Fake news, predatory journals, case reports, biostatistics, and other journalistic musings

By Warren R. Heymann, MD
March 17, 2017

We live in an era of information excess delivered by print, digital devices, webcasts, podcasts, and tweets. Time for reflection is minimal. One of the major precipitants of physician burnout is the endless electronically documenting data, which has replaced speaking to and examining patients, and most importantly thinking about their problems.

Pressure abounds when sorting through the onslaught of data to find what is relevant and true. For those in academia, the need for publication remains undiminished, fueling the cycle further. Although IBM’s Watson can absorb infinite information, unfortunately, the glorious human brain can only assimilate a fraction of the data, and its interpretation is compounded by personal bias.
 
As we have learned, fake news site can generate fabricated stories that can yield devastating consequences when presented as fact.

Predatory journals have proliferated exponentially, soliciting publications (at a hefty fee). Young academicians may be particularly vulnerable, facing the “publish or perish” scenario. The problem is that many journals will literally publish anything that comes their way. This dilutes the quality of the body of medical literature; indeed, when one is accessing information at point-of-care, the reader can only assume that what was published has been editorially peer reviewed, allowing for at least a modicum of validity. I receive requests to publish in these journals daily. Although I chuckle when the requests come from other disciplines such as orthopedics, gastroenterology, or anesthesiology, the situation is not laughable. Out of curiosity, I responded to one journal’s editors, inviting them to visit this website and choose an article that they would find worthwhile. Their response was, “choose whatever you’d like.” Think about that for a moment — whatever I’d like? I can only interpret that as they would publish whatever is sent to them, regardless of the content. How dangerous! I wholeheartedly concur with Benjamin and Weinstein who state: “Predatory journals must be deprived of the legitimacy afforded by inclusion in prestigious databases like PubMed. PubMed, operated by the National Library of Medicine, is heavily used by researchers and clinicians to search the medical literature. Efforts by predatory publishers to gain inclusion in the PubMed database through strategies such as purchasing journals that are already PubMed indexed must be thwarted.” (1) Unfortunately, the blog listing predatory journals, started by Jeffrey Beall at the University of Colorado, is no longer available. Cabell’s International of Beaumont, Texas is planning to develop its own blacklist this year (2).

Journal content is changing, driven by the drive for a higher impact factor. The question is, impact for whom? I read journals for my personal impact factor — how will an article affect the care I deliver to my patients? I am not decrying the importance of topics such as burden of skin disease or quality of life studies – they are vital for the survival of our specialty as we are facing economic duress. I would just prefer that these studies be in a new, separate journal devoted to dermatoeconomics. When I read, I go for the clinically relevant studies.  I understand why case reports are considered the bottom shelf of the evidence-based pyramid. Despite that, I get more out of a good case report and review of the literature than the latest treatise on the economic burden of hidradenitis suppurativa. Educationally, I agree with Packer et al who contend: “Selecting and writing a case report can sharpen critical and observational skills, improve medical writing, strengthen the ability to generate and defend a hypothesis, and increase understanding of patient-centered care. It can give students valuable experience with the editorial process, motivate them to take a scholarly view of their clinical work, and allow them to contribute to the medical literature.” (3) Should case reports be relegated to electronic publications, they will not get read unless someone is searching specifically for an identical case. Increasingly, case reports are published in “open access” journals for a substantial fee, which may be also burdensome for the author or their institution.
 
If anyone wants to fool me, throw some statistics my way. My training in biostatistics was reasonable — in the late 1970s — but my ability has gone the way of my hip-hugging bell bottoms. For example, the following paragraph defines the statistical analysis on a study of filaggrin loss of function and thymic lymphopoietin variation in treating pediatric atopic dermatitis (4).

Demographic and other subject-level data were described as percentages or means as appropriate and presented according to FLG LOF and TSLP variant status. For each variable, differences among genotypes at enrollment were assessed using χ2 or ANOVA as appropriate. Drug usage was described by proportions and displayed graphically. To analyze variation in our outcomes over time, mixed-effects logistic regression were used. We used mixed-effects models to account for intrasubject correlation due to repeated measurements over time. We specified an independence working correlation for these models. While in the past we based our gene variant analyses on additive models, here we chose a genetic model based on grouping FLG wildtype and heterozygous individuals vs homozygotes and compound heterozygotes. Visit number was also included as a covariate in our models. All analyses were conducted using Stata, version 13.1 (StataCorp).

I would love to spend a sabbatical with David Margolis, the senior author of this paper, to learn what all this means. I must take it on faith that the right statistical studies were performed to substantiate the authors’ conclusions. I have always advocated that a sentence or two be devoted to explaining the rationale for choosing analyses and defining them (in plain English). As I am unlikely to either do a dermatoepidemiology fellowship, nor will editors take my recommendation, I will just have to trust (without being able to verify).

We live in litigious times enveloped in social media. How quaint to think of my youth when girls in my class would keep their innermost thoughts locked in their diaries. Nothing is secret, and we are all just a few clicks from going viral. HIPAA should protect us, but safeguards may be inadequate. To avoid litigation, disclosures of patient consent, for even the most obscure possibilities are now de rigueur. I was told by a prestigious journal that I either delete a sentence quoting the patient who said “it feels like gasoline on my skin,” or get consent to use the phrase, because someone might recognize her based on that comment. I’m not kidding. I deleted the sentence.

In conclusion, how can the well-meaning clinician know what’s real and important? Follow the advice of Dr. Richard Lehman, the author of the British Medical Journal’s weekly review — enjoy the privilege of being a physician engaged in the medical literature, but be skeptical of what you read. Abide by the Latin phase “nullius in verba” — don’t take anyone’s word for it (5). Not even mine!

1. Benjamin HH, Weinstein DF. Predatory publishing: An emerging threat to the medical literature. Academic Medicine 2017; 92: 150-1.
2. Singh Chawla D. Mystery as controversial list of predatory publishers disappears. Science. Online January 17, 2017.
3. Packer CD, et al. A case suspended in time: The educational value of case reports. Academic Medicine 2017; 92: 152-6.
4. Chang J, et al. Association of filaggrin loss of function and thymic stromal lymphoietin variation with treatment use in pediatric atopic dermatitis. JAMA Dermatol 2017; 153: 275-281.
5. Lehman RS: Nullius in verba: Don’t take anyone’s word for it. JAMA Intern Med 2013; 173: 1049-50.

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