The Patient Was…

There is perhaps no phrase more descriptive of the culture driving life in academia than “Publish or Perish.” It describes the intense pressure to produce published material —  articles, papers, books, monographs, etc.  — in order to succeed in an academic career. Promotions, reputations, research grants, academic tenure, and more, are largely dependent on one’s ability to generate publications in an academic or scholarly context.

The intense pressure generated by “Publish or Perish” leads to a number of undesirable results. One of the commonest of these is that of quantity over quality.  The number of publications claimed by an author often carries more weight than does the value of the contents.  One hundred mediocre, or even worse, articles may be more highly valued in the general academic community than a mere twenty inventive and innovative ones. Quality of scientific information pales beside the sheer quantity of individual published citations.

It is also reported that the teaching of students, often the primary responsibility of academics in institutions of learning (rather than research laboratories), may suffer since the faculty may devote more time, effort, and energy to generating manuscripts than to actual teaching. Promotion to a higher level of Professorship is often more likely to come based on publication history than on teaching mastery. The university may benefit in several ways from a highly published faculty; the students perhaps less so.

While the problems of quantity over quality and the deleterious effect on teaching are important and unwanted outcomes, the need to publish can also have more serious consequences. Outright falsification of data is one such occurrence. It usually takes a long time for the academic community to recognize that research has been falsified. Often, a researcher has published many articles over a considerable period before somebody realizes that the data are suspect. The institution where the miscreant works is embarrassed and often loathe to make public the full details of the situation. The editors of the journals where falsified research is published are equally embarrassed; their protocols for verifying and approving material submitted for publication clearly have failed. Retractions of published material are difficult and may carry legal and ethical implications.

The effects on the involved researchers themselves are often, and correctly so, devastating. Dismissal from their position, elimination from research grants, damage to reputation, and even legal and financial consequences may follow. The entire field of scientific research, and the scientific community itself, becomes somewhat tainted. And lack of trust in science, lack of belief in well-proven hypotheses and theories, carries serious implications for society as a whole.

My own immersion in the murky world of scientific publishing began when I was still a medical student. It is unusual, even rare, for a student to publish an article in a reputable scientific journal; as a student you have neither the time nor knowledge and experience to do a lot of meaningful research. But two things happened to me during my third and fourth years of medical school that led me into the rarefied world of medical publishing. And both ended rather unsatisfactorily but, happily, without long-term personal consequences.

During my third year of medical school, one of our eminent Professors was engaged in ground-breaking research for which he won many awards and which opened an entire new area of scientific interest. The research work was actually done in dogs, and required collection of the excretory waste of the animals. A small stipend was offered for a student to do the “dirty work,” and since I was recently married the little bit of money meant a lot. I spent hours in the animal lab, collecting nasty excretions and recording the necessary information. (It was summer time, steamily hot, and the smell from my work was on me and my clothes when I got home. My new wife, wonderful as she was, once said, “I love you, but tell me, are you always going to smell like this?”)

As a result of the work in the lab, the Professor was invited to write a special article in a leading journal about the new findings and their implications for further research and ultimately for patient care. He graciously offered to make me a co-author on what promised to be a prestigious publication. This was huge for a student. I was ecstatic.

Writing an actual scientific paper takes time. And as time went by, I assumed the Professor was writing a preliminary draft that I would then see and perhaps comment upon before it was submitted for publication.

Wrong!

Imagine my surprise, and dismay, when the article appeared in a leading journal with only the Professor as author. With trepidation, I approached him and asked what had happened. Why was I left off the paper when he had promised I would be a co-author? His answer: The paper was of such importance that he couldn’t bear to share the attention and admiration for the work.

In my fourth year of medical school, we were sent on “rotations” (secondements or temporary assignments) to other institutions for different clinical experiences. I relished my assignment and was exposed to a practice that I thought was good for patient care. At the same time that I returned to school, a leading medical journal was seeking articles from students on some of their thoughts. I wrote about my experience during my temporary assignment and, because I had no idea how to format an article for a journal, I asked one of my Professors for help.

He read the article with a grave expression and then initiated a process that was painful and frightening to me as a lowly student. It involved meetings with other Professors, including the Chief of the Medical Department and the Dean of the Medical School. Their point was that what I was praising was antithetical to “our” institutional belief about appropriate care for patients.

I tried to point out that they had sent me on the temporary assignment which exposed me to the idea I was writing about. No matter: They ordered me to drop the article.

I was admittedly angry and perhaps stupidly stubborn. I refused to drop the subject. They were angrier and threatened me with various things that would affect my future as a physician. I knew they couldn’t dismiss me from school, but they made the rest of my time there unpleasant and worrisome. After graduation, I never interacted with them again, and to this day I haven’t missed any of them at all.

Fast forward to my specialty training in Cardiology.

But first, two additional things about medical publishing: the hierarchy or order of authorship and the criteria for authorship. The key positions in the listing of authors are first or lead author, and last author who is usually the senior investigator or mentor of the group. Authors in the middle are credited as co-investigators but they are less recognized and their position in the list of authors is less prestigious and significant for promotion and advancement in academia.

The criteria for authorship of a scientific manuscript are somewhat codified by a group known as the International Committee of Medical Journal Editors (ICMJE). There are four basic criteria that relate to the contributions required to be included as an author. Without going into detail here, they insist on substantial contributions to the work described in the paper, not just supervisory activity. In my view, this principle is often violated, and senior people in universities and research institutes are often listed as last author when their actual contribution has been minimal. Knowing how long it takes to do research work and write a proper paper, how else to explain senior physicians and department Chiefs being credited with hundreds of publications. The ICMJE actually describes how such supervisory activity should be acknowledged; it is not as an author.

Now, when I was in my Cardiology Fellowship training, I was involved in a few research projects. One was a particularly important piece of work, even publicly referred to as “seminal” by one expert. I did the vast majority of the work, and a co-Fellow in Training did the rest. I was properly credited as first or lead author, and my colleague was the next author listed. Our Department Chief, whose only real role was simply approving the project, was nevertheless listed as last author, implying a very significant contribution to the research.

In a second example during my Fellowship training, I was the cardiologist assigned to a special clinic that saw patients with heart disease and another specific medical issue (which will not be identified here). Another trainee, from the other specialty, was also active in that clinic. There was a senior physician from Cardiology and one from the other specialty assigned to supervise the clinic; often, neither showed up to see patients. The senior physician from the non-cardiology specialty was editing an edition of a journal in his specialty and wanted to include a paper based on our clinical activity and findings. The other trainee and I did all of the work involved in gathering and analyzing the data. But the author list had the two senior doctors as the lead authors.

What is the bottom line here, in my view?

Scientific research is absolutely essential, and the publication of accurate, meaningful data and information is critical to the welfare of everybody in our world. But the tremendous pressures on academics to publish articles can lead to distortions and even malfeasance in the process. And the assumption of author credentials by those whose contributions are unworthy of the title represents unethical and distasteful behavior.