THE DOCTOR'S WORLD
THE DOCTOR'S WORLD; SCANDALS POINT TO WEAKNESS IN REVIEW PROCESS
By LAWRENCE K. ALTMAN, M.D.
Published: July 21, 1987
IN an ideal world, a study of children and cholesterol by Dr. Charles J. Glueck would never have seen the light of day. The system for preventing questionable findings from being published would have seen to that.
But the system failed, even though some researchers had raised serious questions about the study even before it was published last year in Pediatrics, a major medical journal.
The National Institutes of Health repudiated the work last week, censuring Dr. Glueck, of the University of Cincinnati College of Medicine, for ''serious scientific misconduct'' and misrepresenting data. The decision, the latest in a series of recent scientific scandals, is more evidence that peer review, a revered approach to the publication of scientific findings, is not living up to its billing.
Peer review, in one form or another, is used to assess the quality of research and practice in many fields. In medicine, peer review procedures are used for, among other things, evaluating hospital admission decisions, judging the quality of the medicine practiced in hospitals and determining the merit of applications for research grants as well as in assessing submissions to journals. An Often-Oversold Process
Editors of many scientific journals rely on peer review to help them assess technical and other points, select the most worthy submissions and prevent false claims. Over all, it is regarded as a useful process, even essential; the expert criticism improves many papers and helps weed out poor ones. But the process is often oversold. It cannot insure accuracy, and sometimes, as in the case of Dr. Glueck's report, it seriously fails -how often, no one knows.
The peer review system can impart a false sense of security to doctors who use information from journals as the very foundation of their daily patient care. Assertions in reviewed papers often do not hold up. Yet follow-up reports or retractions seldom appear.
''What do we really know about editorial peer review in science?'' the American Medical Association asked recently. The A.M.A.'s response: ''Not much.''
The association posed the question in seeking research papers on the subject for a meeting in Chicago in May 1989. The call for that meeting, the first of its kind, comes at a time when even defenders of the peer review system are demanding reform of serious defects. Dr. Stephen Lock, editor of the British Medical Journal, has said, ''Editors, the arbiters of rigor, quality and innovativeness in publishing scientific work, do not apply to their own work the standards they apply to judging the work of others.''
For doctors, publication in peer-reviewed scientific journals is often key to obtaining research grants, and one aim of the meeting is to discuss the influence of money on the peer review system. Among the other aims is exploring the often related issue of relationships among authors, editors and reviewers.
There are numerous ways for the peer review system to fail, some of which bear on the Glueck case, others of which do not.
Medicine prides itself on high standards and the precision of its language. Yet there is no standard definition of peer review or of its practice by medical journals.
Many prestigious scientific and medical journals that advertise the quality of their peer review fail to point out that much, if not most, of what they publish is not subjected to peer review at all. Some journals point to peer review - and its intended result that the public receive only accurate information - as an argument for keeping authors from disclosing their data before publication. Critics accuse these journals of misusing this argument to preserve for themselves a form of ''scoop journalism'' to promote circulation, advertising and profits.
In addition, while the peer review system of top medical journals is often described as rigidly objective, and although many doctors have an almost blind faith in it, in reality peer review is largely subjective, sometimes influenced by medical politics to a greater extent than most people recognize.
The practices of peer review vary, but commonly editors select two experts to criticize the submitted manuscript. The experts chosen are called ''reviewers'' or ''referees.'' Usually they are told who wrote the paper, but the authors do not learn the reviewers' names. Reviewers are asked to comment on the quality of the research, to recommend acceptance or rejection of the manuscript and to grade its priority. Fraud Is Nearly Immune
This process can catch inconsistencies in data or results, but it cannot easily detect outright fraud. Reviewers do not examine the raw data from the author's laboratory notebooks or medical charts, instead accepting at face value the validity of these data and the statements made in the text. Reviewers of Dr. Glueck's manuscript, for example, raised questions about his work, but they did not see the raw data that were examined by a committee of inquiry at the University of Cincinnati, whose findings led the National Institutes of Health to censure him.