How clinicians should use the diagnostic laboratory in a changing medical world

In developed countries, clinicians are faced with a plethora of diagnostic tests to apply to patients to guide their clinical management. The quality, effectiveness, and efficiency of patient care should be foremost in the clinician's mind. Laboratory directors should make every effort to guide clinicians in appropriate laboratory test ordering, interpretation, and resulting actions. Medicine, being at its center a moral enterprise grounded in a covenant of trust, and laboratory medicine being a subset of medicine, must first care and advocate for the patient, and consider clinical outcomes as most important.

Prevalence of articles with honorary authors and ghost authors in peer-reviewed medical journals

CONTEXT

Authorship in biomedical publications establishes accountability, responsibility, and credit. Misappropriation of authorship undermines the integrity of the authorship system, but accurate data on its prevalence are limited.

OBJECTIVES

To determine the prevalence of articles with honorary authors (named authors who have not met authorship criteria) and ghost authors (individuals not named as authors but who contributed substantially to the work) in peer-reviewed medical journals and to identify journal characteristics and article types associated with such authorship misappropriation.

DESIGN

Mailed, self-administered, confidential survey.

PARTICIPANTS

A total of 809 corresponding authors (1179 surveyed, 69% response rate) of articles published in 1996 in 3 peer-reviewed, large-circulation general medical journals (Annals of Internal Medicine, JAMA, and The New England Journal of Medicine) and 3 peer-reviewed, smaller-circulation journals that publish supplements (American Journal of Cardiology, American Journal of Medicine, and American Journal of Obstetrics and Gynecology).

MAIN OUTCOME MEASURES

Prevalence of articles with honorary authors and ghost authors, as reported by corresponding authors.

RESULTS

Of the 809 articles, 492 were original research reports, 240 were reviews and articles not reporting original data, and 77 were editorials. A total of 156 articles (1 9%) had evidence of honorary authors (range, 11%-25% among journals); 93 articles (11%) had evidence of ghost authors (range, 7%-16% among journals); and 13 articles (2%) had evidence of both. The prevalence of articles with honorary authors was greater among review articles than research articles (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2-2.6) but did not differ significantly between large-circulation and smaller-circulation journals (OR, 1.4; 95% CI, 0.96-2.03). Compared with similar-type articles in large-circulation journals, articles with ghost authors in smaller-circulation journals were more likely to be reviews (OR, 4.2; 95% CI, 1.5-13.5) and less likely to be research articles (OR, 0.49; 95% CI, 0.27-0.88).

CONCLUSION

A substantial proportion of articles in peer-reviewed medical journals demonstrate evidence of honorary authors or ghost authors.

A comparison of the opinions of experts and readers as to what topics a general medical journal (JAMA) should address

CONTEXT

Journal editors are responsible to many publics, and their choices of articles to publish are a frequent source of dispute.

OBJECTIVE

To assess the extent of agreement between topics identified by experts and by JAMA readers as most important for publication.

DESIGN AND PARTICIPANTS

Modified Delphi process of polling of JAMA Editorial Board members and senior staff (ie, experts) in 1996, and masked direct mail survey of a stratified sample of JAMA readers in late 1996 and early 1997.

MAIN OUTCOME MEASURES

Agreement between experts and readers on the topics most important for JAMA to deal with in 1997.

RESULTS

Of 55 experts polled, the 40 respondents (73% response rate) proposed 178 topics. Editing to combine similar topics left 73. The same 55 persons were asked to stratify all 73 alphabetically arranged topics on a scale of 1 to 5 (85% [47/55] response rate). They were then given the results of this ballot and asked to vote again (76% [42/55] response rate). Of the 55 experts, 40 attending the annual editorial board meeting were given all results; 39 attendees voted on the final topics. In response to the mail survey, a single pass of the same 73 topics yielded a response rate of 41.6% (208 returns). Nonresponders were roughly equivalent to responders demographically. Readers agreed with the experts on only 3 of the top 10 subjects: managed care, cancer, and aging.

CONCLUSION

Expert opinion and the opinion of readers as to what JAMA should emphasize vary widely.

What do managed care plans do to affect care? Results from a survey of physicians

Little is known about physicians' exposure to managed care techniques that affect clinical practice. In 1995, we conducted a survey of 2,003 U.S. physicians asking them about their share of patients subject to a variety of managed care techniques. Nationally, 24% of physicians received some form of capitation payment for their patients. The two most widely used techniques were utilization review (UR), applied to an average of 59% of patients, and discounted fees, applied to an average of 38% of patients. Although UR was common, ultimate denial rates of coverage were very low: at most 3% for the types of care studied. Use of managed care techniques varied more within states than between states. Conventional measures of HMO market penetration revealed little about how managed care affects physicians.

The new medical marketplace: physicians' views

The transformation of the medical marketplace has major implications for the physician workforce. Findings are reported here from national surveys of physicians, hospitals, health maintenance organizations (HMOs), preferred provider organizations (PPOs), and medical group practices conducted in 1995 to measure the impact of those changes. Physicians in higher HMO penetration states were more likely to report serious problems with several aspects of medical practice and patient care and were more likely to perceived oversupply in their specialty areas and changes in their practice arrangements. Some divergence is noted in views of supply between physicians and those that employ them. The majority of physicians would still recommend medicine and their specialty as a career.

The corporate practice of health care ... a panel discussion

The pros and cons of treating health care as a profit-making business got a lively airing in Boston May 16, when the Harvard School of Public Health's "Second Conference on Strategic Alliances in the Evolving Health Care Market" presented what was billed as a "Socratic panel." The moderator was Charles R. Nesson, J.D., a Harvard Law School professor of 30 years' standing whose knack for guiding lively discussions is well known to viewers of such Public Broadcasting Service series as "The Constitution: That Delicate Balance. "As one panelist mentioned, Boston was an interesting place for this conversation. With a large and eminent medical establishment consisting mostly of traditionally not-for-profit institutions, the metropolis of the only state carried in 1972 by liberal Presidential candidate George McGovern is in one sense a skeptical holdout against the wave of aggressive investment capitalism that has been sweeping the health care industry since the 1994 failure of the Clinton health plan. In another sense, though, managed care-heavy Boston is an innovative crucible of change, just like its dominant HMO, the not-for-profit but merger-minded Harvard Pilgrim Health Care. Both of these facets of Beantown's health care psychology could be discerned in the comments heard during the panel discussion. With the permission of the Harvard School of Public Health--and asking due indulgence for the limitations of tape-recording technology in a room often buzzing with amateur comment--MANAGED CARE is pleased to present selections from the discussion in the hope that they will shed light on the business of health care.

Is there gender bias in JAMA's peer review process?

OBJECTIVE

To assess whether manuscripts received by JAMA in 1991 possessed differing peer review and manuscript processing characteristics, or had a variable chance of acceptance, associated with the gender of the participants in the peer review process.

DESIGN

Retrospective cohort study of 1851 research articles.

SETTING

JAMA editorial office.

PARTICIPANTS

Eight male and five female JAMA editors, 2452 male and 930 female reviewers, and 1698 male and 462 female authors.

MAIN OUTCOME MEASURE

Statistically significant gender bias.

RESULTS

Female editors were assigned manuscripts from female corresponding authors more often than were male editors (P < .001). Female editors used more reviewers per manuscript if sent for other review. Male reviewers assisted male editors more often than female editors, and male reviewers took longer to return manuscripts than did their female counterparts (median, 25 vs 22 days). Content reviewer recommendations were independent of corresponding author and review gender, while male statistical reviewers recommended the highest and lowest categories more frequently than did female statistical reviewers (P < .001). Manuscripts handled by female editors were rejected summarily at higher rates (P < .001). Articles submitted to JAMA in 1991 were not accepted at significantly different rates based on the gender of the corresponding author or the assigned editor (P < .4).

CONCLUSIONS

Gender differences exist in editor and reviewer characteristics at JAMA with no apparent effect on the final outcome of the peer review process or acceptance for publication.