AMERICAN
MEDICAL WRITHES
ASSOCIATION
JUNE 1989
^JOURNAL
Vol. 4, No. 2
A Nobel Prize winner describes his MCGOVERN LECTURE: The Making of 3.
!IIS^l ^'1rSn
dS^S'«ri» Medical Television Documentary
Plagues'.
Baruch S. Blumberg 19
Gradually, the profession of psychiatry
has gained a respected and honored
position in health care.
HISTORY: Mental Health Care Clouded
By Stigma, Misunderstandings Bill Weaver
Some scientists look to the skies for
directions in medical research.
TECHNOLOGY: Space-Age Research Adds
to Progress in Medicine Jane Krauhs
Lakshmi Putcha
Mary Anne Frey
Companies now establish rewards for
quality of care of patients.
TECHNOLOGY: Computers Play Major
Future Role in Quality
Management Anne Greer 13
Research is not actually complete until
a report is published.
RESEARCH: The Origins of the Scientific
Paper: The IMRAD Format Robert A. Day 16
Few writers understand the economic
and scholarship strictures imposed on
medical journals.
PUBLICATIONS: The Style and Substance
of the Medical Journal Industry Thomas A. Lang 26
DEPARTMENTS
Editorial 1
AMWA News 33
Letters to the
Editor 39
News Capsules 40
Book Reviews
Dear Edie
Upcoming Medical &
Scientific Meetings
41
42
45
1989 AMWA Sustaining Members
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Warner-Lambert Company
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AMERICAN
MEDICALWRITERS
ASSOCIATION\VJOURNALJune 1989, Vol. 4, No. 2
Ronald J. Sanchez
Editor-in-Chief
J. Eugene White
Administrator, Department of Publications
Lila N. Schwartz
Book Review Editor
Vincent Franco
Meetings Editor
Patricia L. Cornett, Ph.D.
President, 1988-89
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Public Relations Section
Copyright © 1989 American Medical Writers Association. All rights reserved, worldwide.
ISSN 0090-046X
EDITORIAL:
One More Idea
Ronald J. Sanchez
Our Editorial Philosophy
W
e recently asked
readers of the AMWA
Journal to rate the
publication in various
categories and give us
their suggestions and criticisms of the
publication. We received far too few
responses for the results to be statistically
significant; yet we did manage to accumulate
a variety of comments and
recommendations that we will take into
consideration during the next year.
In reviewing the responses, it occurred
to me that few of our readers probably
understand how the AMWAJournal
operates. So here's a capsulized summary
of our editorial position and how
the publication is produced.
As the official quarterly publication of
AMWA, the Journal is supported
through association funds and limited
advertising revenue. Manuscripts may
be received from members and nonmembers
of the association, and no
publication priority is given based on an
author's membership status. Our
primary criteria in publishing a
manuscript are that it is original, well
written and well researched, relevant to
the field of medical communications
and that it offers a unique viewpoint or
perspective on a subject from that
previously published. Occasionally, we
solicit manuscripts from authors on subjects
that we are particularly interested
in considering for publication. We do
not reprint manuscripts that have been
published in other publications.
The AMWA Journal is not a refereed
journal; that is, each article is not
reviewed by a panel of writers and
editors. The decision to publish is made
by the Editor-in-Chief, with consultation
from various members of the Editorial
Advisory Committee, as well as the Administrator
of the Department of
Publications.
We operate under a limited budget.
We do not pay for any manuscripts and,
likewise, all of the editorial work done
for the AMWA Journal by AMWA
members is provided on a volunteer
basis.
Since I have been Editor-in-Chief, the
purview of the publication has been
kept intentionally broad to encompass
not just articles on the technical aspects
of medical communications but also on
issues related to medicine, health and
the media. It has been my philosophy
that we, as medical communicators, do
not exist in a journalistic "vacuum," but
rather we are just one part of a larger
communications process. I prefer to
publish articles that instruct and
educate, rather than those that merely
inform.
Finally, I view the editorial philosophy
of the AMWAJournal as an evolutionary
process. We continue to grow and
develop as we learn more about what
you, our readers, need to enhance your
efforts in the field of medical communications.
We appreciate what you
have to say.
Brain Drain
With all the public furor over the nowdefeated
51 percent congressional pay
raise, few people—including the news
media—seemed to notice that the controversial
provision also included a
much-needed pay hike for scientists and
researchers at the National Institutes of
Health (NIH). That's too bad, because
by pushing the Congress into its selfrighteous
rejection of its own salary increase,
we managed to deal yet another
crippling blow to research in health
care.
During the past five years, NIH has
lost 28 percent of its top scientists to the
private sector—where they can earn
more than twice as much and can have
considerably more funding available to
support their research projects. And
NIH officials say that more high-level
departures can be expected as a result
of this latest salary setback.
It's unfortunate that the Ralph Naderinspired
rhetoric surrounding this
issue focused almost entirely on the
earnings of our senators and representatives
and failed to recognize the other,
and more significant, components of the
proposal. With research on AIDS plodding
along and with a cure or vaccine
perhaps a decade (or more) away, this
is no time to deplete our already slim
research ranks by sending our most
valuable resources shopping for new
jobs.
It's amazing just how altruistic we expect
our "public servants" to be. Entertainers,
sports figures and business entrepreneurs
can earn enormous sums—
with our apparent sanction—but we expect
those in government to be modestly
paid. But with the pressing demands of
a growing health care agenda, this is no
time to pinch pennies. In the end, we'll
pay the price—dearly. •
1
HISTORY:
Bill Weaver
Bill Weaver, Ph.D., is Associate Professor
of Education in Medicine, University
of Alabama School of Medicine,
Birmingham.
The author wishes to acknowledge the
contributions of Virgil Wooten, M.D,
and Jeffery Fahs, M.D., both of the
Department of Psychiatry, University of
Alabama at Birmingham.
Mental Health Care
Clouded By Stigma,
Misunderstandings
Advances in psychiatry lead to more
compassionate treatment for patients
T
he history of mental health
care in the U.S. is a story of
medical need which has
been met very slowly because
of four factors: (1)
stigma of the illness; (2) lack of
understanding of its cause; (3)
general low esteem of its professionals,
and (4) slowness with which
it became a respected field for academic
study and research. While
mental health care in the U.S. cannot
be separated totally from work in
Europe and elsewhere, this article is
devoted exclusively to occurrences
in this country. Furthermore, the
historical part of this article concentrates
primarily on the care provided
in mental institutions. Thus, at best,
this is only a half-history, but maybe
it will provide a glimpse of where
the field has been, as a basis on
which to assess where the field is
now and to predict where it may be
in a few years.
The Past
Mental health care today has improved
greatly from the past. No
longer are hospitals called asylums,
mentally ill persons called lunatics,
substance abusers called opium
eaters, and psychiatrists called alienists.
No longer is all mental illness
categorized simply as insanity and
isolation from the rest of society
without treatment thought to be the
best therapy. And no longer is the
profession characterized by the
hopelessness of its patients. Indeed,
times and labels have changed.
The 18th Century
It is unclear just how much 18th
Century physicians in the U.S. knew
about mental illness, but it is certain
they did little to treat it. Considering
their habit of leeching, purging and
emitting in the treatment of other illnesses,
however, this neglect may
have been a blessing in disguise.
Because physicians believed mental
illness to be incurable, they devoted
little attention to it, choosing instead
to work with patients who could
more readily appreciate their efforts.
Consistent with the medical community,
the public also assumed
mental illness to be incurable and
was satisfied to isolate such persons
either in the home, in a private hospital
if they could afford it, or in the
poorhouse or jail. In all of these locations,
the primary mode of therapy
was isolation, regardless of the type
of mental illness.
The 19th Century
Unlike its predecessor, the 19th
Century witnessed many changes in
the care of mentally ill persons. To
a large degree, the changes that
occurred in the field resulted from
three things: (1) changes in the
understanding of causation; (2)
changes in the number and nature
of mental institutions, and (3)
changes resulting from the rise of
psychiatry as an academic field.
2
The 19th Century witnessed important
changes in the understanding
of the causes of mental illness.
Although there was little formal
education in psychiatry until near
the end of the 19th Century, some
physicians obtained practical knowledge
by working for a year or so at
a mental institution; many of these
physicians later became asylum
superintendents. Without a psychiatric
classification system, psychiatrists
referred to all mental illness as
insanity, and they were convinced it
was a disease of the brain. Thus,
they believed that in every insane
person one could find physical evidence
of brain disease. As time
passed, however, these evidences of
physical damage to the brain could
not be found on autopsy, a fact that
caused some psychiatrists to abandon
this theory.
By the mid-19th Century, the prevailing
view was that there were two
types of causes of mental illness: (1)
predisposing causes (physical defects
of the brain), and (2) precipitating
causes (irritants in the environment
which by aggravating the predisposing
causes actually precipitated
occurrences of insanity). Thus, by
mid-century, insanity could be explained
more fully, and because of
it, changes occurred in the type of
treatment thought to be most effective
in the care of the mentally ill.
In the early decades of the 19th
Century there were few institutions,
and they were largely private ones,
catering to affluent patients.
Through the efforts of Dorothea Dix
and other reformers, the nation became
more aware of the needs of the
mentally ill, and this awareness led
to the establishment of statesupported
institutions in most states.
With the large influx of poor immigrants
and the emergence of statesupported
institutions, the patient
population at these institutions increased
very rapidly and became
less economically selective. Asylum
superintendents worked hard to convince
the public of the appropriateness
of the asylum for mental health
care. They were very successful,
with institutions growing rapidlymore
rapidly than state appropriations
to support them. Thus, each
year asylum superintendents had to
devise new ways of ensuring the
survival of their institutions on the
straight line or decreasing state
support. Under these conditions of
perpetual financial constraint,
asylum management became a
science.
Ironically, help for institutions'
financial survival came from a treatment
plan that called for the use of
patient work as a means of normal"Thus,
they believed that in every
insane person one could find
physical evidence of brain
disease.'
izing the patient's living environment.
The widespread belief in the
early 1800s that insanity was incurable
had encouraged the use of custodial
care that wasted no effort on
therapy. But by mid-century, with
their newly adopted belief in predisposing
and precipitating causes of
insanity, psychiatrists began to believe
that insanity could be cured
and that institutions should replace
their custodial role with one that
involved more aggressive treatment.
They were convinced that if precipitating
causes (family conflicts,
economic stresses, political or religious
excitement, and many others)
could be eliminated, the natural
healing process of the brain would
take care of predisposing causes.
They found just such a therapy in
something known as moral treatment,
a therapy very similar to
today's psychological or milieu
therapy.
Moral treatment is of particular
significance because of its widespread
popularity in the mid-1800s,
its unpopularity in the late 1800s,
and its gradual reintroduction into a
much broader spectrum of treatment
in the 20th Century. Moral
treatment emphasized the asylum as
ideal for three key steps: (1) identifying
the precipitating causes for
each patient; (2) removing those
causes while leaving the rest of the
patient's life as normal as possible,
and (3) preparing the patient for life
outside the asylum. To carry out this
approach, asylums operated as small
societies in which idleness was replaced
by systematic work, and improvement
by the patient was
expected.
Early institutions that tried moral
treatment reported successful results.
More psychiatrists implemented
the program at their asylums,
and soon cure rates of up to
90 percent were reported. In their
literature, asylum superintendents
devoted much attention to descriptions
of how they implemented and
managed their moral treatment
programs.
The bubble of enthusiasm and
optimism was short-lived, however,
when it was discovered that the cure
rates that asylum superintendents
had reported so proudly involved
inaccurate calculations. The cure
rates had been derived by dividing
the number of discharges by the
number of admissions, with some
patients having been admitted, discharged
and counted as "cured"
several times in a year. Whether this
was a simple statistical reporting
error or deliberate deception, the
effect was to discredit asylum superintendents,
asylums and moral treatment.
The pendulum had swung far
in the direction of curability—too far,
in fact.
For several years thereafter, psychiatrists
were disillusioned, as was
the public with them. Most of them
abandoned moral treatment and
reverted to little more than custodial
care for their patients. The optimism
that pervaded the field in the earlier
decades was gone. Instead of concentrating
on therapy, asylum super-
3
intendents devoted more attention to
issues related to managing institutions,
as economic wizardry in asylum
management became a neces­
sity.
While disillusionment over the
curability issue did much to cause a
reduction in the therapy practiced at
asylums, another important factor
was the change in the population of
the asylum itself. The rapid growth
in the number of institutions was
accompanied by an even more rapid
growth in the size of institutions and
in the economic diversity of their
patients. Some asylum superintendents
viewed the limited potential of
their poorest patients as a reason to
devote little time to active therapy.
In 1844 superintendents had professionalized
their field by forming
the Association of Medical Superintendents
of American Institutions
for the Insane. In the association's
journal, theJournal of Insanity, superintendents
devoted much attention
to management issues, a fact that
made them a target of criticism from
other physicians, particularly neurol­
ogists.
Beginning with Benjamin Rush in
the early 1800s, several physicians
demonstrated an interest in the care
of the mentally ill. As the demand
for hospital superintendents increased,
several physicians obtained
whatever training was available.
Because asylum superintendents
were necessarily preoccupied with
their institutions' economic survival,
study and research in psychiatry
tended to be a minor consideration
with them, at least until the 1880s.
Psychiatry as an academic field did
not emerge until the late 19th Century,
and only then in response to
external criticism. The criticisms,
made primarily by neurologists, contended
that hospital superintendents
were content to provide domiciles
for patients without making any
scientific inquiries into the intricacies
of their patients' problems.
Although the charges may have been
true, neurologists may have been at
least as interested in advancing their
specialty as in improving the academic
level of psychiatry. To be sure,
hospital superintendents had little
time for research, but the sting of
this criticism advanced a movement
that had already begun to initiate
formal study of the mind as a part
of medical training programs. This
was begun but not fully incorporated
in most medical schools until
after 1900.
'Mental hygiene introduced an
increased emphasis on hereditary
and environmental deficiencies as
major contributors to mental
illness.'
While the 19th Century witnessed
many changes in mental institutions
themselves, the 20th Century
brought few changes in institutions
and more changes in the field of psychiatry.
Although most psychiatrists
continued to be affiliated with mental
hospitals, the thrust of their specialty
was increasingly away from institutional
practice, and the traditional
relationship between psychiatry
and mental hospitals was beginning
to dissolve. As evidence
mounted of their low status in medicine,
psychiatrists began to look
beyond the mental institution to settings
that seemed more academically
inclined. In an effort to improve
their image, psychiatrists renamed
and reoriented their primary professional
organization into the American
Psychiatric Association and
formed the American Board of Psychiatry
and Neurology, to encourage
more academic rigor in both psychiatry
in general and psychiatric
training programs in particular.
Some psychiatrists began to criticize
the traditional mental hospital's
emphasis on custodial care for large
numbers of chronic patients, especially
as little effort was being made
to establish maximum limits on the
number of beds at mental institu­
tions.
The rise of psychoanalysis and the
mental hygiene movement brought
more changes in the field. Psychoanalysis
encouraged psychiatrists to
look at mental illness in a new way,
and by mid-century, many of the
principles of psychoanalytic thought
had become integrated into the overall
practice of psychiatry. Mental
hygiene introduced an increased
emphasis on hereditary and environmental
deficiencies as major contributors
to mental illness.
As important as these developments
were, the 1950s, 1960s and
1970s, sometimes known as the
"biochemical revolution," brought
some noteworthy improvements and
some mere conveniences. While the
identification of biochemical imbalance
as the cause for some disorders
was an improvement, the
development and widespread use of
sedatives to create a more docile
patient population with little consideration
of patients' chances of
recovery proved to be a mere convenience
to hospital staffs.
The Present
Psychiatry is on its way to becoming
a scientific discipline, something that
has been facilitated immeasurably
by biological psychiatry. Biological
psychiatry has provided psychiatry
with a new basic science, new treatment
methods and the kind of thinking
necessary to operate within the
confines of an empirical science. In
short, psychiatry is more firmly tied
to the medical sciences than to the
social sciences. Advances in behavioral
neurology and neuropsychiatry
have suggested that various
areas of the brain "specialize" in
certain types of thought, language
processes and mood processes.
Despite its progress, psychiatry is
still unable to offer etiological explanations
for most of the major psy-
4
chiatric disorders and, thus, is unable
to offer improved treatment for
patients with these disorders. The
most effective treatments available
today derive from drugs developed
two or three decades ago, many of
which were developed for other purposes
but were found to have psychotropic
properties as well.
Today, more so than ever before,
mental health professionals understand
and appreciate life history as
a factor in persons' mental behavior,
believe that no one treatment
method is appropriate for all illnesses
or for all patients with a particular
illness, and recognize and
appreciate the interrelationships
between physical illness and mental
illness. With DSM III, the diagnosis
manual, mental health professionals
have a comprehensive, detailed,
multidimensional taxonomy. In addition,
assessment methodologystandardized
criteria, rating scales
and the standardized psychiatric
interview—has been refined and
substantially improved. As mental
illness is determined to be more
"biological" in nature, there is a
resulting reduction in the stigma
associated with it.
Despite some in-roads, little improvement
is being made in the
extent to which primary care physicians
appreciate the frequency of
mental problems as underlying
causes of other illnesses and demonstrate
skill in recognizing the various
subtle manifestations of mental illness
in their patients.
The Future
Although one can only speculate on
what will occur in the future, there
are indications that major accomplishments
will occur. It appears
certain that psychiatry will become
more recognized as a medical field
as it becomes more "biological" in
its work. It also appears certain there
will be a continuing need for socalled
"talk therapy."
Some of the advances that appear
to be on the horizon are the fol­
lowing:
1. Because certain endorphin
fragments seem to be natural
antipsychotics, a better understanding
in this area offers
some real hope for many
patients.
2. The fact that there are specific
binding sites in the brain for
the hallucinogen PCP might
lead to a new biological model
of schizophrenia and development
of new treatment
methods.
3. The hope of finding markers of
psychiatric diseases remains
alive, although those already
known are not specific or
reliable.
4. Dissection of psychiatric syndromes
into their component
psychological dysfunctions
could be the next phase in the
evolving process of diagnostic
sophistication.
5. Neuroimaging techniques
should further our understanding
of brain function in particular
disorders and help determine
how medications work
on those areas.
6. More knowledge on the molecular
biological basis of psychiatric
disorders should enable the
development of effective drugs
for those disorders.
7. Mental well-being will become
increasingly recognized as an
integral part of the healing process
of any type of illness, and
all physicians' training will include
more emphasis on
psychiatry.
8. As psychiatry becomes more
biological in its treatment and
as mental well being becomes
more generally recognized as a
part of the healing process, the
stigma of mental illness will be
correspondingly reduced.
'It appears certain that psychiatry will
become more recognized as a medical
field as it becomes more "biological"
in its work.'
Conclusion
Psychiatric treatment in the U.S.
has evolved over the last 200 years
from isolation to involvement, from
at-home to institutional care, and
from custodial to therapeutic care.
While psychiatry has become and is
becoming more research-oriented,
the work in mental institutions
necessarily remains centered on
practical application, normalization
of life within the institution and
attention to individual differences.
Most importantly, the outlook for
persons with mental illness is
brighter than it has ever been, and
even more improvement may be
seen in the not-too-distant future. •
BIBLIOGRAPHY
Bockoven JS. Moral Treatment in American
Psychiatry. New York: Springer Publishing
Company, 1963.
Caplan RB. Psychiatry and the Community in
19th Century America. New York: Basic
Books, 1969.
Dain N. Concepts of Insanity in the United
States, 1789-1865. New Brunswick, NJ:
Rutgers University Press, 1964.
Greenblatt M, York R, and Brown EL. From
Custodial to Therapeutic Patient Care in
Mental Hospitals. New York: Russell Sage
Foundation, 1955.
Grob GN. Mental Institutions in America:
Social Policy to 1875. New York: Free Press,
1973.
Grob GN. Mental Illness and American Society,
1875-1940. Princeton, NJ: Princeton University
Press, 1983.
Rothman DJ. The Discovery of the Asylum:
Social Order and Disorder in the New
Republic. Boston: Little, Brown, 1971.
Van Praag HM. Editorial: Biological Psychiatry
Audited, /. of Nervous and Mental
Disease, 176:4, April 1988.
5
T E C H N O L O G Y :
Jane Krauhs
Lakshmi Putcha
Mary Anne Frey
Jane Krauhs and Lakshmi Putcha are
Senior Scientists with KRUG International
in the Biomedical Laboratories at
the Johnson Space Center, Houston.
Mary Anne Frey is a Visiting Scientist
with Universities Space Research
Association at the Johnson Space
Center and Adjunct Associate Professor,
Department of Community Medicine, at
Wright State University School of
Medicine, Dayton, Ohio.
Space-Age Research Adds
To Progress in Medicine
Technological transfer brings new tools,
information to an already expanding discipline
T
he U.S. space venture
promotes scientific and
technological advances
because new information
and tools are needed to
achieve its objectives. The long-term
investment necessary for such a program—offering
no guarantee of financial
reward—could not have
been undertaken by private industry.
The National Aeronautics and Space
Administration (NASA) has returned
taxpayers' investment by promoting
non-space-related applications of the
products of space-related research
and development. These secondary
applications now number more than
30,000.' Many of them have contributed
to what we call "medical
progress."
Why "Spinoffs"?
When NASA was created, it was directed
by the Congress in the National
Aeronautics and Space Act of
1958 to "provide for the widest practicable
and appropriate dissemination
of information concerning its activities
and the results thereof."
Transfer of space technology is built
into the structure of NASA, in the
form of scientific programs and as
an outgrowth of the nature of spaceflight
problems and the approach to
their solution.
The Technology Utilization Program
helps bring NASA technologic
developments to entrepreneurs,
some of whom are former NASA
employees. Each NASA field center
(Ames Research Center, Goddard
Space Flight Center, Johnson Space
Center, Kennedy Space Center and
Langley Research Center) has a
Technology Utilization Office, which
publicizes research and development
activities at that center and acts as
a liaison between center personnel
and potential users of technology
produced there. These offices also
arrange conferences to inform private
companies of NASA technology
and the technology transfer process.
The highly successful Small Business
Innovation Research Offices at
NASA research centers solicit novel
proposals from small businesses for
development of technology needed
by NASA. Ten Industrial Applications
Centers (IACs) are affiliated
with universities, and NASA recently
has set up cooperative arrangements
with technical assistance
centers sponsored by state
governments. The IACs provide access
to 100 million documents in the
NASA data bank and other databases.
NASA's Computer Software
Management and Information Center
(COSMIC) at the University of
Georgia identifies governmentdeveloped
software programs that
might have secondary applications.1
A current goal of NASA is to
strengthen the engineering capacity
of universities; toward this end, nine
university space research centers
were selected in 1988 as recipients
of funding for long-term research in
6
space engineering and technology.2
Some of the problems NASA must
solve are unusual and would have
low priority for an Earth-bound population.
The space agency brings together
scientists and engineers from
many disciplines to solve them.
NASA scientists interact with colleagues
at other government agencies,
universities and industries and
with students. This "interfacing"
occurs through formal programs
such as Resident Research
Associateships administered by the
National Research Council, through
employment of consultants and
college students, and through
collaborative research projects.
Sometimes NASA contributes to
the development of a "spinback," a
device that will be used primarily
for a non-space-related purpose but
also will fulfill a need of NASA.
NASA shares the cost and products
of this development with private
industry or other agencies. A current
example involves the design of a
flow cytometer that could be used
for biomedical experiments on a
space station. NASA is providing
funds and technical leadership, the
American Cancer Society is providing
funds, and investigators at
the University of Miami (Florida),
Los Alamos National Laboratory
and the University of California,
San Francisco will be collaborating
on the project. The new flow
cytometer should be useful in
monitoring the effectiveness of
cancer therapy for individual
patients.
Cities and states have become
strong supporters of technology
transfer. Cities like Houston, seeking
jobs for their citizens, are trying
to attract and nurture new industries.
The proximity of the
Johnson Space Center and the Texas
Medical Center makes Houston an
ideal incubator for "spinoff" companies
in the field of medicine.
Human delight in the new and
unusual surely plays a role in
application of space technology.
Advertisers have used this
characteristic to sell products
associated with the space
program—powdered orange drink,
"space age" stadium blankets,
satellite-generated weather
information. A letter to Science in
support of a piloted expedition to
Mars stated: "It is the enthusiasm
we generate in our explorations that
will anticipate new technology and
new hope..."3
What Constitutes
Medical Progress
Medicine progresses when research
leads to new information or new
tools for prevention, diagnosis or
treatment of disease; when health
information is disseminated to
physicians and other health care
providers and to the public; and
when health services are delivered
to greater numbers of patients.
NASA-sponsored research has contributed
to progress in all of these
areas.
When the Apollo program began,
spacecraft bound for the moon or
other planets were sterilized, and
the crew and samples they returned
were quarantined. NASA
developed techniques for sterilization
and control of contamination;
many of these now have medical
applications on Earth.4
A dry heat technique used to
sterilize the Viking spacecraft is
now used by hospitals to decontaminate
oxygen systems after patient
use. New plastics and methods
of sealing compartments also are
used in the sterilization procedure.
NASA's Jet Propulsion Laboratory
developed the Aseptic Fluid Transfer
System to preserve the sterile
environment of spacecraft during
launch preparations. It allows the
aseptic connection of two bags
containing sterile solutions. The
connector is composed of two
plastics that melt at different
temperatures, arranged so that when
a heat sealer is applied to two
connectors placed together, they are
made into one unit with a sterile
opening between bags. The system
has been approved by the Food and
Drug Administration (FDA) for use
with intravenous fluids and dialysis,
and it should be applicable to blood
transfer and reconstitution of
powdered pharmaceuticals.5
A biological isolation garment
developed for personnel working
with lunar samples came to the
attention of physicians at Baylor
College of Medicine and was used
by "David," a child with severe
combined immunodeficiency. The
garment is used to extend the germfree
environment of patient
isolation rooms in hospitals. A
different type of NASA-derived
garment, which is disposable and
blocks passage of particles smaller
than 0.5 micrometer, is used in
cleanrooms of pharmaceutical and
medical equipment manufacturers."
New Tools for Diagnosis
Some of NASA's most important
contributions to medicine have
derived from miniaturization,
telemetry, digitization of images and
new materials. Often several of these
technologies have been combined in
one product.
Digital image processing was
developed to produce images of
objects in the solar system (including
Earth) from the bits of digital
information gathered by unmanned
spacecraft. Refinements of the
technique enabled correction of
errors, alteration of contrast and
general improvement of the signalto-noise
ratio of the image. This
technology has contributed
significantly to recent medical
progress, especially in the area of
diagnostics. A NASA engineer who
later became a radiologist thought of
using satellite image enhancement
techniques to simplify inter-
7
pretation in magnetic resonance
imaging (MRI). He and engineers
associated with Landsat image
processing made MRI practical for
medical diagnosis.6
Computed
tomography (CT) and angiography
also have been improved by digital
image processing. Advancements in
ultrasonic scanning have been made
by scientists at NASA's Jet
Propulsion Laboratory; the laboratory
was even awarded a grant
from the National Institutes of
Health (NIH) to further refine this
imaging method, which is much less
costly than MRI or CT. NASA
scientists designed an instrument
that can transmit and receive
ultrasonic pulses simultaneously.
Three-dimensional views of arteries
can now be obtained with ultrasound,
and three-dimensional
computer-enhanced angiography—
also originally developed for
planetary imaging—gives even
better resolution. A number
of medical applications of ultrasound
technology are being
developed in NASA-supported
projects.5
Image analysis has been applied
to light microscopy in the form of
the Automated Light Microscope
System (ALMS), developed at the
Jet Propulsion Laboratory. The
ALMS can perform chromosome
karyotyping in 7-16 minutes. Perceptive
Systems, Inc., a Houston
company founded by former NASA
and contractor personnel, obtained
a license to market the ALMS as
Geneticscan.
Image processing technology also
was used to design the VISISCREEN-100
Photorefractor Ocular
Screening System, an instrument
used to screen for visual defects in
children. The VISISCREEN analyzes
the retinal response of a
subject to a flash of light. Its output
is a color photograph of the eyes;
the color of the pupils is affected by
the presence of a defect, such as
hyperopia or strabismus.1
An instrument using singlephoton
absorptiometry to
determine bone density was
developed for NASA because bone
mineral loss is a potentially serious
problem in long-term space flight.
Dual-photon absorptiometry, which
evolved from the single-photon
method, is now widely used to detect
osteoporosis in its early stages
and monitor the effectiveness of
treatments for it. NASA contributed
to all technical revisions of singleand
dual-photon absorptiometry. A
scaled-down CT scanner that will
provide three-dimensional views of
trabecular bone now is being
developed for NASA.
'A number of medical
applications of ultrasound
technology are being developed
in NASA-supported projects.'
The weightless human body loses
serum electrolytes, and the need to
monitor these losses prompted
NASA to contract with ORION
Research of Cambridge, Massachusetts,
to develop a method to
analyze serum electrolytes that did
not require the use of flammable
gases, as the prevailing methods did
in 1973.5
ORION produced several
instruments that relied on ionselective
electrodes rather than
flame photometry. The first commercial
clinical laboratory instruments
that used more than one
ion-selective electrode (sodium and
potassium) were a direct result of
this contract. These Space Stats are
leakproof, portable, easy to use and
require only very small amounts of
blood. (A competing company,
Nova, was started by a Johnson
Space Center employee who
worked on the project.)
The AutoMicrobic System®
(AMS) was first made for NASA but
found wide use in hospitals and is
being re-adapted for use on Space
Station Freedom. McDonnell
Douglas Corporation developed the
Microbial Load Monitor, an automated
system for detection and
identification of microorganisms on
Apollo spacecraft. The instrument
was not used on Apollo, but
McDonnell Douglas created a
subsidiary, Vitek Systems, Inc., to
adapt it for Earth use. The AMS has
been extremely successful in
hospital laboratories. It requires a
relatively small number (104
) of
cells. The AMS saves time and
expendables; it can perform 30 tests
simultaneously on a plastic card
with test wells. The card is sealed
after inoculation, a particular
advantage in space where
contamination of the environment
must be avoided. The instrument
scans the wells for chemical activity
once an hour and compares its
readings with identification data in
its computer. Results are available
4-13 hours after specimen
collection. Susceptibility of
organisms to antibiotics also can be
tested with this instrument.5
The
AMS used by hospitals is too
cumbersome to carry on a
spacecraft, but NASA has asked
Vitek to make a compact version to
use on the space station, where
there will be a well-equipped
Health Maintenance Facility.
New Tools for Treatment
The alloy Nitinol, composed of
nickel and titanium, was developed
for the space program. This
unusually elastic metal, which returns
to its original shape after it is
bent, allowed compact packaging of
such satellite parts as antennas before
they were deployed. Nitinol is
also an ideal material for the arch
wires of dental braces, which exert
continual pressure on the teeth and
formerly had to be replaced or adjusted
several times during treatment.
Medical uses have been found for
some of the lightweight, cordless
8
tools developed for space exploration.
A company that developed a
drill to remove geological samples
from the moon used the same
technology to manufacture cordless
surgical instruments.7
Pelviscopy, a
new surgical technique in gynecology,
was made possible by
lightweight, miniature instruments
made of titanium. This technique
can often be substituted for
laparoscopy.
Measurement of bone density by
the sensitive techniques developed
for the space program has changed
therapy for osteoporosis, as these
new techniques revealed that many
of the old therapies were useless.
Diphosphonate etidronate was
tested in a NASA weightlessness
simulation (bedrest) study prior to its
introduction to the market.8
It is
now used to prevent metastatic
calcification and post-menopausal
osteoporosis.
NASA technology was used for
the initial development of the
cardiac pacemaker and for improvements
over the years. Hybrid
circuit technology was the basis
for the original pacemaker, which
had short-lived mercury-zinc
batteries. At the suggestion of
The Johns Hopkins University's
Applied Physics Laboratory, these
later were replaced with rechargeable
batteries like those
used in satellites. Pacemakers
became programmable when Pacesetter
Systems of Sylmar, California,
built a device with two-way
communication using telemetry
developed by NASA to communicate
with satellites. The physician can
program as many as six functions
such as the rate, amplitude and
width of stimulating pulses.5
A laser designed by NASA to
measure ozone in the atmosphere
attracted the notice of surgeons
looking for ways to eliminate
atherosclerotic plaque with a laser
beam delivered through fiber optics.
Physicians at the Cedars-Sinai
Medical Center in Los Angeles and
scientists at the Jet Propulsion
Laboratory in Pasadena, California,
developed an instrument for
surgery. A catheter only 1.5 mm in
diameter but containing 5,000
bundles of glass fibers is threaded
through an artery. The laser beam
and light for illumination are carried
by an outer ring of fibers, while a
camera lens is attached to the end
of the inner fibers. This arrangement
allows the surgeon to find
areas with plaque buildup and
destroy the lesion with bursts of
laser beams.8
(Will video games
someday be part of a surgeon's
training?)
One of the most widely publicized
"spinoffs" still under development
is the Programmable Implantable
Medication System for delivery of
insulin to diabetics. Like the
pacemaker, it is a product of collaboration
between Johns Hopkins
University's Applied Physics
Laboratory, NASA (Goddard Space
Flight Center), Pacesetter Systems,
Inc., and Parker-Hannifin/Biomedical
Products Division, Irvine,
California. The PIMS is in the
clinical testing stages now. It
consists of an infusion pump implanted
in the patient and a unit that
programs the pump after implantation.
Both the pump and the programming
unit use NASAdeveloped
microminiaturized
hybrid circuitry. Telemetry like that
used for the Small Astronomy
Satellite allows the programming
unit to communicate with the
pump. Parker-Hannifin provided
the pump, which was based on the
fluid control system used to
dispense nutrients in tests for the
presence of organisms in Martian
soil samples.5
At the request of the American
Foundation for Autistic Children,
the Applied Physics Laboratory and
NASA are developing a SelfInjurious-Behavior
Inhibiting
System that would provide a new
method of administering shock, the
most effective stimulus for suppressing
self-injurious behavior.
When an accelerometer in the SIBIS
detects self-injurious events, a signal
is transmitted to a stimulation
module. A patient fitted with a
SIBIS would not need to be restrained
and would not require intervention
by another person.5
New Information from
Space Research
Medical research has benefited
from many of the instruments
described above. Other devices
generated by the space program
were specifically adapted for use in
medical research projects. One of
these is a solar dosimeter used to
measure sunlight exposure of infants
in a study of vitamin D production.
An engineer working on
the project read in the NASA
publication Tech Briefs about a solar
dosimeter developed by Langley
Research Center and obtained a
license from NASA to fabricate a
modified version of the dosimeter
for use in the study.1
An instrument designed for use in
a Spacelab experiment is now being
marketed to cardiovascular physiologists
for research in kidney function
and control of blood pressure.
The Baro-Cuff, from Engineering
Development Laboratory, is a silicone
rubber cuff strapped to the
neck, stimulating the pressuresensitive
receptors in the carotid
sinuses by pressure or suction.9
A number of scientists, including
the authors, are engaged in NASAsponsored
basic research in space
medicine. Space medicine approaches
human physiology from a
different point of view and for that
reason makes unique contributions
to medical research. When experiments
are performed in space, we
see how the human body responds
to conditions that can be duplicated
on Earth for no more than 30 sec-
o
onds. Microgravity experiments
stimulate interest in comparing microgravity
with hypergravity, which
presents still another unusual
stimulus and another perspective
for understanding the "normal"
human body.
Research in space medicine
generally concentrates on the areas
in which weightlessness is known
to have potentially deleterious effects
on humans and includes finding
ways to prevent or ameliorate
these effects. The solutions to problems
of space medicine will be applicable
to many medical problems
on Earth.
During weightlessness, the lack of
hydrostatic pressure causes a
change in distribution of body fluid.
Fluid redistribution is believed to
lead to changes in cardiovascular
function and to loss of body fluid
and red blood cell mass. The lack of
gravitational pull on weight-bearing
bones and muscles promotes muscle
atrophy and loss of bone mineral.
The body adapts to weightlessness,
but the effects of space
flight can delay return to normal activities
after landing.10
Bedrest, especially with the head
down, is often used to simulate
weightlessness because fluid is
thought to be redistributed in the
same way and bones and muscles
are "unloaded." When NASA
started supporting bedrest studies,
people were staying in bed for long
periods of time while recovering
from giving birth (2 weeks) or
operations like appendectomies or
hernioplasties (2-3 weeks). Physicians
thought these patients were
weak because of childbirth or
surgery, but NASA studies showed
that bedrest itself caused weakness.
As a result, the period of bedrest
after surgery was shortened, and
patients recovered more rapidly.
Physicians formerly thought the
anemia experienced with chronic
diseases was secondary to the
diseases. NASA research has shown
that red blood cell production decreases
during bedrest because of
inactivity. The reason for loss of red
blood cell mass during space flight
is being investigated by NASA.
After landing, astronauts often
have difficulty standing, a problem
also encountered by patients
becoming ambulatory after a long
period of bedrest. Paraplegics and
quadriplegics have severe orthostatic
intolerance when they first
assume an upright posture and try
to ambulate with mechanical or
other assistance. Orthostatic intolerance
is also a common problem
in elderly people and even in
healthy young people who have
become dehydrated. NASA's research
to prevent orthostatic intolerance
in returning astronauts
should benefit patients who might
develop this condition. NASA scientists
are studying the relationship of
baroreceptor reflex function, body
fluid distribution and vascular
resistance and compliance to orthostatic
intolerance. Reduced
cerebral blood flow, cardiac arrhythmias
and cardiac volume
changes are being investigated as
causes of fainting or near-fainting
after standing. NASA is developing
countermeasures, including drinking
fluid, taking salt tablets and
applying suction to the lower half of
the body (lower body negative pressure,
LBNP). LBNP has been used
successfully at the University of
California to treat patients with
pulmonary edema and congestive
heart failure.
High blood concentrations of
calcium and certain other conditions
of space flight, such as a
tendency to drink less fluid than
usual, have led to a concern that the
risk of renal stone formation might
increase in space. Research in this
area has obvious applications to
urologic problems on Earth.
Space motion sickness has plagued
about half the Space Shuttle astronauts,
and the vestibular system is
thought to be involved in the
etiology of this illness. NASA
research is contributing to the basic
understanding of vestibular function.
Space is the ideal vestibular
laboratory, because in the absence
of gravity the vestibular receptors
respond only to head movements.
Investigators supported by NASA
discovered cells in the brainstem
that do not differentiate between
vestibular, somatosensory and
visual input. This has been known
for less than 10 years and has
changed our understanding of
vestibular function.11
NASA-sponsored
research can be expected to
enable physicians to treat many
patients complaining of dizziness.
New drug treatments for motion
sickness on Earth, such as the
scopolamine patch, are the result of
NASA-sponsored research.1 2
Delivery of Information
and Services
Delivery of medical services to patients
and medical information to
physicians and the public is as important
to the individual patient as
new diagnostic and surgical technologies.
Telemetry and miniaturization
have made medical instruments
portable and brought
patient and physician together.
Although telemetry was not
developed by NASA, it was essential
to the space program for tracking
satellites and many applications
of the basic idea were developed for
NASA. From telemetry came biotelemetry,
long-distance acquisition of
physiologic data. Now we have
"telemedicine," a combination of
electronic medical monitoring systems
and communication by
telemetry and satellite.4
The Portable Medical Status and
Treatment System (PMSTS) applies
microminiaturization, telemetry
and other technologies developed
for astronaut monitoring to providing
emergency medical services in
remote areas. A trained medic using
10
this system can monitor and record
vital signs and restore rhythmic
heartbeat with a defibrillator. The
emergency attendant can use the
PMSTS and telephone line to send
medical data to a physician. The
PMSTS was developed by a Houston
company, Narco Scientific BioSystems
Division. The company
also makes Porta-Fib III, a similar
device to be used in hospitals. Both
systems were derived from the
Physician's Black Bag, a portable
unit for monitoring and treatment
developed for the Johnson Space
Center by Telecare, Inc., which was
acquired by Narco.
'Sophisticated space medical
systems may enable us to establish
better methods for individualizing
medical treatment'
Telemedicine is used to provide
health care on a regular basis to the
Papago Indians, who live in villages
in a remote area of Arizona. Physicians
at a hospital monitor consoles
to observe medical data from patients
visiting the Mobile Health
Unit, which calls at each village.
Television allows the physician to
examine the patient and prescribe
treatment to be carried out by
paramedic personnel on the mobile
unit. Information the physician obtains
by telemedicine can be used
to determine whether the patient
should be transported to the
hospital. Telemedicine is also used
in Alaska and on merchant ships.
NASA scientists have used information
about how well the Papago
health care facilities work to
develop systems for future spacecraft.
A Health Maintenance Facility
being designed for the space station
contains 1,200 pounds of equipment
in 60 cubic feet. Instruments
for diagnosis and treatment are included.
The facility has attracted
the attention of the Canadian
government as a possible "emergency
room" for sparsely populated
areas.
The lixiscope (low-intensity x-ray
imaging scope) is an x-ray image intensifier
that can be brought to a patient's
home or the scene of an accident
for performing fluoroscopic
examinations or checking for fractures.
The technology that made it
possible was first used to observe xray
sources in space. Incorporation
of a miniature x-ray generator into
the instrument promises to widen
application of the lixiscope.
Satellites make it possible for
television to bring information
about health to the most remote
parts of the world; television may be
the most important source of health
information in rural areas of many
countries. Many programs are produced
by local or national governments,
and the Spanish language
program Salud Familiar is distributed
by the U.S. Information Agency
satellite system.
Future Medical Benefits
As NASA extends the limits of what
humans and machines can do, we
can look forward to continued
impact of space technology on
medical progress.
For Space Station Freedom and
other programs involving long-term
flight, a maximum amount of health
care must be provided in as small
a space as possible and with as little
"invasion" of the body as possible.
NASA will be searching for and
developing noninvasive procedures
for diagnosis. Collection, storage
and transmission of medical data
also will be critical to preserve the
health of crew members and for
functions such as monitoring exercise.
A Medical Information Bus
will be used for these purposes in
the space station Health Maintenance
Facility and could be adapted
for use by emergency medical services
on Earth. The "bus" enables
all of the medical devices to communicate
with each other and with
the central computer of the facility.
A computerized medical decision
support system using artificial intelligence
techniques is also being
developed by researchers at the
University of Florida for use on the
space station. This medical library
may eventually be put on laser disks
and made available to physicians.13
Sophisticated space medical
systems may enable us to establish
better methods for individualizing
medical treatment. The health of
each crew member is critical to the
success of each flight. Voluminous
data will be available for each
astronaut and can be used for
diagnosis and treatment in space, as
well as for such activities as
monitoring the extent of physical
deconditioning.
Space Flight and
Medical Communications
Technology transfer is highly dependent
on dissemination of information,
the importance of which is
well known to medical writers.
Research and development related
to the space program is described in
a number of NASA publications, including
NASA Tech Briefs and the
publications listed in the references
following this article. Patented
inventions available for licensing
are listed in the NASA Patent
Abstracts Bibliography, published
by the National Technical Information
Service. Scientists engaged
in NASA-sponsored research
publish their results in the medical
literature.
Space flight has contributed to
more rapid and accurate medical
communications through satellites
and computers. Now "space-age"
telecommunications and computers
can be used to bring the science and
11
technology developed for space
flight to medical science on Earth.
We believe NASA has produced a
handsome return on investment for
U..S. citizens and that the space
program will promote medical
progress as long as communication
is fostered between NASA and
medical scientists. •
Many of our colleagues at the Johnson
Space Center contributed information for
this article, and we are most grateful to
them.
REFERENCES
1. Haggerty JJ. Spinoff 1987. Washington, DC: National Aeronautics and Space Administration
Technology Utilization Division Office of Commercial Programs, 1987.
2. "University Space Technology Centers Picked by NASA," Aviation, Space, and Environmental
Medicine, 59, 1988, p. 698.
3. Spencer KC. "Manned Mars Expedition," Science, 238, 1987, p. 732.
4. Anderson M. Manned Space Flight Benefits. Houston, TX: RCA Government Services,
1987.
5. National Aeronautics and Space Administration, Technology Utilization Division Terrestrial
Applications Program, Bioengineering and Rehabilitation (NASA Publication
EP-216), Washington, DC, 1985.
6. Haggerty JJ. Spinoff 1985. Washington, DC: National Aeronautics and Space Administration
Technology Utilization Division Office of Commercial Programs, 1985.
7. National Aeronautics and Space Administration, Technology Utilization Division Office
of Commercial Programs, Aerospace Spinoffs: Twenty-Five Years of Technology Transfer,
Washington, DC, 1983.
8. Garshnek V. Earth Benefits from Space Biomedical Research: Improving the Management
of Cardiovascular Diseases. Washington, DC: National Aeronautics and Space Administration,
1987.
9. Haggerty JJ. Spinoff 1986. Washington, DC: National Aeronautics and Space Administration
Technology Utilization Division Office of Commercial Programs, 1986.
10. Nicogossian AE and Parker JF, Jr., Space Physiology and Medicine (NASA Publication
SP-447], Washington, DC: National Aeronautics and Space Administration, 1982.
11. Lackner JR. "Some Aspects of Sensory-Motor Control and Adaptation in Man," in Intersensory
Perception and Sensory Integration, ed. by RD Walk and HL Pick, Jr. New
York: Plenum, 1981, pp. 143-173.
12. Black FO, Correia, MJ, and Stucker FJ. "Easing Proneness to Motion Sickness," Patient
Care, March 30, 1980, pp. 114-128.
13. National Aeronautics and Space Administration, Life Sciences Division Office of Space
Science and Applications, Life Sciences Report 1987, Washington, DC, 1987.
Members in the News
Joel Tail, a member of the Delaware Valley
Chapter, recently was selected from more
than 40,000 volunteers to receive the
prestigious U.S. Volunteer of the Year Award
from the Medic Alert Foundation International.
Mr. Tau became associated with Medic
Alert in 1986 as Chairman of the National
Pharmacy Task Force Group, organized by
representatives of the country's leading pharmacy
organizations to increase public
awareness of the Medic Alert program by
making information available in pharmacies.
The ICI Pharmaceuticals/Newsearch
Medical Communications Awards were
presented during the 1988 AMWA Annual
Conference in Philadelphia. The awards
were presented for the best stories developed
from leads found in Newsearch.
Kathy Lopate, of Waukesha, Wisconsin,
won first place for "Loss of olfactory sense
'a rarely treated disability'" published in The
Medical Post. Second place was awarded to
Maxine Karpen, of Woodmere, New York, for
"An electronic patient," published in Computer
News. Third place was shared by Steven
Haksha, DMD, for "Going to the dentist no
longer a huge pain," published in the Ventura
County (California) Star-Free Press, and Gerald
McKee for "Exit jogging, enter jarming,"
published in Sports Medicine Digest.
* * *
Martha S. Dwyer, of Randolph, New Jersey,
has been promoted to Project Manager of
Medical Publications of Sandoz Pharmaceutical
Corp. A graduate of the University
of Notre Dame, Ms. Dwyer joined Sandoz
in 1987.
The Case Western Reserve University
School of Medicine has named Claudia M.
Caruana as its Journalist in Biomedical
Research Fellow. Ms. Caruana, a New Yorkbased
medical and science writer, spent a
week at the medical school, speaking with
researchers, participating in discussions
about journalism and observing medical
procedures.
Adele Lubell, editor of the newsletter of the
New York Chapter's newsletter in 1985-88,
recently received several awards. She was
selected to receive the American College of
Radiology's First Place News Award for an
article, "Liquid Gold Creates Safety, Costs
Dilemma," published in the American Medical
News. The same article also received an
award of merit in the Society for Technical
Communication 1988 competition. Ms.
Lubell, who continues to head an active consulting
and writing business, is currently a
contributing editor to the Physician and Sportsmedicine
magazine. Her article, "Artificial
Ligaments: Promise or Panacea" also won an
STC award of merit in 1987.
12
TECHNOLOGY:
Computers Play Major
Future Role
In Quality Management
A new paradigm calls for measuring
and rewarding the quality of care
Anne Greer
Anne Greer is Marketing
Communication Supervisor for 3M in
St. Paul, Minnesota.
EDITOR'S NOTE: Though perhaps best
known to the general public for its
adhesive tape and abrasive products,
3M is also known in the health care
industry for the more than 1,000 health
care products it markets worldwide. 3M
is one of the fastest growing and most
diversified of the major health care
companies in the world, with 1988
global sales in excess of $1 billion. The
company participates in all major
categories of health care, including
computerized health information
systems, medical supplies, devices and
equipment, diagnostics, pharmaceuticals
and dental products. 3M also works
with Rush-Presbyterian Hospital in
Chicago to offer a Tbtal Quality
Management program designed to
improve hospital productivity.
magine that you could engage
an average physician or hospital
administrator in a multiple
choice test. Imagine that you included
this statement in your
test: Changes in the American
health care delivery system over the
past 10 years have been:
a. Significant
b. Unsettling
c. Startling
d. Unnerving
e. All of the above
Chances are good that he or she
would choose the answer "e."
To be sure, the health care
delivery system in the U.S. has been
beset—even besieged—by changes.
We have witnessed the birth of the
DRG system ... and the increasing
demand for health care services by
an aging population.
We have seen movement of services
to alternate care sites and the
formation of hospitals into buying
groups. We have seen an increasing
number of physicians and a
decreasing number of practicing
nurses.
We also have witnessed the
emergence of AIDS as a major
health threat—a disease that has
extracted a heavy toll on the health
care delivery system as well as our
peace of mind.
We have seen increasing cost
containment pressures put on
providers and suppliers by
insurance companies, Medicare and
other payers.
The health care delivery system,
once as solid and stately as an oak
tree, is creaking and cracking under
the weight of these burdens while
costs continue to escalate.
Joseph A. Califano, Jr., former
Secretary of Health, Education, and
Welfare, wrote in the New York
Times Magazine in 1988: "Health is
devouring an ever-increasing share
of our national wealth...nearly 12
percent of our gross national product.
During 1986 and 1987 the
price of American health care shot
up at more than twice the rate of
inflation."
And the bad part, says Mr.
Califano, is that "a large portion of
the money spent on health care is
wasted."1
In the face of these problems, we
are beginning to recognize the flaws
within the old, activity-based
paradigm ... where delivery of service
was the major method to determine
payment. We are now in a transitional
phase, where we are beginning
to recognize the imperative of
a quality-based or outcome-based
system.
Health care visionaries have
begun to plant the seeds for this
new system. Paul Ellwood, M.D.,
who popularized HMOs, proposed
last year that all physicians administer
brief health outcome
surveys to their chronic care ambulatory
patients and submit the
results to a national data bank. The
results, together with information
on the patients' clinical conditions
and types of medical interventions
1 Q
used, would answer the bottom-line
question — how effective was the
physician?
Dr. Arnold Relman, who published
Dr. Ellwood's article, has called
outcomes management and assessment
"the third big revolution in
medicine in our time."
The head of the Health Care
Financing Administration also is
pushing for outcomes measurement.
An outcome-based system would
focus on the total patient
experience—not just a single activity
or procedure in the health care
delivery process. This new
paradigm calls for measuring and
rewarding the quality of care. It requires
measuring long-term health
outcomes, the acceptability of care,
access to care, the quality of the
physician-patient relationship and
patient satisfaction. Such data have
seldom been collected or used in
any meaningful way in the past.2
This movement toward an
outcome-based system would be
impractical, if not impossible, without
extensive use of computers.
Total Quality Management
This article offers a general overview
of the role that computers
play, and will play, in helping the
health care system deliver on
the promise of Total Quality
Management.
First, I'd like to consider the concept
of total quality. Just what is
quality?
At 3M, we adopted a "Total Quality"
approach back in 1979. We
define it as "meeting the customer's
expectation." First, we need to know
what the customer expects. Then
we set plans to meet those needs
and wants. The customer is defined
as anyone who is the recipient of
our work; so, we have customers
inside the company, as well as
outside the company.
We invested money in quality
training ... and on products that
would improve our performance.
We found that quality saves
money. In fact, in 1986, the last year
for which we have figures, we
achieved a savings of $55 million.
Hospitals and other providers are
starting to recognize that "total
quality" can help them survive.
Quoted in a recent issue of Hospitals,
Dr. Steven Steiber of Gallup
Hospital Market Research stated:
"The quality of health care is not a
new issue by any means. But it is
a new criterion by which hospitals
will be more closely scrutinized,"
and, he adds, "by which they will
likely even be reimbursed, in the not
too distant future."3
'The quality of health care is
not a new issue by any means.
But it is a new criterion by
which hospitals will be more
closely scrutinized.'
Still another recent article notes
that "80 of 130 [hospital] coalitions
put quality at the top of their
agendas for 1988."4
If "total quality" is a "white
knight" to ensure organizational effectiveness,
then "computer technology"
is the swift, and surefooted,
steed on which it rides.
Many companies in the health information
systems business are
working closely with hospital financial
managers, clinicians and others
to develop computer technology
that will:
• Improve the quality of care;
• Improve the quality of hospital
operations;
• And, at the same time, improve
the hospital's profitability.
Computer technology is on the
verge of becoming a tremendous
tool in that regard. I say "on the
verge" because, historically, hospital
information systems have been only
marginally helpful in the areas of
quality and cost containment. They
have improved the speed and accuracy
of collecting, storing and
retrieving data.
But only recently have we begun
to develop those systems' potential
to integrate data, creating information
that health care providers can
use to decrease costs and increase
quality.
Computers could be put to work
on applications such as:
• Patient care plan suggestions;
• Clinical findings, to prevent
oversight;
• Suggestions of possible diagnoses
and procedures;
• Warnings or alerts;
• Standing orders;
• Identification of potential allergic
reactions and contra­
indications;
• Protocol implementation;
• Resolution of scheduling
conflicts; and
• Options for drugs and options for
test alternatives.
This is the type of information
that can be generated through use
of an "expert system."
For a description of an expert
system, I went to an article in
Computers in Healthcare magazine
by Scott Slivka and John Morgan.5
The article said an expert system
involves: "The joining of a comprehensive
clinical database with
sets of protocols, criteria and rules
which replicate the expertise of individuals
in specialized fields of
clinical practice and management."
As an example, the authors cited
a surgeon ordering medication for
a hospital patient. The expert
system would provide detailed information
and suggestions from the
"clinical pharmacy" component of
14
the system. It would compare
everything known about that drug
to everything known about that patient.
It might suggest another drug
and give the reason why.
Perhaps the patient had an
allergic reaction to a similar drug,
several years ago. The expert system
also might provide a plan of how
and when the medication could be
administered, and how these would
fit into the current care plan.
'We have come from a period
that has been called "the most
permissive possible"... to one
that may be too restictive.'
The system might identify potential
reactions to other medication
the patient is taking. Or a possible
interaction with lab tests that have
been scheduled for that patient the
next morning.
"Thus," the authors explain, "an
expert system is an information
system that does more than just
store and report data. It participates
in and enhances clinical decisions."
All of this information plays a role
in increasing the quality and
decreasing the cost of health care.5
So how many years do we have to
wait for these wonderful systems?
To some degree, these systems are
available today.
One of these systems is called
HELPHELP
system is an expert system
developed over the last 20 years by
a team at LDS Hospital in Salt Lake
City.
The system performs many of the
tasks previously cited, ranging from
helping physicians reach a diagnosis
to optimizing usage of expensive
equipment to assisting in discharge
planning.
This type of system—and coming
generations—will play an important
role in the future world described
by futurist Jeff Goldsmith. In an article
titled "2036: A Health Care
Odyssey," from Hospitals magazine,
Goldsmith writes: "The major
vectors for change in U.S. health
care delivery are scientific progress
in biomedical research; technological
innovations in diagnosis, treatment
and clinical information systems;
changing clinical practice (as
influenced by the two forces listed
above); and institutional and
managerial strategies that bring
innovation to the patient."6
In other words: computer technology
and the human brains to
use it.
Technological Advancements
Goldsmith describes everything
from bedside terminals to
computer-controlled implants that
will allow more patients with
serious illnesses to be sent home
safely. He talks of remote fetal
monitoring systems that can
transmit signals over the telephone
and other elaborate monitoring
systems that will enable physicians
to extend their therapeutic and
protective powers beyond the walls
of their offices or hospitals.
He predicts that systems providing
continuous medication and
patient monitoring will reduce the
need to hospitalize patients, perhaps
dramatically. "The patients of the
21st Century will be connected to
their physicians or hospitals by
webs of telemetry similar to those
used in cellular communications,"
he says.
"Perhaps these communication
webs will be coordinated or
monitored by computer systems
that could trigger responses in advance
of crises."6
Will computer technology really
do all that?
Probably so. And probably more.
So where have we come from?
And where are we going?
We have come from a period that
has been called "the most permissive
possible...for technology..."
to one that may be too restrictive.
I believe computer technology is
one technology that will thrive in
this new era...because it offers the
most promising avenue to total
quality...to achieving the elusive
dream of excellent clinical results,
rendered by solvent providers, at a
cost that payers are able to afford. •
REFERENCES
1. Califano Jr., JA. "The Health-Care Chaos," The New York Times Magazine, March 20, 1988,
pp. 44 +.
2. Meyer H. "National Health Care Outcome Data Base Proposed," American Medical News,
July 22, 1988, p. 11.
3. Steiber S. "Quality of Care Good for Patient and Provider," Hospitals, December 20, 1987,
p. 76.
4. Droste T. "Quality is Top Concern for Coalitions," Hospitals, February 5, 1988, p. 60.
5. Morgan JD and Slivka S. "Benefiting From Expert Systems," Computers in Healthcare,
January 1988, p. 44.
6. Goldsmith J. "2036: A Health Care Odyssey," Hospitals, May 5, 1986, pp. 69 + .
The Origins of the Scientific
Paper: The IMRAD Format
The sameness of a manuscript's
organization provides reliability
RESEARCH:
Robert A. Day
Robert A. Day is a Professor of English
at the University of Delaware in
Newark.
The greatest invention of the nineteenth
century was the invention of the method
of invention.
—A.N. Whitehead
scientific experiment has
not been completed until
the results have been
published. If we accept
that statement as true,
we then can appreciate the overwhelming
correlation that exists between
scientific research and scientific
writing. We can see that one is
the reflection of the other. Therefore,
by studying the literature of science,
we can learn something about the
history of science. And, although
comparatively little has been written
on the subject, we can learn something
about the history of scientific
writing.
When we examine modern scientific
papers, we see a certain sameness
about them. That sameness
derives from the fact—and it is a
fact—that almost all research papers
in the sciences are organized in the
same way. That organization has
come to be known as IMRAD, the
acronym standing for Introduction,
Methods, Results and Discussion.
Why is this so? When did the
IMRAD format develop?
The Early History
It is tempting to say it started with
Hippocrates some 24 centuries ago.
After all, it is Hippocrates who is
credited with the "discovery" of the
scientific method. And perhaps it did
start then. However, I contend that
the modern scientific paper, especially
in our field of biomedicine,
was born one century ago, not 24,
and that it has come into widespread
use only during the past 50 years.
Hippocrates' scientific method
(usually stated as: identify a problem,
gather relevant data, formulate
a hypothesis from these data, and
then empirically test the hypothesis)
was fine as far as it went. But it
lacked (or at least did not overtly
state) what we now recognize as the
cornerstone of the scientific method:
the reproducibility of results. The reproducibility
principle did not become
established in biomedicine until
the 19th Century.
Prior to the 19th Century, scientists
and scholars communicated
with each other orally, by letter and,
after the invention of the printing
press in A.D 1455, by books. The
first journals were established in
1665. The early journals were of
course "letters" journals (some of
which still exist). The style of writing
was descriptive, usually chronological.
("First I did this, and then I did
that," etc.)
The Real Beginning
Not until the latter half of the 19th
Century did the style of scientific
papers begin to change. The change
16
in style resulted primarily from the
work of Robert Koch and Louis Pasteur.
The famous "Koch's Postulates"
and Pasteur's development of germfree
methods gave final confirmation
to the germ theory of disease while
at the same time administering the
final coup de grace to the old theory
of "spontaneous generation."
Until the development of the germ
theory of disease, the practice of
medicine could hardly be called a
science. The practitioners of medicine
were powerless to prevent or
treat the plagues and other infectious
diseases that killed by the millions.
Once the germ theory was accepted,
the practice of medicine did indeed
become a science and the results
have truly been spectacular.
One can argue, and I do, that Pasteur's
greatest contribution was his
ability to argue. For Pasteur, it was
not enough to prove the germ theory
to his own satisfaction. Pasteur was
hounded by numerous, and important,
adversaries, most of them fanatic
proponents of the theory of
spontaneous generation. Pasteur
courageously, in his books and other
publications as well as in personal
and public confrontations, argued effectively
and persuasively in support
of his ideas.
Particularly, what Pasteur did was
to describe his experiments in such
exquisite detail that any reasonable
person could repeat them and get
the same dramatic results. And thus
did Pasteur essentially demolish the
opposition. And thus did he espouse
the power of the principle we now
call reproducibility of results. And
thus, by establishing "methods" sections
in his publications, he established
the basics of the modern
IMRAD paper.
Pasteur and IMRAD
In his classic Etudes sur la Biere, Pasteur's
use of the IMRAD style resonates
throughout the book. Each section
of the book describes a particular
"study," and these sections read
almost like a collection of journal articles.
I will quote a few sentences
from one of Pasteur's most famous
studies. (I quote from the English
translation edited by Frank Faulkner
and D. Constable Robb and published
under the title Studies on Fermentation
by Macmillan & Co. in
1879.)
The "Introduction" covers several
pages in which Pasteur outlines the
"vital energy" theory of Fremy. The
last sentence (p. 54) of this Introduction
states Pasteur's purpose in
no uncertain terms:
We at once resolved to demolish
M. Fremy's theory, by a decisive
experiment on the juice of grapes.
After this ringing statement of purpose,
Pasteur immediately launched
into a detailed description of the
methods he used in this experiment.
We prepared forty flasks, capable
of holding from 250 c.c. to 300 c.c.
[from 9 to 11 fl. oz.] and shaped
as represented in Fig. 8. These we
filled with filtered must, which
was perfectly bright, and which,
like all acid liquids, would remain
sound, after having been boiled for
a few seconds, although the ends
of the long curved necks of the
flasks containing the must might
remain constantly open for
months or years.
After describing how the 40 flasks
were divided into four series of 10
flasks each and variously treated,
Pasteur is then ready to present his
results, in good IMRAD form. His
first sentence (p. 56) makes this transition
absolutely clear:
The following are the results presented
by our four series of comparative
experiments in the different
cases.
When Pasteur completes his Results
(of course he doesn't use these
headings, perhaps not yet realizing
that he invented them), he then begins
the Discussion. Again, his polemical
style makes this transition
(p. 57) abundantly clear:
These experiments cannot leave
the least doubt on our minds:
That must, if boiled, will never
ferment when in contact with air
that has been freed from the
germs which exist in it in a state
of suspension.
'Until the development of the germ
theory of disease, the practice of
medicine could hardly be called a
science. The practitioners of medicine
were powerless to... treat the
plagues and other infectious
diseases...'
To again show that he was not a
student of Dale Carnegie, Pasteur
stated his central conclusion:
"Thus, the hypothesis of MM.
Trecul and Fremy, according to
which albuminous substances
transform themselves into grains
of yeast by the action of a peculiar
vital force, is annihilated."
IMRAD Comes of Age
In the 50 years or so following the
work of Pasteur, many journal papers
began to look "modern." The
papers of Paul Ehrlich (Salvarsan) in
the early 1900s, those of Alexander
Fleming (lysozyme, penicillin) in the
1920s, and those of Gerhard Domagh
(sulfa drugs) in the 1930s are
reasonably good examples of "modern"
papers. Insofar as the papers in
the first half of this century were
not "modern," the organization
tended to be loose and the language
excessively wordy.
After World War II, science became
big business. The wonder drug
penicillin (although "discovered" a
decade earlier) was developed during
the War, and the later 1940s and
1950s saw the development of strep-
tomycin, the tetracyclines and many
other "wonders." It was no surprise
that the federal government began
contributing massive financial support
to scientists producing these
wonders.
This positive reason for supporting
science was soon followed by a negative
reason. In 1957, the Russians
flew Sputnik around our globe.
Thus, in fear of getting behind, our
Senators and Representatives eagerly
appropriated still more money
for science.
Money meant research, and research
meant papers. And our journals
were virtually overwhelmed by
manuscripts pouring out of our research
laboratories.
What could be done in this crisis
atmosphere? We look back now, and
what was done makes obvious
sense. The editors of the journals,
themselves and working through
their organizations, began insisting
on tightly written manuscripts in the
IMRAD format.
Eventually, in 1972, the IMRAD
format became "standard" with the
publication of the American National
Standard for the preparation of scientific
papers for written or oral presentation
(ANSI Z39.16-1972). Some 45
organizations approved this standard,
including the American Chemical
Society, American Institute of
Physics, American Library Association,
Association of American PubUshers,
Council of Biology Editors,
Medical Library Association and
National Academy of Sciences.
In the 25 years since the adoption
of this ANSI standard, the IMRAD
format not only has been adopted
throughout the sciences but also has
spread to the social sciences and
even to some professional journals
in the arts and humanities.
In the early days of IMRAD, some
editors and many writers argued that
the IMRAD format was too rigid and
that this rigidity would inhibit the
personal "style" of authors. Later,
many editors (if not writers) came to
believe the great accomplishment of
IMRAD devolved precisely from its
rigidity. Scientific papers are now
logically and rigidly organized in a
format readily recognizable and understandable
by their writers, reviewers,
editors and readers.
Medical writing is still not easy.
And we all know that medical editing
is still not easy. However, thanks
to Pasteur and IMRAD, we are all
following the same roadmap and we
usually arrive at or close to the destination:
the logically organized, wellwritten
scientific paper. •
Medical Writer
Allergan, Inc., the world's largest eye-care company, is
actively searching for a talented medical writer. Responsibilities
include writing and editing journal articles,
technical reports, posters and presentations for scientific
meetings, and marketing materials related to contact
lenses and contact lens care solutions.
The ideal candidate will be able to demonstrate his or her
ability to understand and clearly express scientific information.
The position requires at least 1 year applicable experience
in a medically-oriented environment plus experience
equivalent to a 4-year college degree in physical
sciences, life sciences, or humanities. Excellent organizational
and interpersonal skills are required. Computer experience
and an ability to express data graphically are
pluses.
Achievement is rewarded with an excellent salary and
flexible benefits which can be customized to your individual
needs, and strong promotional opportunities in
this fast-growing company. For immediate, confidential
consideration, please send your resume, including salary
requirements, to: Allergan Optical, Human Resources
Dept. BR-AMW, 2525 Dupont Drive, Irvine, CA 92715.
Equal Opportunity Employer M/F/H/V.
Growth With Vision
4 b A L L E R G A N O P T I C A L
18
MCGOVERN LECTURE:
The Making of a Medical
Television Documentary
A Nobel Prize recipient ventures
into new areas of communication
Baruch S. Blumberg, M.D., Ph.D.
Baruch S. Blumberg, M.D., Ph.D., is
Vice President for Population Oncology
at the Fox Chase Cancer Center in
Philadelphia.
T
he project—the production
of the medical documentary
"Plagues'—was begun
on the initiative of Ms.
Lenora Berson, a freelance
writer from Philadelphia who, in
1977, asked me if I would like to
create and narrate a series of television
documentaries on medical history.
I expressed an interest in doing
so, since I had an amateur interest
in history and in medical history in
particular. I recently had been
awarded (in 1976) the Nobel Prize in
Medicine, and Ms. Berson thought
it would be an opportune time for a
medical history series to originate
from Philadelphia, a city rich not
only in medical history itself, but
also possessing extraordinary library,
academic and museum resources
pertaining to the subject. We approached
our local public television
station, WHYY, with the concept for
the production.
It was not until 1984 that the
station director decided to proceed.
Mr. David Othmer of WHYY was
appointed Executive Producer. In
the meanwhile, Ms. Berson had
joined the government of the City of
Philadelphia in the Office of the
Mayor's Special Representative. The
city decided to grant "start-up"
money to hasten the project on its
way, realizing that producing such a
program in Philadelphia would enhance
the city's image as well as add
to the movie-making activities there.
Our creative group decided the film
would be shot primarily in the city
and that institutional and personnel
resources of the community would
be used extensively in its production.
It was not designed to be a
"publicity film" for Philadelphia, but
rather, in a subtle way, it was
intended to convey positive images
of our city to viewers.
Stimulated by this support from
civic authorities and empowered
with a financial grant, I prepared an
outline of possible shows in a series
that we thought might include as
many as a dozen separate programs.
We then convened a committee of
academic, medical and scientific
leaders from the Philadelphia area to
serve as an advisory board to help
select the topics to be covered and
solicit reactions to our ideas. Our
initial meeting could be described as
exciting, vigorous and, in fact,
heated. It was surprising to experience
the level of controversy raised
by what, at first glance, would
appear to be a bland academic topic.
However, in rereading my notes of
the meeting I noted that, although
there were differences of opinion,
there was considerable agreement
on how we should proceed, and a
list of possible programs was
drafted.
Reality Vs. Fantasy
What were the general themes we
wanted to express? In discussing
these, it might be useful to consider
why I was interested in undertaking
19
this time-consuming project during
a period when I was deeply involved
in a fascinating research program.
Basically, the major motivation was
my passion for the movies. I'm a
"twenty-fiver" (that is, born in 1925),
and my generation went to the
movies every Saturday, rain or shine,
irrespective of what was showing at
the "nabe" (the local neighborhood
theater). I believe it was the novelist
Norman Mailer who commented
that for our generation, the littoral
of the imagination was made up of
the movies of the 1930s and 1940s.
Our expectations of what life would
be were molded by the images conveyed
by the Silver Screen with all
of its high morality, unreality and
happy-ending messages. In my view,
it provided an excellent distortion of
how to view the world.
I've always been intrigued by the
power of the flicks to sense the
border-line between reality and
fantasy. Movies are, in some respects,
the most literal of the visual
arts. In one sense they are exact
images of reality—moving, breathing,
colored as nature is or should
be. But they are also very unreal;
they are, in fact, flickering lights on
a blank two-dimensional screen. The
colors are more vivid than those of
life, and the management of time,
which we readily accept in a movie,
is a gross misrepresentation of the
linear dimension where we think we
live. Take, for example, the movie
"Blow Up," in which the whole story
hinges on whether an enlargement
of a photograph shows the feet of a
murder victim partially concealed by
a clump of trees. Reality is dependent
on the discoloration of a few
grains of a photosensitive chemical.
The final charade of a mimed tennis
game hammers home the ambiguity
of reality and fantasy.
It may not be recognized that the
scientific process also moves between
fantasy and a testable reality.
The scientist acquires a body of data
abstracted from nature. From this he
constructs a hypothesis or model
guided by scientific laws that explains
the data in a satisfactory and
sometimes elegant fashion. A necessary
feature of a scientific model is
that it must be testable, but initially
it is a product of the imagination
(read fantasy) of the scientist. Having
created this "image," the scientist is
now obliged to test it against the
harsh demands of reality by experiment
and observation. If the imagined
model survives these tests, it
achieves a kind of reality in the
sense that it can be used to predict
future experimental and observational
outcomes and, in some cases,
can be applied for practical use, for
example, as a medication. The data
generated from this testing process
can be used to make additional
hypotheses and models, which are
again subjected to a reality test. The
scientist goes through repeated
phases of imagination and reality
reminiscent of the movie-making
process in which there are rapid successional
changes between the activity
of the location, the technicalities
of filming and sound recording, and
the ultimate fantasy which requires
believing that flickering light is life.
There were other themes we
wished to incorporate into the documentary.
We did not want it to be a
dramatization of the ultimate success
of scientific medicine, a relentless
and ordered progress to problem
resolution. That would be a distortion
of history. On the contrary, problems
are rarely totally solved; the
solution of one always seems to generate
others, and success is rarely, if
ever, complete. We wanted the film
to show this seeming paradox so
fundamental to scientific research.
We also wished to illustrate the process
of discovery in a narrative style
to illustrate that it is often, perhaps
always, an indirect, Shandean sequence
(as in Sterne's novel, The
Lives and Opinions ofTristam Shandy,
Gentleman) of events seemingly
meandering from one unexpected
outcome to another, and not the
precise, linear, logical process that
science is sometimes imagined to be.
It also was not to be a story of the
laboratory, hospital and clinic, but
rather an account of the disease itself
filmed in the field, the streets, the
forests, the cities, the villages and the
homes where disease occurs. It was
to emphasize the contributions of
public health and epidemiology in
addition to those of therapeutic
medicine.
Finally, I wanted to incorporate
my own research into the actual
story-writing and film-making, since
I planned to do the film while conducting
my regular work at the Fox
Chase Cancer Center.
Based on the advice we received
from our committee, the work of a
cadre of researchers, and the general
principles we established, a treatment
for one program was developed.
This was presented to several
funding foundations in the Philadelphia
area, and we obtained generous
support from the Pew Charitable
Trusts. Additional support was obtained
from the Pfahler Foundation
and the Pennsylvania Humanities
Council. We were gratified to find
these funds for an essentially untried
concept and certainly an inexperienced
television narrator.
Writing the Script
Enough philosophy for the moment
and on to the mechanics of actual
script writing. We never really had
a full script, or, if one did exist, I
never saw it. The directors, the producer,
one or more researchers and
I would sit together and I would tell
stories about epidemics culled from
my general knowledge, medical
training and previous historical
interests. The others then would
indicate which of these they considered
most interesting, contribute
stories and ideas of their own, and
we eventually selected several diseases
and themes that we thought
20
should be included as anecdotes in
the film.
The researchers then were requested
to obtain additional information
on the topic and incorporate
this into an essay that was added to
other documentary" material. The
original source materials used by the
researchers were often included in
their reports, allowing me to read
through them to check their interpretations
and, in some cases, add
medical insights. From this multiplepage
document, the directors and I
would prepare a shorter—one- or
two-page—essay. Armed with this,
the directors would prepare a script
of the actual material to be used in
the program.
An attempt was made to get the
script to me in advance of the shooting
date, but usually I saw my
"lines" for the first time on location
while the director of photography
and other members of the staff were
setting up their equipment. It is
accurate to say I never once accepted
the script exactly as it was
prepared. Thereupon, a dialogue
ensued between the writers and
me—lively, even heated, creative,
but never acrimonious. Added piquancy
was provided by fading sunlight
and the temperament of cameramen.
Once their equipment is
assembled, cameramen do not like
to wait and, what is more, are well
within their rights to charge overtime.
We became expert at resolving
script problems swiftly. I have enormous
respect for co-producers Alan
Goldberg and Marilyn Nissenson,
professional writers, who allowed
me to criticize (and in some cases
ravage) their prepared script. They
always took this assault on their egos
with grace and style.
Having decided on the script I
would then "narrate." Early in the
process we decided it would be inadvisable
for me to read the script
using a teleprompter or similar
device; a practice video revealed I
would require glasses to read the
text and the requisite "glare-free"
specs were never obtained. I also
discovered that memorizing a prepared
script had disadvantages,
such as loss of spontaneity, so,
although I occasionally memorized
a piece of script, for many of the
takes I would paraphrase the words
that had been written.
The whole process seemed makeshift;
in effect we were creating the
actual script more or less as we went
along, although of course it was
based on research and writing. Early
in the process, when I had complained
once too often about these
informal arrangements, Mr. Goldberg
told us that "Casablanca" had
been filmed without a script. From
then on I was happy to continue our
style of filming, if it allied us with
the Bogart classic.
Acting and Narrating
How did a reasonably content medical
researcher, that is, me, suddenly
find himself in show biz? The "official"
story, of course, is that I was
drinking a milk shake at Schwab's
Drug Store in Hollywood, when Mr.
Goldberg walked in, saw me, and
exclaimed to the creative group that
always accompany him like a cloud
around a rain storm, "There sits a
natural medical documentary narrator."
The rest is history. I don't
expect everyone to believe that story,
and I'll provide some alternatives to
it.
Actually, aside from a supporting
role as a pilgrim in a Thanksgiving
Day play in elementary school and
the narration of a sophomoric
speech at medical school graduation,
intended to be off-color by the standards
of the day, I had never acted
on stage. Mr. Goldberg and the
others had assured me this would be
unnecessary for "Plagues" since I
would be a narrator. My son-in-law,
a senior editor with the British
Broadcasting Corporation, gave me
'The whole process seemed
makeshift.. .we were creating the
actual script.. .as we went along...'
several items of advice: stand
straight, look at the camera, imagine
that you're talking to one or a few
people huddled in front of their television
sets in a darkened living
room. The directors advised me to
be conversational, speak rapidly and
be "energetic." I realized I would not
be acting but speaking, that I would
not have to qualify for the former
craft and therefore not have to join
the actors union.
With this in mind I carefully
avoided acting. However, problems
arose. For example, we were filming
a sequence in Australia at the former
home of Thomas Austin, a rich
farmer and herder who had imported
wild European rabbits along
with other luxury items from Britain
to his home in Geelong near
Melbourne. I was standing in the
foyer of the enormous mansion he
had built, describing the items in
addition to the rabbits he had
brought. When I said "wood for the
staircase," I pointed to the stairs
behind me. When I referred to the
"stained glass for the windows," I
pointed to the windows. When I
mentioned the "china for his dining
room," I pointed to the dining room
on my right. Francis Kenny, our
director of photography, objected.
"Barry, don't turn to the right, it puts
you in an awkward position."
"Francis," I responded, "the dining
room is to the right." He soundly
advised me no one in televisionland
would know that. "But Francis," I
answered, "I know it. If I point to
the right I'm narrating. If I point in
any other direction I'm acting, and
I'm not supposed to do that." Ever
a spineless compromiser, during the
retake I waved vaguely in front of
me and considered it a con-
21
cession to art.
Another of the conflicts between
fantasy and reality arose during the
filming of the malaria sequences. We
had planned to shoot these scenes in
Fiji. However, just before our
planned arrival, a military coup
occurred, the first time for a political
takeover in an otherwise stable government.
We debated going anyway,
but learned there had been disruptions
of transportation and that an
Australian film crew had been detained
by the police. We then had to
substitute Hawaii as a location for
the filming; Hawaii was a stop on
our round-trip ticket and would not
increase our already considerable
travel costs.
This solution resulted in another
problem (as solutions always do).
Malaria has never existed in Hawaii!
Further, we were looking for a typical
"jungle" location to film the
sequences related to mosquito control.
We selected the Lyon Arboretum
of the University of Hawaii for
this purpose. This also presented
problems on the reality/fantasy
interface. The location of the Arboretum
previously had been a
mountain pasture that had been
given to the University. The curators
then proceeded to plant tropical
species from all over the world, and
only a handful were native to
Hawaii. The "jungle" certainly
looked authentic but was, in fact, a
meticulously designed human
creation.
These "problems" may sound
trivial, but they were recurring
metaphors for the conflict between
the scientist who imagines he is
representing things exactly as they
are and the filmmaker who knows
he relies on illusion.
Anecdotes and Concepts
As a frequent movie-goer, I often
read film criticism. In Philadelphia,
we are fortunate to have several
.'.. they were recurring
metaphors for the conflict
between the scientist who
imagines he is representing things
exactly... and the filmmaker
who knows he relies on illusion.'
good critics who clearly enjoy the
medium and, rather than telling you
why they do or don't like a particular
movie, explain what they think the
writers, actors and directors had in
mind when they created their films.
Occasionally, I've read accounts
written by the writer, director or
others directly involved with the
film, describing their intent and
motivation. These have been particularly
valuable and interesting, for
it allows the analysis of the film in
terms of the stated thought process
of the creators. I will attempt to do
that for several of the episodes included
in "Plagues."
Early in our discussions, we decided
that the style of the film would
be anecdotal rather than didactic.
We stuck to this plan with only two
exceptions in which we tried to present
ideas by the use of metaphor.
These were the episodes in which
we examined the "war against
disease" model, and found it wanting,
and the heavily symbolic use of
the Daedalus myth to stress the
problem-creating as well as the
problem-solving character of scientific
research. The former sequence
was filmed on a moth-balled World
War II Navy cruiser at the Philadelphia
Navy Yard, and the latter in an
elaborate yew hedge labyrinth (an
illusion to the Daedalus story) at
Hever Castle in southern England.
In retrospect, I don't think these two
abstractions were successful. My
experience in presenting scientific
lectures has been that, in general,
audiences like stories, but they don't
want to hear philosophy.
Influenza
In the 1918 influenza sequence, we
wanted to convey the impact of a
vast, worldwide, brutally destructive
epidemic that affected all ages and
both sexes. It was, with the probable
exception of the Black Death of the
Middle Ages, the greatest pandemic
of all time, in which nearly half of
the world's population was infected
and about 25 million people died.
The toll it exacted on individuals and
families was dramatized by the
testimonies of several peopleresidents
of Philadelphia—who had
survived the epidemic, but whose
family members or friends had been
infected or died. Nearly every family
in this and many other communities
was affected.
We attempted to explain why this
disease spread so rapidly and widely.
There had been a major change in
the character of the influenza virus
and there were few people alive who
had ever experienced this new
strain. As a consequence, there was
little immunity against it and nearly
everyone was susceptible to
infection. However, as the epidemic
continued into the fall, more and
more people became infected. Not
all developed the disease, and many
became immune. Eventually there
was a sufficiently large number of
immune people in the population,
and the virus could no longer
spread.
The themes emphasized in this sequence
were the mutability of the
influenza virus in which a new
strain had developed and eventual
changes in the population that increased
the "herd immunity."
Another theme stressed was the terminology
used for the disease (i.e.,
"the Spanish flu"), which indicated
the desire to imply the foreign origin
of a disastrous epidemic. People
want to believe that bad things come
22
from elsewhere, and this can sometimes
be incorporated in a name.
This fear of contamination from
others, from "outsiders," often leads
to a demand for quarantine of the
infected or those thought to be
susceptible to infection. This may
sometimes be warranted, but often
is not, and can have destructive and
unnecessary effects.
The influenza story also was
meant to provide a basis for comparison
with the current concerns
we have with another serious
epidemic, AIDS, and to point out
that society has been down this road
before. "Plagues" are not just a
concern of the past.
Constant Change as a
Characteristic of
Epidemics-Myxomatosis
The notion of the changes that can
occur in the infectious agent, in the
population that provides the hosts
for the infection, and in the environment
in which they coexist was the
theme of the Australian rabbit sequence.
As noted previously, wild
European rabbits were imported into
Australia by Austin, a successful
farmer and rancher who wanted to
be surrounded by the familiar
animals he had remembered from
his childhood in southern England.
Unopposed by any natural
predators or diseases, the rabbits
multiplied rapidly and spread
thoroughout Australia. They competed
with cattle and sheep for the
available pasture and soon became
the major agricultural pest in the
country. (They actually provided the
mainstay for an important industry
in rabbit pelts.)
A variety of desperate measures
was used in an attempt to control
this "epidemic" of rabbits. In the
1950s a program to introduce myxomatosis,
a virus deadly to the rabbits,
was begun. Within a short time
the virus had killed more than 90
percent of the rabbits in the area
where it was introduced. The
epidemic was followed carefully
over succeeding years. It was found
that the virus bcame less virulent
with time, and in successive
epidemics killed fewer and fewer
rabbits. Also, it was possible to
demonstrate that over the years of
the epidemic the surviving rabbits
and their offspring had become
more resistant to the virus. Overall,
the epidemic was less deadly than
it had been at its inception. The
population of rabbits and of viruses
had adjusted so that they could coexist.
Obviously, a virus could not
be perpetuated if all of the susceptible
hosts were killed.
In the meanwhile, the virus had
been accidentally released in
Europe. In a short time a large
percentage of the rabbit population
in Europe had been killed, but again
the virulence of the virus decreased
and the resistance of the rabbits
increased. We dramatized the
return of the virus to Europe by
showing scenes in Austin's home
village of Baltonsborough, England,
where local rabbit hunters, old and
young, discussed the rabbit situation
before and after the myxomatosis
epidemic. This lively conversation,
in the nearly
undecipherable Somerset dialogue,
concerned the epidemic and its effect
on the rabbits and the country
people who depended on the rabbits
to supplement their food
supply.
The directors decided to center
the dramatic focus of the rabbit
story on the family that had brought
them to Australia. The film sweeps
from the village of origin directly into
the mansion that Austin had built
in Geelong in Australia. I was
fascinated by this time-play.
Although Baltonsborough and
Geelong were separated by
thousands of miles, and the location
filming by months of time, in the
show they appear to follow one
directly on the other. This
precipitated a near crisis, as I had
to remember exactly what I was
wearing in England, and duplicate
that in Australia.
There was another interesting
"time event" associated with this sequence.
At the time we filmed in
Baltonsborough, a group of sailing
ships set off from London to reenact
the voyage of the "First Fleet"
which brought the first group of
convicts to the new penal colony of
Botany Bay in New South Wales.
My daughter (who lives in England)
and I witnessed this fleet sailing
down the Thames past Greenwich
on its way to the East. It didn't arrive
in Australia until months after
we had finished our filming there.
It was fascinating to consider the
different time scales of the filming,
the film content, the historic events
and the reenactment.
In the case of the influenza virus,
a major change had made it more
deadly. In the case of the myxomatosis
virus, the changes had an
opposite effect, and the disease
became less deadly. This again has
a bearing on the AIDS epidemic, in
which it is feared that the currently
common strains of the virus—
which are, compared to other
viruses, relatively difficult to
transmit—could suddenly mutate to
a more readily transmissible form.
Although many strains of the AIDS
virus now have been identified,
none appears to have made this
dreaded transition.
Cholera, Snow and the
Scientific Process
Cholera has been and continues to
be one of the most deadly and
widespread diseases. It was mentioned
in several places in the film.
We used the history of the disease
to illustrate the application of the
scientific process in determining
how cholera is transmitted and the
social and professional reactions to
the discovery of its transmission.
John Snow, a physician living in
London, is one of the "heroes" of
epidemiology. We focused on his
contributions, drawing heavily on
the account of studies given in his
book, usually referred to as "Snow
on Cholera."
Dr. Snow's work started with a
series of mid-19th Century observations
on patients with cholera. We
reenacted several of these observations,
using professional actors.
Although the disease possibly could
have been transmitted by a variety
of methods, Dr. Snow was most impressed
by the possibility of waterborne
disease. He even postulated
the existence of particles that were
carried in the patient's excreta,
entered the water supply, and then
were consumed by others who also
became ill; that is, something in the
nature of a bacterium or other infectious
agent. And, in fact, in each of
these cases it appeared that the
disease was always transmitted
because people had eaten food or
drunk water that contained the fecal
waste of someone who had had
cholera. This, of course, all happened
before the establishment of the
germ theory of disease by Pasteur,
Koch and others, which occurred
later in the 19th Century.
Based on these anecdotal observations,
Dr. Snow made a formal
hypothesis which was, in effect, a
restatement of the message of the
original "anecdotal" observations.
He said that cholera was transmitted
by materials (particles)
emanating from the fecal waste of
a patient that entered the water
supply; this contaminated water
then was consumed by others. In
the scientific process, once a
hypothesis has been proposed, even
though it is a restatement of observations
that have already been
made, new data have to be collected
to test it.
'One of the most striking features
of the successful scientist is
persistence.'
An opportunity arose to do this
during a severe outbreak of cholera
in London in 1854. Dr. Snow
observed there were many cases in
the area surrounding Broad Street,
but unexpectedly several groups of
people were spared. He determined
that only those who drew their
water from the Broad Street pump
were affected, and postulated that
the water from that well had been
contaminated with fecal waste from
a cholera patient. He then proposed
an intervention experiment: he
would remove the handle from the
pump and observe if there were a
decrease in the incidence of cases
in the area. Indeed, there was a
decrease. However, the formal experiment
was faulted because the
incidence of cases had been
decreasing even before Dr. Snow
had removed the pump handle, and
it wasn't possible to say whether the
decrease he had observed was due
to the removal of the pump handle
or to the natural waning of the
epidemic.
One of the most striking features
of the successful scientist is persistence,
and Dr. Snow
demonstrated that quality. He saw
another opportunity to test his
hypothesis. A few years after his
original "experiment," there was
another epidemic in London, but by
this time several of the water supply
companies had considered the
possibility of waterborne infection.
They had moved their inlet pipes
downriver away from the contamination
of the raw sewage coming
from the densely populated sections
of the city. Dr. Snow made his
observations in a section of London
where some of the households obtained
their water from the company
that supplied clean water and
other households obtained water
from a company still drawing its
water from the polluted Thames
near London. He predicted that
those drinking the contaminated
water would be far more likely to
develop cholera. His prediction was
correct.
This observational experiment
was wholly convincing and it had a
major impact on future water supply
management procedures.
However, the argument on the
cause and transmission of cholera
did not end; scientists still rejected
Dr. Snow's contagion hypothesis
well into the 20th Century. Prominent
among them was Pettinkoffer,
a distinguished German bacteriologist.
He was so convinced that
the cholera bacterium (which had
been discovered by Koch a few
years previously) was not the sole
or even the primary cause of the
disease, that essentially no data
presented would cause him to
change his mind. This can be a
dangerous impediment to scientific
process because it renders experiment
and observation useless, in the
face of granite-like belief. When a
scientist equates his ego with the
validity of his hypothesis, there is a
danger that objective evaluation is
impossible.
To compound this lack of objectivity,
Pettinkoffer performed an experiment
on himself and several of
his colleagues. They drank bacteria
from a culture supplied by Koch.
There were no deaths, although
they all became ill and one of his
assistants seriously so. Yet, Pettinkoffer
still interpreted this as supporting
his views. He reasoned that
cholera always resulted in death,
and because he and the others
didn't die, this implied that they
24
hadn't developed cholera. His
strongly held views and the emotional
impact of self-experimentation
robbed his studies of any
validity.
In "Plagues" most of the cholera
sequence was shot on location in
London, but we did an indoor
scene—one of the few in the
program—in the greenhouse of the
Fox Chase Cancer Center where I
do my research, showing our
beautiful landscaped campus in the
background. Our current research
intruded into this; we gave a cameo
appearance to a plant that we are
currently using in our research to
find a virucide for the hepatitis B
virus. It's also a kind of coming attraction,
as we plan to use the plant
as the subject of a forthcoming
episode in our continuing series of
medical films.
Myth and Metaphor
In the Daedalus section of the program,
we departed from the
predominating anecdote-driven
thrust and attempted to develop a
concept using a Greek myth as a
metaphor.
One of the most impressive
characteristics of successful
research is its apparent unending,
and probably eternal, duration.
Every time a problem is solved,
another develops; each time we
answer a question, we end up with
several new ones that weren't obvious
before the first experiment
was done. This means that the more
we know, the more we know about
what we don't know!
The myth of Daedalus is
fascinating because it illustrates the
problem-solving and problemcreating
character of science and
technology. Daedalus is less well
known than his son Icarus, probably
because the boy was a flamboyant
loser, but to me, the father
was the more interesting character.
Daedalus was obsessed by problemsolving,
and he needed the constant
stimulation of new problems, many
of which he managed to generate,
directly or indirectly, himself. I
strung together in a monologue a
series of stories about Daedalus collected
from various places to illustrate
the theme. The directors
decided we should film the sequence,
appropriately, in a maze as
Daedalus is often associated with
and sybolized by the great labyrinth
he built on Crete. Our location
scouts found a wonderful, high,
elaborate yew hedge maze that had
been built by William Waldorf Astor
when, at the turn of the century, he
acquired Hever Castle, originally
the home of Anne Boleyn, the illfated
wife of Henry VIII. We filmed
on a glorious spring day, with
brilliant sunshine, blue skies, green
grass and exuberant gardens—in
which I managed to get lost. The
directors were concerned enough
by this episode to acquire for me a
two-way hand-held radio so they
could locate me when I wandered
off looking for plants in the long intervals
between shots. This, to my
recollection, was the only concession
made to my star billing and
general eccentricity.
Daedalus' problem-solving started
when he was asked to deal with the
passion that Pasaphae, the Queen of
King Midas (of Crete), had
developed for a great white bull
given to them as a present by the
gods. He resolved this by placing
her in a hollow, life-size bull in
which she was, in due course, impregnated
by the divine bull. This
solved the passion problem, but
generated the beast Minotaur, who
terrorized the country. Daedalus
solved this by constructing the great
labyrinth in which Minotaur was
imprisoned.
However, another problem arose
when Midas caused Athenian
youths to be sacrificed to the beast.
This was solved when the everresourceful
Daedalus aided Theseus
and his paramour Ariadne (the
daughter of Midas and Pasaphae) to
kill Minotaur and escape the maze.
The next and most famous solution
(well, partial solution) came when
Daedalus and his son, Icarus,
escaped the maze in which Midas
had imprisoned them after the killing
of Minotaur. The fate of Icarus
is well known, but Daedalus
escaped to continue his career of
problem-management.
The scientist is intrigued by questions;
he lusts after the unknown.
In applied science and, in particular,
in medicine, this implies that you
rarely get perfect solutions, as new
problems are generated by the process
of discovery. Hence, medical
science can rarely provide the
assurance that a new medicine, a
new procedure, is completely riskfree,
although it can often be said
that the risk is of very low
probability.
We thought it necessary to make
this point in presenting episodes in
medical history. In fact, in none of
the anecdotes do we imply that the
solutions have been ideal, but
always leave the episode with some
degree of uncertainty remaining.
We have not used the model often
used in medical documentaries, that
the story of science is a logical progression
from a big mystery to a
total solution. On the contrary,
there is always much left for further
discovery, a ceaseless search. It can
be inferred from this that the consumers
of the products of medicinal
research, that is, patients, should adjust
their expectations to reality.
Very often, the good is better than
the perfect, particularly when the
latter cannot be achieved.
Making "Plagues" was exciting,
instructive (to me) and fun. I hope
we will be able to create more sequences
of this medical history
series. •
PUBLICATIONS:
Thomas A. Lang
Thomas A. Lang is an instructor of
technical writing and grants officer at
the California State University, Chico.
The Style and Substance of
The Medical Journal Industry
Interesting issues of scholarship and
economics envelop the field
S
cience and technology
depend heavily on a vast
and cumulative body of
knowledge. The quantity,
quality, comprehensibility
and accessibility of this knowledge
determine to a large extent the
degree to which science and technology
can be applied to improving
the human condition. Much of this
scientific knowledge is contained in
technical and professional journals.
Yet, as important as these journals
are to human endeavors, their
production, distribution and quality
have not been widely studied.
This relative lack of attention to
our scientific information base
extends into the medical literature as
well. An overview of the industry of
medical journals reveals several
interesting scholarly, economic and
communications research issues.
Thus, this article reviews the general
structure, scholarly importance and
economics of medical journals. It
describes some of the constraints
under which these journals are
published and details some of the
problems encountered in studying
the selection and distribution of
medical information. Many of the
topics are illustrated with examples
from the leading general medical
journals.
The Structure of the Industry
The scientific journal industry is
complex and not well studied.
Among the major problems
encountered in defining its structure
are:
• Problems in defining what is
and is not a journal. There is little
agreement on what characteristics a
journal should have. How frequently
is the "journal" published? Is it peerreviewed?
Does it contain accounts
of original research, review articles,
or applications? Is it designed to be
stored and indexed, or to be read and
discarded (the so-called "throwaway"
journals)?
• Problems in defining what to
include under the title of
"medical." Do nursing, environmental
health or psychotherapy
qualify as "medical?" Do topics of
basic research with medical
applications qualify?
• Problems in researching the
industry. Should English-language
journals published abroad be
included? Should foreign-language
journals be considered? How can the
importance of a journal be
determined? What are the criteria
for cost-effectiveness in the
production, distribution and
referencing of biomedical
information?
• Variation in the characteristics
of publishers. Is the journal
26
published for profit or for professional
reasons? How many titles and
related documents does the
publisher publish? How much does
the journal depend on advertising?
What are the editorial policies? Is it
produced by part-time, voluntary
staff? Does the journal cater to individuals
or to libraries?
The implications of the above
questions are that the scientific
journal publishing industry is
characterized by a large number of
units of analysis that vary widely on
a great number of qualitative and
quantitative dimensions. In addition,
the topic as a whole has not
received much attention from
researchers. In fact, much of the
data that would assist in this
research is apparently not collected,
reported or compiled into useful
forms.
What Constitutes a
Medical Journal?
A major problem for librarians and
researchers in the field of scientific
communications is the lack of clear
definitions and reporting categories
for the variety of documents involved.
Consider the similarities and differences
among the following
documents', serials, periodicals,
magazines, journals, newspapers,
monographs, annual reports, yearbooks,
proceedings and transactions.
Most data reported for serials
or periodicals include data on journals,
as well as on a host of other
types of publications that have little
in common with scientific
journals.
The American Library Association
distinguishes between serials
and periodicals (numbered serials),
but not journals.1
The association
defines a periodical as "...a serial
publication that constitutes one
issue in a continuous series under
the same title, usually published at
regular intervals over an indefinate
period, individual issues in the
series being numbered consecutively
or each issue being dated." Included
here are newspapers,
magazines, newsletters and other
publications in addition to scientific
journals.
Machlup and Leeson2
conducted
a major study for the National
Science Foundation and the National
Endowment for the Humanities
titled "Information Through the
Printed Word: Dissemination of
Scholarly, Scientific and Intellectual
Knowledge." They never identified
a reliable definition of a journal.
They did develop a classification of
some usefulness, however. They
classified their sample into four
types of journals:
1. Nonscholarly journals containing
general information for intelligent
and well informed readers.
2. Learned journals containing
scholarly material in the classical
sense and having national or international
appeal. These journals
were further divided into primary
research journals containing accounts
of current, original research
and secondary research journals containing
reviews, abstracts, literature
surveys and other derivative
material.
3. Practical professionl journals
containing applied information
of national or international appeal.
4. Parochial journals, which
could be placed in any of the other
categories, except for the fact that
they appeal exclusively to narrow
groups of readers defined by
geography or other restrictions, e.g.,
the Missouri Medical Association
Bulletin.
This taxonomy, while useful, is
not ideal. Many nonscholarly journals,
for example, come perilously
close to being magazines, and the
New England Journal of Medicine,
which is a regional journal, might
be a parochial journal if not for its
superlative reputation. Also, most
data on periodicals are not reported
in these categories.
As a result of the ambiguity of
what constitutes a journal, we do
not even have an accurate estimate
of the total number of scientific and
technical journals. The Bowker data
base lists 69,000 periodicals from
63,000 publishers in 196 countries.
Ulrich's International Periodicals
Directory3
, a subset of the Bowker
data base, lists 34,500 periodicals.
Also published by Ulrich's is a supplemental
directory of irregular
serials and annuals. The supplement
is updated quarterly and adds
some 1,500 entries with each issue.
Machlup and Leeson2
in 1978
reported estimates of between 5,000
and 100,000 science and technology
journals currently in publication.
(The authors do not say if the
number includes international and
foreign journals.) Another often
cited estimate is that provided by
Fry and White4
, who list the figure
as 2,459 (domestic) journals. These
figures illustrate the problems
created by different definitions of
"journal."
A second major problem is that
data on periodicals are often broken
down only into general topical
headings. It is not uncommon for
medical journals to be included
under life sciences or health
sciences, which makes identifying
the number of medical journals impossible.
Even the topic of
"medical" presents problems, not
only in distinguishing between
basic and applied research journals
but in distinguishing between
"primary" and "adjunct" topics. For
example, journals of nursing, environmental
health, clinical
psychology, medical economics and
so on may or may not be categorized
as medical journals.
Despite the vagaries of definition
and reporting categories, some
researchers have estimated the
Table 1. The Five Leading General Medical Journals As Determined
By Impact Factor, Citations Received, Immediacy Index and Cited
Half-life (1986 Data)
Journal Impact Factor Citations
Received
Immediacy
(yr)
Half-life
(yr)
NEJM 15.921 58,308 3.764 5.6
Lancet 9.444 58,847 3.744 6.0
AIM 8.2111 22,029 2.011 5.8
JAMA (3.804)* 24,555 1.113 8.5
BMJ (2.804)* 30,329 1.964 6.8
*The World Health Organization's Technical Report Series and Medicine are
the forth and fifth ranked, respectively; JAMA and BMJ are the seventh and
ninth, respectively.
number of biomedical journals.
Morgan5
reports that there are approximately
20,000 medical journals,
about 3 percent (600) of which go
out of publication each year, to be
replaced by an equal number of new
journals. He also mentions that the
National Library of Medicine indexes
only 3,200 titles; new titles are
added only as others are dropped.
While this figure is not an estimate
of the number of medical journals,
it probably includes the most important
domestic and foreign
publications.
Ulrich's International Periodicals
Directory3
classifies entries under
557 subjects, including "medical
science," which contains an estimated
4,900 foreign and domestic
titles. The Journal Citation Reports6
compiled by the Science Citation Index
breaks down medical journals
into at least 41 different subheadings
that include 1,353 foreign and
domestic titles. This estimate could
vary widely depending on whether
one includes the 40 titles for "public
health" or if one excludes the 36
titles under "research and experimental
medicine."
Assessing the Scholarly
Importance of a Journal
Several indicators provide rough
measures of "scholarly importance"
by which journals can be judged.
These indicators include:1,67
• The number of articles published
by a journal each year;
• The number of cited articles
published by a journal each year (the
number of "source items"
published);
• The impact factor (a ratio between
the number of articles cited
within two years of publication and
the number of articles published). A
high impact factor indicates that the
journal is publishing many articles
important enough to be cited in
subsequent publications. An impact
factor of 15.9, for example, indicates
that about 16 percent of the articles
published by the journal are cited in
other articles within two years;
• The total number of citations for
articles published by a journal in a
year (a measure of how many important
articles are published);
• The immediacy index (a
measure of how quickly the
"average article" in a particular journal
is cited after original publication);
and
• Cited half-life value (the number
of years, from the current year going
back, in which 50 percent of a
journal's articles cited in the current
year were originally published). A
short half-life may indicate that recent
articles in the journal are being
cited often, which implies their intellectual
importance to the field; a
long half-life can indicate the journal
is publishing landmark articles
with profound impact on the field.
These criteria can be used to
designate the relative importance of
journals. For example, of the 79
general medical journals listed in
Journal Citation Reports6
, the five that
usually have the highest ratings on
these and other criteria are: the New
England Journal of Medicine (NEJM)
published by the Massachusets
Medical Society; the Journal of the
American Medical Association
(JAMA), published by the American
Medical Association; the British
Medical Journal (BMJ), published by
the British Medical Association; the
Annals of Internal Medicine (AIM),
published by the American College
of Physicians, and Lancet, published
by Lancet, Ltd., in London. Values of
these criteria for the leading journals
are shown in Table 1.
Ranking journals by the number
of source items published favors
larger journals and journals with
more frequent publication. By this
criterion, NEJM and AIM are second
and forth, respectively. Two
other regional medical journals
(NEJM is a regional journal), the
Southern Medical Journal and the
Western Journal of Medicine, rank
first and fifth. The Archives of Internal
Medicine ranks third.
(Incidentally, four of the five
28
leading journals are among the
oldest of medical journals. The
NEJM, founded in 1812, is the oldest
medical journal. Its establishment
was followed in England by Lancet
in 1823 and by the BMJ in 1832;
JAMA was begun shortly thereafter,
in 1848. Annals did not appear until
1927. Thus, most of these journals
have had long histories, during
which they established many of the
editorial and economic practices of
medical journals.)
Selecting Articles
for Publication
The most important considerations
in selecting articles for publication
are: 1) to provide the highest quality
of current medical information
and, in so doing, 2) to build or maintain
the credibility and reputation of
the journal.
The exclusionary rule, also called
the Inglefinger-Rellman rule
after the two NEJM editors who
established it as a norm, states that
articles will be reviewed "...with the
understanding that neither the
substance of the article nor the
figures or tables have been published
or will be submitted for publication
elsewhere...."8
The rule was
created in response to "abuses by
tabloids and some representatives
of the general press."9
Thus, the
norm has been established that
"...publication in a peer-reviewed
journal marks the beginning of an
ongoing dialogue within the
medical community."9
Peer review is the process by
which an article is evaluated by experts
in the field, who then recommend
that it be published, revised
or rejected. It is a gatekeeping process
that affects whether, where
and in what form an article will be
published. The principle is widely
held to be an important element in
maintaining good science—it is
regarded by many as the "heart of
the publication process."1 0
However, many studies of peer
review show that it is little better
than chance in determining which
articles will be published in a given
j o u r n a l . 1 0 1 1 1 2 1 3
Too, one of the
leading primary medical journals,
Lancet, did not use peer review until
just recently, and many of the
more valuable "throw-away" journals
that fit under the practical professional
heading also do without
peer review.
Even when peer review is successful
for a given journal (for example,
see Stephen Lock's discussion
of peer review for the BMJ1 1
,)
for the industry as a whole it is apparent
that "...there are scarcely any
bars to eventual publication.... Most
rejected articles are eventually
published elsewhere."14
Thus, peer
review may function more to determine
where an article is published
than whether it is published.
Authors generally submit articles
to the most prestigious journal in
their field. If the article is rejected,
it will usually be submitted to the
next most prestigious, and so on. In
one study of family practice,
physician-authors Whitman and
Eyre1 5
found that 11 percent of articles
published in 8 journals of interest
to family practitioners had
first been rejected by NEJM. In fact,
a clear pattern emerged of submitting
first to NEJM, then to JAMA,
AIM, and Lancet (BMJ was not included
in the study). The percentage
of the articles published without
pr:.or rejection by other journals was
89 percent for NEJM; 71 percent for
Lancet, 70 percent for AIM; and 68
percent for JAMA. Although an article
can be rejected for a number
of legitimate reasons (outside the
scope of the journal; improper
length, improper documentation,
poor editing, not timely and so on),
it appears that there is a pecking
order for journals that has important
implications for authors and for
science.
Peer review is fraught with difficult
issues, including its effectiveness
in differentiating between
strong and weak articles; its effect
on the final form of the published
article, especially for articles submitted
to several journals in sequence;
its cost; and its reliability
among reviewers. In response to a
growing concern about these and
other issues about peer review, the
American Medical Association is
sponsoring in 1989 an International
Congress on Peer Review in
Biomedical Publication.
The Economics of
Publishing a Journal
"Deciding whether to start a journal
or, alternatively, assuming the responsibility
from a professional society for
publishing itsjournal, is handled in the
same manner as a proposal for a new
book, but the stakes are higher."16
"It is easier to talk someone out of
committing suicide than out of starting
a new journal."5
Journal publishers usually fall into
one of four general categories:2
1. C o m m e r c i a l publishing
firms (who also publish books);
2. Professional societies;
3. Other not-for-profit firms
(e.g., research laboratories, foundations,
religious and political
organizations); and
4. University presses.
The diversity of factors affecting
these categories, as well as individual
publishers within each
category, is great. Whatever the
diversity, however, most journals
face two major problems: maintaining
their economic health and maintaining
a high standard of scientific
quality.
The economic health of medical
journals is affected by several
factors:
• The general expansion of
science and the corresponding increase
in the number of
on
manuscripts submitted for
publication.
• Increases in the number of
subspecialty and "throw-away"
journals that compete for advertising
money (and for physicians'
reading time).
• Increases in production and
distribution costs.
• Decreases in library budgets
and, hence, in library subscriptions,
which constitute a large portion of
journal income.1 7
These problems are encountered
differently by different categories of
publishers. As the vice president of
a major scientific publishing house
described it:
You approach a scientific area
this way: you try to set up a
primary journal first, then begin
publishing advances, reviews,
serial, or continuation lines.
Then you bring out a multivolume
state of the art. After all
this, a monograph series can be
spun off. Then you tie it in with
a reprint line, particularly if the
reprints in this area date back
before 1900 and are in the public
domain. At the end of each year,
our journal subscriptions bring in
hundreds of thousands of dollars
of income, on which we don't
have to deliver any goods immediately.
The orders for the
serial publications build up in advance.
We have large standing
orders for many of our books. We
try to send our promotion mailings
prior to publication, and
then we get a number of advance
orders. We can use our journals
to advertise our books. It's a very
effective program....1 6
Also, however:
It would look bad if we stopped
publishing a journal even if it
was unprofitable. Even though
we can't count its profitability in
pennies, journals bring in and
maintain a clientele. They are
often very prestigious. By no
means would we ever quit doing
[a journal]. That could be a fatal
mistake.16
Although general medical journals
are "very profitable," the editorial
and printing costs of producing
them are much higher than
those of specialty journals.5
The
broader the journal's scope, the
harder it is for the editor to keep up
with advances and contacts in
rapidly changing fields. For example,
AIM maintains a list of 5,500
reviewers for its articles.7
Keeping
this list current and tracking dozens
of manuscripts through multiple
reviewers is a costly and timeconsuming
task.
'Although general medical journals
are "very profitable," the
editorial and printing costs of
producing them are much higher
than those of specialty journals.'
Several indicators could be used
to evaluate the economic characteristics
of scientific journals, if they
could be obtained:
• Annual budget.
• Size of the circulation/subscription
audience.
• Number of journal pages printed
per year (including advertising
space).
• Size of advertising revenues.
Unfortunately, it appears that
these data are not systematically
collected, reported or compiled.
Ulrich's3
does provide circulation
figures for domestic journals. (For
the five leading general medical
journals-the circulation figures for
1986 were: JAMA, 279,000; NEJM,
215,000; AIM, 91,000; Lancet,
42,306; BMJ, not available.) The
variation among categories of
publishers is undoubtedly a factor
in this absence of information.
The Market for
Medical Journals
The market for medical journals, including
general medical journals,
consists of two main components:
libraries and individuals.1
Subscription
rates differ for these two
markets. Libraries typically pay
much larger rates because their
readership is obviously larger and
because they offer opportunities for
inter-library loan and extensive
photocopying, both of which are
believed to reduce subscriptions by
individuals.1
Individual subscribers
are usually physicians who are
members of the professional society:
the subscription is included in
annual dues.
Library and institutional subscriptions
are important sources of
revenue for many scientific journals.
Institutional subscribers tend
to tolerate price increases better
than do individual subscribers,2
and
they tend to drop subscriptions only
when faced with budget cuts.1 7
An interesting problem here is
that many libraries order journals
from subscription services, such as
F.W. Faxon Co., Inc. and EBSCO.1 7
Such services help libraries reduce
the paperwork of ordering and paying
for subscriptions. The services
also may play an important part in
selecting which journals a library
orders, either by supplying the
library with a "package" of journal
titles, or by their decision to carry
or not carry a particular title or a
particular publisher. The implication
is that journals must consider
marketing to subscription services
as well as to individual libraries.
The F.W. Faxon Co., Inc. produces
the Librarian's Guide to Journals,
which lists the journals they
market, as well as advertisements
for these journals.1 8
The company
has a Medical Information Services
Division specifically set up to handle
medical school, hospital and
30
research libraries. An Academic Information
Service assists university
libraries in the development of
their collections. Contacting these
divisions and other subscription services
is important in marketing a
journal.
Other types of journals have
developed different markets with
different economics. The "throwaway"
or "tabloid" journals depend
almost exclusively on advertising,
usually from pharmaceutical or
medical devices companies. These
"journals" vary greatly in quality
and usefulness, are widely read, are
often free, and address physicians
not so much by their role as
therapist or scientist but by their
roles as businesspeople in private
practice ("medical cookbookery
journals"), travelers to professional
meetings ("glorified travel magazines"),
or faculty who need to
publish ("loose-leaf cumulations
published more quickly than books
and with more authority than
review articles").19
The tabloids offer
material that is "...usually timely
but often transitory."9
In addition to market forces and
competition from tabloids, general
medical journals must compete
with a large number of specialty
and subspecialty journals for advertising
money and physician reading
time.2 0
Advertising in Medical Journals
It is a strange paradox that both
the publishers of scientific journals
and their prospective advertisers
see space advertising as a
necessary evil. The editors of the
journal reluctantly accept it
because it ultimately becomes
necessary for the existence of the
journal, and the advertiser resists
buying it because he is never
really convinced that it pays off
in terms of product sales. Both
exhibit a considerable amount of
'The medical community fears
that the influence of specialinterest
groups, primarily the
pharmaceutical and medical
device manufacturing industries,
will bias and perhaps exploit
medical science.'
naivety about the objectives of
the other, a fact that makes the
whole procedure extremely dif­
ficult.17
Advertising in scientific journals
is a touchy subject. The medical
community fears that the influence
of special-interest groups, primarily
the pharmaceutical and medical
device manufacturing industries,
will bias and perhaps exploit
medical science. And, in fact, many
pharmaceutical companies push to
have the research findings of a new
drug published in a journal: it is free
advertising, and it helps legitimize
the drug. Advertisers then advertise
the drug in the same issue. The
practice has resulted in "articles"
that are actually poorly disguised
promotions for the proprietary drug
that is advertised on the next page,
so to speak. To prevent this practice,
and to avoid the risk of "promoting"
a product, most journals that accept
advertising have a policy similar to
that of the publishers of Postgraduate
Medicine. Their policy
reads: "By long-standing tradition,
Postgraduate Medicine does not place
adjacent to editorial or advertising
material, advertising that relates to
the same or similar subject...."
Advertisers, for their part, realize
that, although medical journals can
target their markets effectively,
several other factors make advertising
in these journals less desirable.
Library and student subscribers, for
example, which comprise a large
percentage of subscribers in many
journals, are of no interest to advertisers
and, in fact, are considered to
be liabilities. Other characteristics
of journals are also of concern to
advertisers.17
Among these characteristics
are:
• Journals are often "thinner"
than preferred (advertisers view
"thickness" as a sign of success);
• Publishers may not provide an
audit statement;
• Journals are often drab and
unattractive;
• Journals may not be published
frequently enough to carry timely
advertisements;
• Journals may not carry enough
editorial matter to maintain the
preferred editorial-to-advertising
ratio of 50:50; and
• Journals provide relatively poor
market research information to
advertisers.
Several of these characteristics
could be addressed by journals to
increase their advertising revenues.
For example, many journals
"bunch" advertisements at the
beginning or end of the journal,
rather than distribute them
throughout the pages where readers
will encounter them in the course
of scanning the articles. The NEJM
places all advertisements in the first
50 pages and in the last 50 pages of
each issue. The remaining 50 pages
in the middle are the journal proper.
These pages can be read and
photocopied without the distraction
of advertising. (It should also be said
that NEJM has a long and
distinguished reputation that probably
allows it to dictate to its
advertisers more than other journals
can dictate to their advertisers.)
The more frequently published
journals, such as NEJM, can carry
classified ads from individuals.
Many journals also rent their mailing
lists, although some give
subscribers the option of having
their names removed from the
rented list.
All the above reasons contributed
to the development of "controlled
Q 1
free-circulation journals" (the
"throwaways"). These journals,
considered by many to be scientifically
irresponsible17
, differ from
scholarly journals in that their
primary objective is to sell advertising.
As a result, they are much more
flexible in responding to the wishes
of advertising. As a group, these
journals attract about 80 percent of
the advertising sales market.1 7
Biomedical
journals should be able to
attract some of these dollars with intelligent
planning. •
Manuscripts
Wanted
If you've been considering
a topic for a possible
future article in the
AMWA Journal, don't
delay. We're always looking
for new, fresh ideas.
If you have an idea that
you believe might be
relevant to the AMWA
Journal, contact the
Editor-in-Chief, for more
information.
REFERENCES
1. American Library Association. Anglo-American Cataloging Rules. In Machlup F,
Leeson K. Information through the printed word: The dissemination of scholarly, scientific,
and intellectual knowledge. Vol 2: Journals. New York: Praeger Publishers, 1978.
2. Machlup F, Leeson K. Information through the printed word: The dissemination of
scholarly, scientific, and intellectual knowledge, vol. 2: Journals. New York: Praeger
Publishers, 1978.
3. Ulrich's International Periodicals Directory, 24th ed. New York: RR Bowker Co. 1985.
4. Fry BM, White HS. Publishers and libraries: A study of scholarly and research journals.
Lexington: D.C. Heath, 1976.
5. Morgan P. An insiders guide for medical authors and editors. Philadelphia: ISI Press,
1986.
6. Journal Citation Reports, 1986. Philadelphia: Institute for Scientific Information Press
(a component of the Science Citation Index).
7. Huth E. (Editor, Annals of Internal Medicine) Personal communication, October 2,
1987.
8. Rellman AS. Talking to reporters at medical meetings. Clinical Research 32:119-20,
1984. Cited in Croes KJ. Exclusionary editorial policy of peer-reviewed publications
and the accuracy of news tabloids. Archives of Ophthalmology 10:104:1111, 1986.
9. Springer MD. Letter to the editor. Archives of Ophthalmology 10:104:1112, 1986.
10. Bohannon RW. Letter to the editor. Physical Therapy 66:9:1431-2, 1986.
11. Lock S. A difficult balance: Editorial peer review in medicine. London: The Nuffield
Provincial Hospitals Trust, 1985.
12. Zuckerman H, Merton RK. Patterns of evaluation in science: Institutionalization,
structure, and functions of the referee system. Minerva 9:66-100, 1971. Cited in
Bohannon RW. Letter to the editor. Physical Therapy 66:9:1431-2, 1986.
13. Scott WA. Interreferee agreement on some characteristics of manuscripts submitted
to the Journal of Personality and Social Psychology. American Psychologist 29:698-702,
1974. Cited in Bohannon RW. Letter to the editor. Physical Therapy 66:9:1431-2,
1986.
14. Drummond R. Letter to the editor. Journal of the American Medical Association
256:17:2392, 1986.
15. Whitman N, Eyre BA. The pattern of publishing previously rejected articles in
selected journals. Family Medicine 17:1:26-8, 1985.
16. Powell W. Getting into print: The decision-making process in scholarly publishing.
Chicago: University of Chicago Press, 1985.
17. Economics of Scientific Journals. Bethesda, MD: Council of Biology Editors, Inc.,
1982.
18. Librarian's Guide to Journals. Faxon Co., Inc., 1987.
19. Squires B. (Editor, Canadian Medical Journal). Personal communication, October 2,
1987.
20. Morgan P. (Former editor, Canadian Medical Journal.) Personal communication, October
2, 1987.
Advertising in the Journal
Brings Results. . .
.. . and it's easy to do
If you haven't considered advertising in the AMWA Journal, now is the time
to do so. Reach all AMWA members with your ad.
Publishers, employers and others have found that advertising in the AMWA
Journal is an effective way to get results. Contact the AMWA national office,
(301) 493-0003, to reserve space now.
AMWA News
Dr. Brazelton Named McGovern Medal Recipient
T Berry Brazelton, M.D., will
• receive the prestigious John P.
McGovern Medal — one of the highest
honors that AMWA can bestow on an
individual in medical communications
— at the upcoming Annual Conference
in Boston. Dr. Brazelton, host of
Lifetime's popular child-rearing program
"What Every Baby Knows," is
Clinical Professor of Pediatrics at Harvard
Medical School and founder and
retired Chief of the Child Development
Unit at Boston's Children's Hospital
Medical Center.
Dr. Brazelton will receive the award
at a luncheon ceremony on Thursday,
Nov. 16.
Dr. Brazelton has authored more than
150 articles and 15 books on child
development, including an updated version
of his classic Infants and Mothers,
which has been translated into 16
languages, and the popular Working and
Caring, which offers sound advice for
working parents on raising children in
the 1980s.
One of Dr. Brazelton's foremost
achievements in pediatrics was the creation
of the Brazelton Neonatal Behavioral
Assessment Scale, which he began devising
more than 30 years ago. Commonly
known as "the Brazelton," this landmark
Dr. Brazelton
procedure is now used worldwide to test
not only the physical and neurological
responses of newborns, but more importantly
the psychological well-being and
individual differences between babies at
birth.
Dr. Brazelton, who Time magazine
calls "the new Dr. Spock," received his
B.A. degree from Princeton University
in 1940 and attended Columbia University
School of Medicine. After graduating
from medical school in 1943, he accepted
a medical internship at New York's
Roosevelt Hospital. In 1945 Dr.
Brazelton moved to Boston to serve as
medical resident at Massachusetts
General Hospital before undertaking
pediatric training at Boston's Children's
Hospital Medical Center. Dr. Brazelton's
interest in child development then led
to training in child psychiatry at Massachusetts
General Hospital and James
Jackson Putnam Children's Center from
1947-50. Dr. Brazelton integrated his
psychiatric training into the private
practice of primary care pediatrics, a
practice he continues today.
And what about his own children? Did
the physician who has examined more
than 30,000 babies in his career heed his
own child-rearing advice? Dr. Brazelton
gets off the hook this way: "You'd have
to ask my kids. Parenting is too personal
to be intellectual ."•
Patent Medicines To Be Explored
Alecture titled "Public Pharmacology:
Patent Medicines and How They
Worked" will be offered by J. Worth
Estes, M.D., during the Nov. 16 General
Session at the Annual Conference in
Boston.
Dr. Estes is Professor of Pharmacology
(History of Pharmacology) and Associate
Professor of Socio-Medical Sciences at
the Boston University School of
Medicine. The author of several books
and numerous articles in the medical
literature, Dr. Estes is a recognized
authority in the history of pharmacology.
Dr. Estes earned his M.D. from the
Boston University School of Medicine in
1964. He also holds an M.A. degree in
pharmacology from the Boston University
Graduate School and an A.B. degree
from Harvard College. He served an NIH
Fellowship in Clinical Hematology at
University Hospital in Boston and an
NIH Fellowship in Hematology at the
Clinical Genetics Research Unit, University
of London, and the Hospital for Sick
Children in London.
Dr. Estes is the author of Hall Jackson
and the Purple Foxgloves: Medical Practice
and Research in Revolutionary America,
1760-1820, The Changing Humors ofPortsmouth:
the Medical Biography of an
American Tbwn, 1623-1983, and The
Medical Skills of Ancient Egypt. •
(Photo courtesy of the National Library of Medicine)
William Harvey Award Recipients Announced
The recipients of the William Harvey
Awards for excellence in the reporting
of hypertension have been announced.
The program is sponsored by
AMWA, the National High Blood
Pressure Education Program and the
Squibb Corporation.
The recipients of the awards are:
Newspaper competition
First — Robin Marantz Henig, New York
Times Magazine, "Defining Hypertension,"
Jan. 24, 1988
Second — Gina Kolata, The New York
Times, "Costly New Medications
Overtake Diuretics in Treating Blood
Pressure," April 14, 1988
Third — Jamie Talan, New York Newsday,
"White-Coat Hypertension, From Fear of
the Doctor," Jan. 15, 1988
Honorable Mention — Dennis L. Breo,
Chicago Tribune Sunday Magazine, "Could
Anyone Have Saved Mayor Washington's
Life?" March 20, 1988
Magazine competition
First — Jeff Schein, Consumers Research,
"Diet and High Blood Pressure," January
1989
Second — Britain Nicholson, M.D.,
Harvard Medical School Health Letter,
(2-part series) "High Blood Pressure: A
New Look," December 1988, and "High
Blood Pressure: Newer Treatments,"
January 1989
Third — Janis Graham, Self, "Pressure
Points: Surprising News about Blood
Pressure, Aimed Straight at the Heart,"
January 1989
Honorable Mention — Dalton Narine,
Ebony, "Heart Disease: How to Beat the
No. 1 Killer of Blacks," June 1988
Radio competition
First — Jeff McKinney, Medical Journal
Radio Network, "Side-Effects of
Hypertension Medications," Dec. 1-3,
1988
Second - Nanci McGraw, KYXY-FM
Radio, San Diego, California, (4-part
series), "High Time to Know about
Hypertension," December 1988
Television competition
Third — Julie Slavik Budnik, "High Blood
Pressure: A World of Discovery," Emory
Medical Television, December 1988
What AMWA Journal Readers Say
Following are some of the comments received from readers of the
AMWA Journal in the recent editorial evaluation:
' Could you use the AMWA Journal to develop some of the courses m
your Core program? I never get a chance to go to your conlerenc cs and
miss out on your Core Curriculum courses.'
"I'm interested in seeing more ways of communicating medical information
to patients and consumers. That is my business! Also, more editorial hints
i.e. how to refine a query letter."
"I'd like to see more of the tilings Edie Schwager writes about."
I read the AMWA Journal almost exclusively to get information that
helps me do my job Ivtter! Id like to see fewer 'literary forum' types of
reflective or perianal experience articles. They re good, and I think they
deserve to be published someplace, but I don't think they generally are most
appropriate for a journal with our audience.'
"News capsules are well clone, but rather dated and not at all useful.'
1 lave the AMWA Journal and read every page'. 1 find it useful and
informative'."
"The AMWA Journal is much easier and more enjoyable to read than
its predecessor. I would like to see more how to articles, such as tlie patient
education materials and grant proposal articles. Also interesting would be
a profile on a person in a specialized area of medical communications."
'You were better off with a newsletter. The AMWA Journal is/remains
chatty a mistake sinre I expect a journal to contain original, professumal
inlormalion. Original articles read more like advertisements than journal
7 enjoy reading letters to the editor. Overall the AMWA Journal is
a vast \mprovement over previous format"
"I object to articles that stray from the purview of a professional journal
e.g.. the editor's recent article on alcoholism. 1 understand his desire to
inform, but surely he could have found a more appropriate forum for doing
so. This journal seems often to include writing from a personal slant that
I judge inappropriate land more to the point, uninteresting!. As a
professional. I expect writing about 'hard stuff—informative material
applicable to my work, not my personal concerns."
"I'd hke to see an alternative to features that try to be journal papers.'
laden with references and written in 'textbemkese.'"
"Overall, it's excellent."
34
Five Members to Receive
AMWA Fellowships
Five members of AMWA will be awarded Active
Fellowships during the Annual Conference in Boston.
They include:
• Michael F. Bruckner. A former president of the Greater
Chicago Chapter (1982-83), Mr. Bruckner has presented
numerous workshops at the Annual Conference and for
various AMWA chapters. He also has served as a moderator
and panelist for several panel presentations at the Annual
Conference. He has been active in the Mid-Year Section
Program, serving as a Networking Luncheon Table Leader
(1983, 1985). In 1988 he produced the Workshop Leaders
Instruction Tape.
• Leo R. Maestripieri. A member of the Metropolitan New
York Chapter, Mr. Maestripieri has served as Administrator
of the Department of Awards, Chair of the Allied Health
Book Awards Committee and member of the Fellowship
Committee. He has served as Chair of the Pharmaceutical
Section Plenary Session at the Annual Conference (1985-86)
and as chair of the Pharmaceutical Section Breakfast (1985).
In 1988 he developed the AMWA Awards Handbook.
• Ronald J. Sanchez. A former president of the Mid-Atlantic
Chapter, Mr. Sanchez has served as Editor-in-Chief of the
AMWA Journal since its inception in 1986; he authors the
regular editorial column "One More Idea" that appears in
the publication. He previously served as Editor of the
AMWA Newsletter (1985-86) and as a member of the
Nominating Committee. He also has served as a Networking
Luncheon Table Leader at the Annual Conference
(1986).
• Elizabeth S. Stone. Ms. Stone has served as president
(1985-87) and as secretary of the Pacific Southwest Chapter.
She also has served as the Chair of the Editors Section
Plenary Session at the Annual Conference (1987), a Network
Luncheon Table Leader (1984) and a workshop leader
(1985). Ms. Stone also has served as Chair of the AMWA
Constitution and Bylaws Committee (1985-86) and as a
judge for the book awards competition. She also has served
as Program Chair for the Asilomar conference.
• /. Eugene White. Mr. White has served as Administrator of
the Department of Publications (1988-89) and the Department
of Annual Conference (1987-88). In addition, he has
served as Chair of the Public Relations Plenary Session for
the Annual Conference (1986), Annual Conference Program
Chair (1988), a Networking Luncheon Table Leader (1988),
moderator for the Public Relations Plenary Session (1987)
and a workshop leader (1984-85). He also has served as Core
Curriculum Workshop Coordinator (1986-87).•
1989
Fellows
Mr. Bruckner Mr. Maestripieri
Mr. Sanchez Ms. Stone Mr. White
Forums Slated for Annual Conference
• "Desktop Publishing"
Wednesday, Nov. 15, 2-5 p.m.
Moderator: Bill Brooks
• Paper Presentations: "Medical Priorities: Messages of the '90's"
Thursday, Nov. 16, 2-5 p.m.
Moderator: Lynn Alperin
• "State/Small Journal Editors"
Friday, Nov. 17, 2-4 p.m.
Moderator: Jordan Burkey, M.D.
• "Medical Marketing: The Age of Accountability"
Saturday, Nov. 18, 10 a.m.-noon
Moderator: Joel Tau
• "Career Development"
Saturday, Nov. 18, 9-11 a.m.
Moderator: Richard Bell Smith
• Education: "Medical Communication in Higher EducationPrograms
and Possibilities"
Saturday, Nov. 18, 2-4 p.m.
Moderator: Doug Haneline, Ph.D.
1989-90 Slate of Nominees for National Office Announced
Ms. Robie Ms. Smith Dr. Hodgson
At its April 7 meeting in Arlington,
VA, the Board of Directors approved
the following slate of nominees for
1989-90:
President-Elect: (President for 1990-91)
Pat Robie
An AMWA member since 1975 and a
Fellow of AMWA (1986), Ms. Robie is
currently serving as Secretary of AMWA
and as Administrator of the Department
of Membership. Before that she was Vice
President and Administrator of the
Department of Publications (1986-87)
and Chair of the San Francisco Annual
Conference (1985-86). In 1984 she was
the local arrangements chair for the San
Antonio Annual Conference, and in 1985
she was Workshop Coordinator for the
Montreal Annual Conference. While
serving in this capacity, she devised an
evaluation system for ranking
workshops at that conference that was
proven to be an invaluable tool in
measuring the quality of AMWA
workshops. Ms. Robie was a member of
the Long-Range Planning Committee in
1986.
Ms. Robie has long been active in the
Southwest Chapter, beginning in 1982,
when she was on a committee to
revitalize the chapter. She was chapter
treasurer from 1982-84 and chapter
president in 1985-86. She continues to
serve as the production editor of the
chapter newsletter, a position she has
held since 1982, and she also has been
the chapter membership chair since
1986. In addition, in 1983, she co-chaired
the first Southwest miniconference, a
forerunner of AMWA's current regional
conferences.
At Houston's St. Joseph Hospital, Ms.
Robie has served as Editor of the Houston
Medical Journal and as the Senior
Medical Editor. She was Assistant Director
of the PR Department at St. Joseph
Hospital until 1984. Ms. Robie is currently
editor of Houston Medicine and
employed by the HCA Woman's
Hospital of Texas.
Secretary: Elizabeth Smith
Ms. Smith has been a member of
AMWA since 1980 and was awarded
Fellowship in 1988. She is currently serving
on the Executive Committee as Administrator
of Sections, a position that
she also held in 1987-88. She is currently
serving as President of the Delaware
Valley Chapter. Ms. Smith has served
the Delaware Valley Chapter as
Treasurer, Workshop Coordinator and
delegate to the national Board of Directors.
She has developed programs for
chapter meetings and participated in
local programs as both workshop leader
and panelist.
Ms. Smith has co-produced the
Audiovisual Core Curriculum workshop,
"Scriptwriting for Film and Video," and
has led the workshop frequently since
1983. She has been a panelist for several
other workshops given at annual conferences
and will be a panelist for the
Freelance Section Plenary Session in
Boston.
The Smiths have their own company,
Smith Simon Company, which provides
writing services in all media for both
general and special markets. Ms. Smith
is also involved with her own company,
Medslide Inc., which is producing a
series of videopresentations on Downs
Syndrome and audio/workbook programs
on cancer prevention.
Treasurer: Helen Hodgson, Ph.D.
An AMWA member since 1983, Ms.
Hodgson is currently serving on the Executive
Committee as the Administrator
of the Department of the Annual Conference.
She chaired the paper presentation
sessions at the 1987 and 1988 annual
conferences and served on both the
Nominating and Budget and Finance
committees in 1987-88. She has
presented a workshop on writing style
at several annual conferences. Her appointment
as New Member Delegate to
the Board of Directors in 1983 led to her
involvement in AMWA at the national
level.
Ms. Hodgson became committed to
establishing the Rocky Mountain
Chapter in 1983 and saw that become a
reality in 1985. She has been chapter
delegate to the board since the chapter's
inception and served as chapter president
in 1987-88.
Ms. Hodgson is President of
Health/Life Planning, an innovative
educational and research corporation
committed to resolving conflicts in the
field of medicine through a new
understanding of physician leadership
and effective medical team interactions.
Materials that she has been instrumental
in creating over the past several years
have formed the basis for a 3-V2 day
seminar titled "Caring for Difficult Patients,"
which she now teaches about
once a month.
According to the AMWA Bylaws (Article
Il.l.b), any member in good standing
may submit additional nominations for
these three offices, provided the nominations
are sent in writing to the Secretary
at least 30 days before the Annual
Business Meeting. This year's Business
Meeting will be held at the Boston Annual
Conference on Friday, Nov. 17.
Such nominations must state clearly
the qualifications of the candidate, they
must be signed by at least 10 members
in good standing and they must be accompanied
by a letter from the candidate
stating that he or she will serve if
elected. •
Expanded Core Curriculum to be Introduced in Boston
F
or a decade, the Core
Curriculum program of
continuing professional
education in biomedical
communications has
earned high praise from AMWA
members and has been the envy of
other professional associations. Now,
the Core Curriculum has been expanded
to provide new opportunities
for professional enrichment and
education. The expanded Core program
will be initiated at the 1989
Annual Conference in Boston, Nov.
15-19.
A Brief History. AMWA visionaries
shaped the Core Curriculum
in the late 1970s. Four
courses—Scope of Medical Communications,
English Usage and
Abusage, Organizing the Medical
Paper and Introduction to Medical
Public Relations—earned Core credit
for the first time in 1979 at the Kansas
City Annual Conference. As President
Byron Scott wrote in the annual
conference program, "At this meeting
we inaugurate the Core Curriculum,
a project brewing among AMWA's
leadership for years.... It may be
the most important addition to our
meetings since we initiated workshops
in the late 1960s."
The following year, at the 1980
Annual Conference, 18 Core courses
were offered, and during the next
eight years, 42 courses were
developed and put through the
rigorous approval system that
qualified them as part of the Core
program. Over the past decade, Core
courses have been fine-tuned,
polished and offered at least 350
times at annual conferences and
another 100 times at chapter, section,
regional and outside meetings.
Workshop planners have traditionally
given preference to Core
workshops at annual conferences to
assure maximum availability. A
Department of Regional Meetings
has been established to administer
a regular series of Core programs at
selected locations around the country,
providing greater access to the
Core program.
The E x p a n d e d Core Curriculum.
Here's what the Expanded
Core Curriculum looks like.
There will be 6 to 12 required
courses (formerly called "Trunk"
courses) and 45 to 50 elective
courses in the specialty areas of
audiovisual, editing, freelance, pharmaceutical
and public relations/advertising/marketing
(PRAM
fcr short). What formerly was public
relations will be expanded to include
courses that will address the needs
of people in advertising and
marketing as well. Many "Stem"
courses from the established Core
Curriculum will be retained, and
useful new workshops will be added
as elective courses.
Registrants will have the opportunity
to earn two types of
certificiates:
CROSS-DISCIPLINARY: 4 required
courses plus 4 elective
(specialty) courses selected from any
combination of specialty courses. No
special interest area will be identified
on the certificate.
SPECIALTY: 4 required courses,
plus 4 elective courses from a single
specialty area (all, say, in pharmaceutical
or editing). The cerBoston's
Old South Meeting Place
tificate so earned will name the
specialty.
A person may earn a second certificate
by paying a second matriculation
fee and completing an additional
4 courses in a specialty area,
and may earn a third certificate by
paying a third matriculation fee and
completing 4 more courses in yet
another specialty area. The opportunity
to earn additional Core certificates
will be welcome to those
biomedical communicators with diverse
responsibilities and skills and
those with employers who make
Core credit a contingency in reimbursement
for AMWA meeting
expenses.
Another benefit of the new program
is that some courses will carry
credit for more than one specialty
area. An example would be "Preparing
the Clincial Summary of an
NDA," which could be applied to
either a pharmaceutical certificate or
an editing certificate. "Working with
a Medical Illustrator" could be applied
to any of three certificatesediting,
audiovisual or freelance.
The listing on the next page is a
partial list of courses in the Expanded
Core Curriculum.D
Beacon Hill in Boston
Core Curriculum Courses
R E Q U I R E D (RE)
RE Scope of Medical Communications
RE Usage and Abusage
RE Bibliographic Resources for Medical
Communications
RE Tables and Graphs
RE Sentence Structure and Patterns
RE Basics of Punctuation
E L E C T I V E
AUDIOVISUAL (AV)
AV Audiovisual Alternatives in Medical
Communications
AV Slide-Tape Programs
AV Instructional Writing for Audiovisual
Media
AV/ED Making Effective Slides
AV/ED Scriptwriting for Films and Videotapes
EDITING (ED)
ED Effective Paragraphing
ED Writing Abstracts
ED The Organization of the Biomedical Paper
ED Biomedical Manuscriptions Other Than
Journal Articles
ED Proofreading
ED How to Train, Supervise and Evaluate
Copyeditors
ED Outlining for Writers and Editors
ED/AV/FL Working with a Medical Illustrator
ED/FL The Author-Editor Relationship
ED/FL Copyright Law
FREELANCE (FL)
FL Launching a Freelance Career
FL Business Aspects of a Freelance Career
FL Effective Interviewing Techniques
FL Marketing Your Manuscript
FL/ED Medical Writing for Magazines
FL/ED Writing a Book Proposal
PHARMACEUTICAL (PH)
PH Introduction to the Drug Regulatory
Process
PH Writing Clinical Study Protocols
PH Preparing IND Applications
PH Packaging Inserts
PH/AV Scientific Exhibits and Posters
PH/ED Preparing the Clinical Summary of an
NDA
PH/ED Preparing the Nonclinical Section of an
NDA
PH/ED Drug Monographs
PH/ED Publications Office at a Pharmaceutical
Company
PH/ED Final Clinical Study Report
PH/FL Writing Patient Education Literature
PH/PRAM Pharmaceutical Advertising
PUBLIC RELATIONS/ADVERTISING/MARKETING (PRAM)
PRAM Introduction to Medical Public Relations
PRAM Public Relations Materials and Techniques
PRAM Broadcast in the Public Relations Mix
PRAM Product Publicity
PRAM Issues Management
PRAM Crisis Management
PRAM/AV/FL Making Effective Presentations
Forum to Feature Salary Survey Results
As of May 1, more than 730 responses have been received
to the 1989 salary survey that was sent to all AMWA
members in March. These responses are being tabulated and
analyzed by Pat Robie, the AMWA Secretary and Membership
Administrator. Results will be presented at the Annual
Conference in Boston during the Career Development Forum
on Saturday morning, Nov. 18. A complete report of the survey
will be published in the AMWAJournal after the Annual Conference,
and a preliminary report will be available at the
forum.
The Career Development Forum is open to all conference
registrants at no extra charge. In addition to presentation of
the survey results, the forum will feature a panel discussion
by four experienced AMWA members on career opportunities
in their various specialty areas of medical communications,
including the pharmaceutical industry, medical journal
publishing, public relations, freelance writing and the
audiovisual specialty. •
Be There in Boston
You will soon be receiving the
Program Announcement for the
AMWA Annual Conference in
Boston. The Registration Program
for the meeting will be mailed in
early August.
38
Letters to the Editor
WHAT'S IN A NAME?
Dear Editor:
I support your recommendation that
medical writers and editors read Randy
Shilts' book And The Band Played Cm. I
also strongly second your disclaimer concerning
the accuracy of some of his more
sweeping statements.
In reading your comments, however, I
was upset by your use of the phrase
"AIDS victims." For several years, people
who have been diagnosed with AIDS have
consistently fought the image of being
identified as "victims." The preferred
phrase that has been gaining wider and
wider acceptance and has helped to shift
the media's, public's and even the medical
professionals' image of these people is
"people with AIDS" (PWAs).
As a medical writer specializing in immunology,
as a resident of San Francisco
and as a volunteer for an HIV Day Care
Center, I cannot avoid the psychological,
personal and philosophical issues of AIDS
any more than the clinical.
I was recently informed that people
with AIDS is now being replaced by the
phrase "people living with AIDS" (PLAs).
This change is being made to project an
image of people having a chronic disease
rather than a necessarily fatal one. Hopefully,
this will soon become a clinical reality
as well.
In the meantime, medical writers and
editors can have an active and influential
role in facilitating the usage of the phrase
"people living with AIDS" and in supporting
the connotations it implies.
Regards,
Marjorie Little
San Francisco
MORE PATH TO RECOVERY'
Dear Editor:
I recently read your article on
alcoholism and the program of recovery
in Alcoholics Anonymous in the Fall 1988
issue of the AMWA Journal.
You correctly noted that "Anonymity
is one of the principal traditions of
Alcoholics Anonymous." Unfortunately,
you forgot this principle when you decided
to disclose your membership in AA at
the public level, using the AMWA Journal.
I suggest you review and study the
concepts on anonymity. This spiritual
principle is so important that two traditions
— 11 and 12 — are devoted to its
understanding. Basically, these traditions
tell us that we are to depend upon attraction
rather than promotion to increase
our ranks in AA. Also, we may disclose
our membership in AA quietly below the
level of press, radio, films and television
when to do so might do good. We are
never to disclose the identity of other
members of the program without permission,
and we are never to identify
ourselves as members of AA at the public
level. The spiritual principle tells us that
who we are is not important. We are
simply alcoholics. Don't forget that beginners
are usually very reluctant to let people
know they have a problem and like
the idea that their membership may remain
a secret if they wish.
In the future, please try to be a more
viligant guardian of our traditions. Our
survival depends upon it.
Sincerely,
Name Withheld Upon Request
SECTION MEETINGS PLANNED FOR
BOSTON ANNUAL CONFERENCE
• AUDIOVISUAL SECTION
Thursday, Nov. 16, 2-4 p.m.
"Spreading the Message — Live: From Boston"
Moderator: Lois Gaeta
• EDITORS SECTION
Friday, Nov. 17, 9-11 a.m.
"Responsible Medical Communication"
Moderator: Betty J.B. Cohen, Ph.D.
• FREELANCE SECTION
Saturday, Nov. 18, 2-4 p.m.
"Exploring New Markets for Freelance Writers"
Moderator: Donna Raphael
• PHARMACEUTICAL SECTION
Friday, Nov. 17, 2-4 p.m.
"The Challenges of Promise: Biotechnology in the Pharmaceutical
Industry"
Moderator: Michael J. Brennan, Ph.D.
• PUBLIC RELATIONS, ADVERTISING & MARKETING
SECTION
Wednesday, Nov. 15, 2-4 p.m.
"Easing the Crisis in Crisis Communications"
Moderator: Ellen Soo Hoo
OBITUARY
William Bennett Bean, M.D., Sir William Osier professor of
medicine emeritus at the University of Iowa College of
Medicine, died at his home on March 1. Dr. Bean was head
of internal medicine at the University of Iowa Hospitals and
Clinics until his retirement in 1970. He was named a Fellow
of AMWA in 1958. A prolific writer — the author of Seven
books, approximately 300 scientific articles and hundreds of
book reviews — he also served as editor of a dozen medical
journals. Among his many honors was AMWA's Swanberg
Award, presented in 1969. In 1984, Dr. Bean was the Distinguished
Guest Lecturer at the AMWA Annual Conference.
39
News Capsules
A Collection of Items of Interest
for Medical Communicators
Special thanks to Toni L. Goldfarb
for continuing contributions to News Capsules
Bladder Cancer Test Under Study
The National Cancer Institute (NCI) is working on a test that
will detect bladder cancer and other hard-to-detect cancers in
high-risk individuals at earlier stages. The NCI bladder test
will detect the presence of the protein cytokine in urine
samples. Cytokine is an autocrine motility factor (AMF), a
secretion of cancer cells that induces movement and allows
their spread.
More than 10,000 Americans die each year of cancer of the
bladder. NCI researchers plan to develop a highly sensitive
test that will detect AMFs in the blood to find cancers in other
parts of the body.
Non-Smokers and Body Fat
A study by the National Institute on Aging provides more
positive evidence why cigarette smokers should give up the
habit.
Researchers have shown that increases in a measurement
of body fat known as the waist-hip ratio were significantly less
in men who quit smoking versus those who continued to
smoke. The waist-hip ratio is significant because studies suggest
that body fat above the waist is closely linked to an increased
risk of cardiovascular disease.
The study, which included more than 1,100 men age 19 to
102, showed that the redistribution of body fat associated with
smoking results in a higher waist-hip ratio. The study findings
were reported in a recent issue of the Journal of the American
Medical Association.
Outgrowing Cavities
A new study reveals that we do not outgrow cavities as we
grow older, contradicting a long-held popular belief.
Dr. Howard Chauncey, of the Boston Veterans Administration
Outpatient Clinic, and colleagues examined the dental
records of 750 healthy men they had followed since 1968. The
researchers found that the men, who ranged in age from their
early 40s to the 90s, still had—on the average—24 of their 32
original teeth. Those men over 55 averaged about 2.5 new
cavities every three years, compared with two cavities during
the same time period for those men under 45.
"People thought that as you got older, you got fewer cavities.
But the reason for that was that older people had fewer teeth.
Now, people are maintaining their teeth, so they're still getting
cavities," Dr. Chauncey said.
Elderly Prone to Drug Reactions
Almost a quarter of a million of the nation's elderly are
hospitalized each year due to adverse reactions to prescription
or over-the-counter drugs, according to a study by the
Department of Health and Human Services (HHS).
Richard P. Kusserow, inspector general of HHS, warned that
the department has found "a widespread problem of
mismedication among older adults."
Mr. Kusserow said the problem results from "inadequate
training and education for physicians in the area of geriatric
pharmacology," and the failure of patients to follow physician
orders.
Part of the problem, according to Mr. Kusserow, is that drugs
are usually tested initially on healthy young people but may
end up being used widely among the elderly, whose reactions
and metabolisms are often different.
Condom Sales Fall Short
Condom sales in the U.S. in 1988 increased by only 7 percent
over the previous year, leading some health experts to speculate
that the heterosexual population is becoming complacent over
the AIDS epidemic.
Approximately 417 million condoms were sold in the U.S.
in 1988, not including an additional 200 million distributed
by the army, hospitals and other institutional sources. That
figure is considerably more than condom sales in the 1970s
and early 1980s. However, the industry expected a higher
percentage of increase in sales in 1988—and there's considerable
concern as to why that didn't happen.
"I think denial has resurfaced in the heterosexual community,"
said Mervyn Silverman, president of the American
Federation for AIDS Research. "We have to be explicit if we
are going to get the job done."
Drug May Aid Memory
A drug previously approved by the Food and Drug Administration
(FDA) to treat stroke patients has been shown to revive
the power of the brain in rabbits to learn, according to a recent
report in Science. The drug, nimodipine, might be useful
in treating memory loss in humans, although researchers caution
that more studies must be performed before any conclusions
can be drawn.
The drug, manufactured by Miles, Inc., was first noted to
improve learning in 1985 when German physicians noticed
that stroke patients taking the drug experienced improved
memory function, but usually with debilitating side effects.
Nimodipine does not have severe side effects.
40
Book Reviews
Medical Cover-Hps in the White House. By Edward B. MacMahon,
M.D., and Leonard Curry. Washington, DC: Farragut
Publishing Company, 1987. 171 pp, $16.95.
Most of us are now aware that Woodrow Wilson suffered
a debilitating stroke in 1915 that left the presidency in the
hands of his wife and his physicians. We know that Jack Kennedy
suffered from a variety of physical ailments, including
a serious case of Addison's disease that was treated with the
drug cortisone. And we're certain in our knowledge that
Franklin D. Roosevelt, with an advanced case of
atherosclerosis, was in no condition to attempt to serve an
unprecedented fourth term as president during World War II.
The authors of this potentially provocative account offer
much more than they actually serve up. The stories of medical
deception at 1600 Pennsylvania Avenue are interesting,
primarily because it was usually the president himself who
engineered the cover-ups in order to maintain national security
or economic harmony. However, most of the secondguessing
of diagnosis and treatment is based on medical information
and advancements known today, but unavailable
during the time in question. In medical issues, hindsight is
a luxury few of us have.
Perhaps the most interesting account is that of the assassination
of James A. Garfield and his subsequent medical treatment
to remove a bullet lodged within his body. Though
historians have long held that President Garfield died from
his assailant's bullet, the authors apparently rightfully contend
that the president died from the gross incompetence of
his attending physicians, who insisted on probing for the
bullet with unsterilized equipment. Riddled with infection,
the president eventually died of a heart attack. The assassin,
Charles Guiteau, argued that the president's physicians were
guilty of malpractice and pleaded for a lesser sentence. This
line of defense might be considered clever today; however,
it was ridiculed at the time and he eventually was hanged
for the murder.
The authors also tell of the medical misadventures of President
Grover Ceveland. President Cleveland was told by his
physicians that he had a large cancerous tumor in his mouth
that required the removal of most of his upper jaw. Not wanting
his condition known, the president and his physicians
planned the surgery on a ship sailing in New York harbor.
The operation was performed, apparently successfully, and
Cleveland survived another 15 years without a recurrence
of the cancer. Medical authorities now question whether the
original diagnosis was indeed correct and whether such an
extensive surgery was necessary. Current medical evidence
suggests it was not.
Medical Cover-Ups in the White House provides few insights
into the medical care provided the most powerful man in the
world. It might have been so much more.
(Reviewed by Ronald J. Sanchez)
AIDS and Its Metaphors. By Susan Sontag. New York: Farrar,
Straus and Girous, 1989. 95 pp, $14.95.
Susan Sontag reprises her popular essay Illness as Metaphor,
this time with a piercing look at all the various metaphorical
images that encircle AIDS and serve to define it. Considering
the frightening and ravaging images generated by the
disease, she has formidable material with which to work.
The author first tests our concept of disease, whether it be
cancer or AIDS, as an invading force that infiltrates our bodies
and slowly gains strength and power over us. Disease is seen
at war with our cells. This military metaphor is important,
she believes, because it symbolizes our views of the conquest
of disease, with the patient as the vanquished. She
distinguishes between those diseases that merely destroy versus
those diseases that disfigure and make alien the bodies
we inhabit. She also notes the significance between those
diseases that fall upon the victim as merely unfortunate circumstances
of life and those that can be considered selfimposed
by abuse or nihilism.
The concept of AIDS as a global plague, a sign of the
apocalypse, is given considerable attention by Ms. Sontag.
Because of its means of transmission — either sexually or by
illicit drug use — AIDS is considered to be a disease to be
hidden but, upon discovery, curiously identifies the person
as a member of a social minority, a subclass, and as a pariah.
Because we view it as a plague, we prefer to imagine its
origins as foreign, far away — in this case, Africa. She
discusses at length the progression of the disease and the concept
of the "future ill," those people now infected with the
AIDS-causing virus who eventually may develop symptoms
of the disease.
AIDS and Its Metaphors is an interesting, if a bit redunant,
work. It won't add anything new to the reader's understanding
of AIDS as a disease entity, but it is a well-written,
thoughtful discourse on the subject. Certain passages have
a ring of familiarity, however. The author might have
benefited from an editor who would have noted and
eliminated those passages that tread over familiar ground.
-RJS
Reviews Welcome
If you're interested in serving as a book
reviewer, contact the Book Review Editor, c/o
AMWA National Office, to suggest possible
titles for review.
41
"Dear Edie"
Edie Schwager
Institutional affiliations are given here
for information and convenience only.
The views expressed are not necessarily
those of the institutions named or of
AMWA.
DEAR EDIE: I would like your advice on word usage
in reporting clinical testing of pharmaceuticals in
animals. I've recently become aware of the controversy
of using the word (or euphemism) "sacrifice." I've
been told that "humanely killed" is a possible and better
alternative. Does AMWA have a position on this,
and can you give me information about this controversy
and who supports either term?
I would prefer using "humanely killed" in our
documentation and reports, but I would need some
backing to convince those of our scientists and administrators
resistant to change; they also may not be
convinced if only a small minority in the field has implemented
this change in terminology. Could you
please also tell me which disciplines have adopted the
preferred usage (i.e., in pharmaceutical, medical, scientific
fields)?
GAYLE EARLY
Liposome Technology, Inc.
Menlo Park, California
DEAR GAYLE: I'm sure your letter will elicit
responses from our colleagues in AMWA (which does
not take positions on such issues). In the meantime, the
short reply to your question is not to use the
euphemism "sacrificed," but rather to use the accurate
"killed," not "humanely killed." Certain government
agencies and research institutions regulate experiments
on animals so that this criterion is met. Some readers
may want to elaborate on this point.
Both the AMA Manual of Style, 8th ed. (p. 156), and
the CBE Style Manual, 5th ed. (p. 277), frown on sacrifice
as a euphemism for kill. Most medical editors and
writers use these sources extensively, and in general
do consider them the authorities in the field of
medicine. On this specific issue I agree with these two
giants, and I believe that many, many other editors and
writers do also.
DEAR EDIE: Regarding Ed Lindner's letter (Vol. 3,
No.3), it is surprising to read that anyone serious about
communication cannot be bothered to address women
appropriately in a letter, yet expects those women to
"pass it on to a guy." Such letters go directly into many
women's circular files, unread. Anyone writing such
letters on behalf of an employer should wonder if he
or she is misrepresenting the employer's attitude
toward women, thus jeopardizing its relationship with
clients, suppliers, readers, members or whomever.
A readership is appropriately addressed by gender
if that is, indeed, the group the writer wishes to reach.
Otherwise, "Dear Colleagues," "Dear Editor," "Dear
Monograph Reader" or any such specific salutation will
do the job without alienating 50 percent (or 30 percent
or 60 percent, depending) of readers.
Wake up, Mr. Lindner!
POLLY THOMPSON
British Columbia Medical Journal
Vancouver, B.C., Canada
DEAR EDIE: Ed Lindner's "I don't give a damn" attitude
towards appropriate salutations is an affront to
all writers, and to all women.
If writers don't take responsibility for eliminating
sexist language, how can we expect others to relinquish
thoughtless if not downright misognist attitudes?
Mr. Lindner may foolishly assume that women
42
(editors?) opening a letter addressed to "Gentlemen"
simply "pass it on to a guy that hangs around the office."
More likely, they note his arrogance before making
a mental note not to do business with him.
ELAYNE CLIFT
Potomac, Maryland
DEAR EDIE: Thank you for your reference sources.
This is a fascinating list (from the Merck Manual to the
Bible!). I've already purchased Harper's English Grammar
and plan to get several other titles.
Harper's makes good reading, but a few of the
prescribed usages seem faulty. For example, what do
you think of using interchangeable pronouns to avoid
the monotony of one and one's as recommended on p.
59: "One sees many interesting sights as he [emphasis
mine] travels through his native land"? I find this
switch of pronouns confusing—not to mention sexist
and just plain clumsy. Shouldn't one stick with the pronoun
one has chosen?
SABINE J. BEISLER
American Occupational
Therapy Association
Rockville, Maryland
DEAR SABINE: John B. Opdycke, in Harper's English
Grammar, is not the only authority to recommend varying
one to avoid the monotony of repetition. Another
source—Modern English Handbook, 4th ed., by Robert
M. Gorrell and Charlton Laird—treats this grammatical
problem as follows:
Unnecessary shifts from one person to another can
produce awkward constructions, especially in impersonal
constructions, which do not develop
gracefully in modern English. Constructions like
we find, they say, and you go are common, but ambiguous.
The indefinite one is less ambiguous but
can become awkward, especially when the
possessive one's is required. For all but the most
formal writing, however, one can be combined
with he and his.
For those who don't own Harper's—which I recommend
for its scholarliness and comprehensiveness but
not for its gender-specific language—I quote the following
from it:
[One] is often used, however, as a personal pronoun
. . ., and it is called the indefinite personal [in
this context]. The affected use of one for the sake
of avoiding I, by which first person / becomes
subordinated as indefinite third person, has
nothing to recommend it. . .
Perhaps one is the greatest offender in the violation
of pronominal sequence... It may correctly be
followed by another one, as One never knows what
one may come to. But pronouns of first and second
persons should not be used to refer to it, as One
never knows what you or we may come to.
One should note that the latest copyright date of
Harper's is 1965 B.G.C. and of the Handbook 1967
B.G.C. (before gender consciousness). Hence one
understands the lack of hesitation in both sources about
using the "indeterminate" he and his.
DEAR EDIE: There are in Stockholm a hospital called
in Swedish Karolinska Sjukhuset and an associated
research institute called Karolinska Institutet. The "et"
at the end of each name is the Swedish definite article,
which is tacked on at the end of a noun without
a space. The institute is apparently doing a lot of significant
medical research and is often cited.
The hospital was founded by the emperor Charles
XII to care for the wounded among an elite corps of
soldiers. Karolinsk is a formal Swedish adjective meaning
"Charles's" and derived from the New Latin form
of the name.
The institute is now being referred to in English
through the bastard form, "Karolinska Institute." I
have seen it in the New York Times and heard it in the
public-television program, Nova. It has even crept into
French as I'Institut Karolinska.
But English already has a perfectly respectable Latinderived
adjective meaning "Charles's," and that is
"Caroline." The hospital should be called in English
"The Caroline Hospital" and the institute "The
Caroline Institute." My Esselte Swedish-English dictionary,
which I as a translator by profession have
always found extremely reliable, gives "Caroline" as
a translation of Karolinska. Furthermore, Charles' tomb
in Stockholm, Karolinska Mausoleet, is called "the
Caroline Mausoleum" in the latest edition of Bannister
Fletcher's standard History of World Architecture.
I wrote the Times about this and they replied that
they would keep on using "Karolinska" because they
have been doing so since 1980. Still, a practice of eight
years hardly seems inveterate, and the reasoning seems
weak for a publication that leaped on the "Beijing"
bandwagon so readily while continuing to use
"Moscow" instead of Moskva, "Munich" instead of
Munchen, etc.
What do you think?
By the way, a prominent California research institute
is now becoming known in literature around the world
as "The Kaiser Permanent Health Care Institute."
THOMAS J. SNOW
New York, New York
DEAR TOM: I was delighted to receive your letter.
We don't hear enough from translators.
Karolinska is the Swedish equivalent of the Medieval
Latin Carolus (Charles), thus the adjective Caroline—
of or relating to Charles. One trouble may be that some
Americans are unable to make the leap from K to C,
although these may be the very same people who are
still using EKG (the German form) for electrocardiogram
or electrocardiography instead of the logical
English ECG. Then again, the greatest problem may
be that many people don't know that Caroline relates
to Charles. Everyone, however, knows at least one
Caroline—who has nothing whatsoever to do,
necessarily, with Charles.
I venture to say that Americans in general are more
familiar with French, Italian or German than with
Swedish. Now that you've enlightened us, at least our
readers will use "Caroline Institute" rather than the
inaccurate "Karolinska Institute." In time we may see
the correct form used in all instances; in the meantime,
the writer or editor could write "Caroline Institute
(Karolinska Institutet)" as an aid to the reader.
You may have encountered, in your correspondence
with the New York Times, the dragon known as House
Style. There is no defense against this monster, whether
it lies caged, panting heavily, at the New York Times
or in my office in Philadelphia. You've done your bit,
tilting your lance at HS. It does seem strange to see the
Times perpetuate an error out of mere habit. One could
come up with some better bit of sophistry than that.
It also seems to me that the Times could change this
"habit" with a mere wave of an editorial memo.
World atlases and gazetteers in English use "Beijing"
rather than "Peking," in accordance with the directives
issued by the government of the Republic of China.
After 20 years of romanization of the Chinese alphabet,
the authorities there came up with Pinyin (from the
Chinese for "transcription"—transliteration), which
was adopted by the U.S. Board on Geographic Names.
This agency decides the spelling of place names for the
use of the federal government. Pinyin was also adopted
by the Times as of March 5, 1979. However, although
the Chinese government specified "Beijing" for "Peking"
and other changes for names of places and persons,
the Times chose to retain Peking, Canton, Tibet
and Inner Mongolia rather than substitute the Pinyin
designations, stating that these "four place
names. . . will continue to appear in The Times in their
familiar forms."
It wasn't until November 26, 1986, that the Times surrendered
to the red flag and started to use "Beijing"
in its datelines and other places.
I didn't know whether to laugh or cry when I read
your last paragraph. If that health care institute is indeed
permanent, I'm glad. But is it the institute that's
permanent or the health care—or what? For those who
like a little American history once in a while, here's
some:
Henry J. Kaiser (1882-1967) is unfairly remembered
by some only as a failed automobile manufacturer. In
truth, he was one of America's most innovative construction
experts; he was the chairman of the executive
committee of companies constructing the Boulder and
Parker dams, and he devised methods of prefabrication
and assembly that saved much time in ship construction.
In conjunction with Howard Hughes,, he
designed plans for giant cargo planes. He was also chairman
of the Kaiser Community Homes Corporation.
He built a cement plant in California. His wife liked
the name of the nearby body of water so much that
she asked him to include it—the Permanente Creek—
in the name of his newly formed health organization.
And so the Kaiser Permanente Foundation Hospital and
Health Plan were born.
All the physician groups affiliated with this health
plan carry the name Permanente in addition to any
other designation.•
COMING IN FUTURE ISSUES
• Editorial Services at a Medical Research Center
• Patient Education and Paternalism
• Attracting Minorities to the Health Professions
• A State-of-the-Art Report on Medical Communications
in the Pharmaceutical Industry
• The Women's Health Movement: A Historical
Perspective
• Folk Media: Old Ways to Communicate New Health
Information
• Trends in Authorship in Medical Journals
• A Behind-the-Scenes Look at Work in a PR Agency
• News of the Upcoming Annual Conference in Boston
Upcoming Medical and Scientific Meetings
Following is a list of upcoming meetings
that might be of interest to AMWA
members. To include a meeting announcement
in future issues of the
AMWA Journal, please send the
necessary information to Vincent W.
Franco, 4400 East-West Hwy., Bethesda,
MD 20814.
• International Congress of
Gerontology
Acapulco, Mexico, June 19-23, 1989
Contact: American Geriatrics Society
770 Lexington Ave.,
Suite 400
New York, NY 10021
• Calcium and Cell Function
FASEB Summer Research Conference
Saxtons River, VT, July 9-14, 1989
Contact: Dr. Robert W. Krauss
Executive Director
FASEB Summer Conferences
9650 Rockville Pike
Bethesda, MD 20814
• Health Law and Ethics
Second International Conference
London, England, July 16-21, 1989
Contact: American Society of Law
& Medicine
765 Commonwealth Ave.,
Suite 1634
Boston, MA 02215
• Biotechnology and Public Health
Boston, MA, July 18-20, 1989
Contact: Office of Continuing Education
Harvard School of Public
Health
677 Huntington Ave.
Boston, MA 02215
• Somatostatin
International Symposium
Montreal, Canada, Aug. 6-9, 1989
Contact: Somatostatin Secretariat
3450 University Street
Montreal, Quebec H3A 2A7
Canada
• Therapy With Amino Acids and
Analogues
First International Congress
Vienna, Austria, Aug. 7-12, 1989
Contact: Dr. Gert Lubec
University of Vienna
Department of Pediatrics
A 1090 Vienna
Wahringer Gurtel 18
Austria
• Editing Into the Nineties
Joint Meeting of Council of Biology
Edito-s, European Association of
Science Editors, and Association of
Earth Sciences Editors
Ottawa, Canada, Sept. 10-14, 1989
Contact: Ken Charbonneau
CBE/EASE/AESE Meeting
National Research Council of
Canada
Ottawa, K1A OR6, Canada
»Mammalian Developmental Genetics
First Biennial Workshop
Bar Harbor, ME, Sept. 14-17, 1989
Contact: Linda Fournier
The Jackson Laboratory
Bar Harbor, ME 04609
• Molecular Mechanisms and Their
Clinical Application in Malignancies
12th Annual Bristol-Myers Symposium
on Cancer Research
Toronto, Canada, Sept. 26-27, 1989
Contact: Virginia Mintz
Ketchum Public Relations
1201 Connecticut Ave., N.W.
Suite 300
Washington, DC 20036, or
Panacea Convention Management
3370 South Service Road
Burlington, Ontario
Canada, L7N3M6
Just published:
C. Eichhorst (Ed.)
Medical Dictionary
English-German German-English
2nd Edition, 1989
• 703 pages, 6 x 8.5 inches, laminated hardcover, sewed binding
• over 80,000 translations, recommended price DM 68 + postage
Order through any bookshop or directly from:
Lingenbrink GmbH & Co.
Postfach 101434 • D-6000 Frankfurt 1 • West Germany
* * * * *
Please note:
For a considerable future enlargement of this work, we are still
urgently looking for free-lance medical translators and terminologists,
as well as editors for the phonetic transcription (IPA
alphabet) and syllabification of medical and pharmaceutical terms.
If you are interested, please write immediately to:
Klaus-Peter Eschenbach Verlag
Franklinstrasse 16 • D-1000 Berlin (West) 10 • West Germany
AMWA Presents a
Regional Conference
Serving Two Masters: EEC and FDA
Regulatory Documents
September 15, 1989
Schering Corporation
Galloping Hill Road
Kenilworth, NJ 07033
In 1992 the European Economic Community (EEC) will
institute uniform requirements for regulatory documents
submitted to member nations. The morning panel discussion
will analyze the new EEC requirements and explore
how we can make the U.S. Food and Drug Administration's
(FDA) requirements fit the EEC's new guidelines.
The discussion will cover the historical development of
EEC and FDA guidelines and their respective problems.
The afternoon sessions will go into more detail on how
we can plan our tabular/graphic materials and text to fit
EEC and FDA requirements.
PROGRAM
Morning Panel Discussion:
"Historical Development and Problems with EEC and
FDA Documents (Moderated by Art Gertel, Schering Corp.)
Afternoon Sessions (choice of one}:
"Producing Tabular and Graphics Materials for
Regulatory Documents (Howard Smith, A.H. Robins
Company)
"Producing Written Materials for Regulatory Documents
COST $95 for AMWA members and employees of
Schering Corporation
$105 for non-members
For more information, contact the AMWA national office:
(301) 493-0003
It's Never Too Early
To Begin Planning
For The AMWA
Annual Conference
Be There in Boston,
The Lafayette Hotel,
November 15-18, 1989
A M E R I C A N
MEDICAL WRITERS
A S S O C I A T I O N
AW
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Bethesda, MD 20814
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