medicine, for instance.

Junior people, it's a little bit different. There are issues these days for a visa and being asked to do a peer review or being on an editorial board. Even doing just peer reviews as part of that becomes important. So there are some niche areas that doing peer reviews and be able to document that you've done them is important. But for most, I think the answer is no. It's a, it's critically important, but a low tier for academic progression.

Dr. Tony Tizzano:

Very good. Well, taking a little higher level look, how does this transformation that seems to be ongoing of scientific publishing in general impacted your work? You know, the digital publications and proliferation of journals and open access, et cetera?

Dr. Brian Mandell:

Yeah. It hasn't really affected us directly at, at our journal very much. We do what we do. We do publish a print version. We go out to about 110,000 physicians, mainly internists, cardiologists, and some designated specialty groups. That's subsidized actually by Cleveland Clinic. We don't charge a subscription fee. That also is very unique for our journal these days. We used to get a lot of advertising revenue to make up for some of that cost. That's less and less these days. We are open access online, which I like and I certainly as an educational journal think is critically important.

Anybody can search for the Cleveland Clinic Journal of Medicine online and open and get a PDF manuscript, published paper and read it, copy it, distribute it. So that's very important. So that digital spread of information, that has been important to us. The overall change in the publication of medical journals, that, that hasn't affected us too much other than the issue of advertising.

Pharmaceutical advertisements used to be a big way that most journals were able to cover their costs. That has backed off from use of those funds for direct-to-consumer advertising. Anybody who watches the Cleveland Cavaliers is gonna find , you know, themselves watching commercials for the latest and greatest drugs for treating psoriatic arthritis. So that part has impacted the cost of actually managing the journal.

But day-to-day for us doesn't affect us too much. I don't think there's that much competition for other journals to where an author is going to send, you know, going to send it to Cleveland Clinic Journal of Medicine or someplace else. I don't think that has changed too much in terms of the landscape of what we get.

Dr. Tony Tizzano:

Very well. How about as far as trainees submitting work for you to consider it? Are there numbers of those and do they present some special issues for you to consider?

Dr. Brian Mandell:

You know, I, I emphasize, and I'll continue to emphasize the educational value and role of the Cleveland Clinic Journal of Medicine. So I like having trainees, uh, submit. We actually have a publication policy that if you are a trainee, you must have a full faculty, co-author on the paper, which, which I think is appropriate for any number of reasons, not the least of which is just, you know, the guarantee, the quality and the experience that goes into the words of that paper for our readership.

But I, I think, you know, the idea of trainees writing review articles gives them the opportunity to synthesize their thoughts, get peer review comments back on them, and the thought process, and I think that's part of the learning experience. Getting comments back on a writing style there I think is critically important and useful for trainees as well. So we, we like the idea of having trainees as long as they are clearly mentored through. We have had some challenges with trainees. There is a tendency to do a little bit more cut and paste, particularly in review articles than is appropriate where the line is between a little too much cut and paste and outright plagiarism.

Sometimes that can be a tough distinction to make. So we use duplication recognition software for all our manuscripts, which will pick things up and we see more with junior authors involved, trainees included in that junior authorship as a little bit more kind of cut and paste going into their writing and we'll give them feedback as appropriate to the manuscript itself.

Dr. Tony Tizzano:

Excellent. Well, that kind of opens the door for the next question. So what sorts of opportunities and complications or hurdles are posed by the emergence of artificial intelligence?

Dr. Brian Mandell:

So depending on what and how, you know, AI is utilized, one could argue that in fact duplication software is to a certain extent, you know, extension of artificial intelligence use. Maybe a little bit stretch in that terminology, but that has impacted us as well. In terms of having, you know, ChatGPT, essentially write your paper for you, there's a big to-do in the, you know, national and international, you know, editor population about this. Obviously, it's very strongly frowned upon. You cannot be an author if you are not a human being.

That's pretty much agreed on. How much AI is appropriate to do, you know, a basic draft that then you go after and work on. I don't think there's clarity in that. For our own sense, we've had a good amount of internal debate about this in-house. My own feeling is I'm okay with, you know, drafting parts of a paper that come from ChatGPT or equivalent and then the humans go at it and rewrite it, and check the references, check the nuances of the citations and what's being said and then crediting.

In fact, we did use AI for this purpose and this is what we did. There are growing trends to looking to recognize AI written manuscripts. Software, I think has lagged behind a little bit in terms of recognizing that, but that's coming along very quickly. We've not confronted something that we think was completely artificially written, but we have had some that we have suspected parts of it that clearly were not written by a, a thoughtful human who understood really what they were writing about.

So this is a very much in flux area of the role of AI in, in medical authorship and writing of manuscripts or writing drafts of, of manuscripts. There's a trend towards thinking about could you use artificial intelligence to do peer reviews, to check accuracy and content. That I've not seen used yet, but it strikes me that we should be able to at some point in time, be able to count on that for some component of peer review. Not entirely. Nuance is not a strength of AI to me.

Dr. Tony Tizzano:

Yeah. Interesting times for sure. I was reading a commentary. I can't remember the professor's name, but it was out of Boston University in journalism and he was saying, you know, it's one thing in an upper level course to see this used and then embellished by the human editing of what has been put out. But when you see students at the beginning using AI to generate an article or some... Or even a paragraph. He's now had to revert to actually having work done in class, so he knows it's their own work.

Dr. Brian Mandell:

Hmm.

Dr. Tony Tizzano:

You know, but it's interesting. But, uh, you know, like anything else, this technology comes about and we, we find ways to use it. We find ways to abuse it, but overall I think it's going to be very interesting.

Dr. Brian Mandell:

Interesting is an understatement and I totally agree and there's, you know, there's something in the writing process and the thought process that goes into writing that is very valuable to do within your own head as opposed to, you know, something that's handed to you as a template that then you go after. It's never quite the same, writing a revision of something to writing an original of something.

Dr. Tony Tizzano:

That was exactly his point. The ability to articulate your thoughts in a way that is engaging and understanding as opposed to just correcting something that you had somebody else give you. That, that's exactly what he was after. Well, if all this were not bad enough, I ran across an article about predatory journals. I'm not exactly sure I understood that. Can you kind of frame that a little bit?

Dr. Brian Mandell:

Yeah. So the concept of predatory journals is, is relatively new and the, the definition I, I think is a little bit of a moving target. I look at predatory journals as something that will take something that somebody has written, presumably a, a human that they want to be published and they will publish it under the guise of we are really a reputable journal and we, we're putting this out there for public consumption. What's missing in that is what we really expect from a high quality medical scientific, or really any, any peer review journal, which is a true peer review process.

So predatory journals tend to charge an awful lot of money to get something in print. Their goal is to make money. So they're not going to do a very heavy-handed peer review job because they might lose the manuscript or they might say, "Well, this is not worth publishing at all." So they're not going to do a very heavy-handed or quality peer review and it's going to come out and it's going to be published, and there it is. It's not the same as reading it in the New England Journal and the Annals of Internal Medicine, Cleveland Clinic, Journal of Medicine, when that comes out that way. So the paper itself will not have the same gravitas as something that has undergone a true peer review prior to acceptance and true publication.

Dr. Tony Tizzano:

I'm quite sure that our listeners hearing what you've had to say can be thankful that this information is vetted in the way that you do so that when someone reads it, they have a reasonable expectation that what I'm reading is true and accurate to the best of our abilities to do. Well, I know we've got a lot of podcast lovers out there, so I understand that the Cleveland Clinic Journal of Medicine has a Beyond the Pages podcast.

Dr. Brian Mandell:

Yeah, this is a relatively new thing that we've, we've played with. You know, the kids on the block and the editorial staff have been pushing to do more electronic and, and creative, non-traditional, you know, glossy black and white print journal for a while. So what we've done with Beyond the Pages is we've taken articles which seemingly have some interest either to different types of audiences, is a really hot topic, it's timely. And what we've done is bring them into this studio, bring the authors in and have an independent moderator basically interview the author about, uh, the content of the paper and beyond what they actually have, have written, pushing them for commentary on the commentary.

And it's been a fun short series. We're really just into this done, you know, probably less than a dozen now, but it is been fun. I've moderated a couple of these and we've had others moderate them as well. Not all, you know, subspecialty content experts have been the moderators, which is nice because it, it pushes the author to really explain things in a basic detail. It's been a fun exercise and so far it's seemingly been very well received.

Dr. Tony Tizzano:

It seems that it might appeal to persons who might be interested in publishing to hear what an author goes through, and to have somebody go back and forth with questions. I, I could see that would be curious. I'm going to have to look at that.

Dr. Brian Mandell:

Yeah. You know, we sometimes will ask one another, "Well, what made you write this? This is the direction you went into. And you know, you say these are all the facts, but what do you really do, you know, beyond the closed door of an exam room? Are you really writing it and using it this way? Or have you learned something that you weren't quite happy in putting in print, but what do you actually do?"

Dr. Tony Tizzano:

Very well said. So you've given us a lot to consider. That said, what do you see on the horizon for editors in your position?

Dr. Brian Mandell:

You know, you hit a couple of the topics that people are struggling with, you know, how do we get more into the electronic space, both in terms of publication, in terms of processing of manuscripts? I think those are directions that people are going into. The major challenge, I think to many journals now are twofold. And one is financial. How are our journals going to fund their own existence? You know, you can put things online with obviously less cost if you don't have to print and, and mail, but there still are all the editorial costs of processing of manuscripts if you're going to do it well, and if you're going to copy edit and spend really a lot of time doing that.

So who's paying for this? A lot of journals are coming under financial scrutiny. Some are funded by medical society, so dues to the medical society will pay for it. Advertising, as I said, which used to be a, a prime funder for journals, has really shrunk. So we're looking for other ways. There used to be a lot of... Well, I don't know, a lot. There used to be relatively a lot of medical centers, medical schools having their own journals.

This has really shrunk dramatically. I mean, I think the Cleveland Clinic Journal obviously is still there. Mayo Clinic proceedings is still there. We've changed both of our structures a little bit. The Mayo Clinic has gone, you know, essentially online and not really mailing anything out anymore. And they've gone with different publishers. We are still, you know, self-publishing. So those are financial stressors that are facing journals, and I think that's going to be an ongoing challenge.

Dr. Tony Tizzano:

Well, thank you so much, Brian. This has been an intriguing and wonderfully insightful podcast. To our listeners, if you would like to suggest a medical education topic to us or comment on an episode, please email us at education@ccf.org. Thank you very much for joining, and we look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.