Clinical Conversations

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Eric Rubin is editor-in-chief of the New England Journal of Medicine.

I asked him how COVID-19 has affected that journal, which has been around since the War of 1812 and seen its share of pandemics.

Listen in — it’s the first in a planned series of interviews with the editors of the principal clinical journals.

Running time: 19 minutes

NEJM’s Covid-19 resources page

TRANSCRIPT

Joe Elia: Welcome to Clinical Conversations. I’m your host, Joe Elia.

Dr. Eric Rubin, a specialist in infectious diseases, took over the reins of the New England Journal of Medicine as its editor-in-chief about a year ago. He had just enough time to settle in before — you know — the biggest pandemic in a century arrived.

He’s kindly agreed to take part in what’s planned as a conversational survey of the editors of the principal medical journals about their takes on COVID-19. These chats won’t focus so much on the clinical science of the pandemic as much as its broader effects.

In addition to editing the Journal, Dr. Rubin is an associate physician at Brigham and Women’s Hospital and a professor in the Department of Immunology and Infectious Diseases at the Harvard T.H. Chan School of Public Health.

Welcome to Clinical Conversations, Dr. Rubin.

Eric Rubin:: Thanks, Joe.

Joe Elia: These have been strange times for medical journals, haven’t they?

Eric Rubin::They sure have. I don’t have much of a basis for comparison, but as far as I can tell, this is pretty unusual.

Joe Elia: Yeah. I mean how is the journal doing? You’re all working in isolation? You’re not up in the top of the Countway Library on Shattuck Street, these days, are you?

Eric Rubin:: Yeah. That’s right. We’re all shut down, although I must say it’s worked out pretty well to have people working from home. I suspect that, like a lot of businesses, we’re going to find that we don’t have all that many people in the office when we finally do get back.

Joe Elia: I remember from years ago the kind of bustling newsroom feeling at the journal offices, and you would have these conversations in the corridor, like oh, you know, “This thing just came in, you should take a look at it,” but you really can’t do that over Zoom so readily, can you?

Eric Rubin:: Yeah, I think that’s right. It’s not as if we haven’t lost something.

Joe Elia: Yeah.

Eric Rubin:: It’s so much easier for people to walk in and out of each other’s offices with questions or ideas or “Here’s just something cool,” so we miss that, and I’m hoping that we recapture that, but on the other hand, there’s a lot of just get the work done stuff that people can do very efficiently at home, much more efficiently.

Joe Elia: Yeah. Yeah. When I was there, people would say, well, you know, “How often does the journal come out?” And I would say “Every damned week.” It’s relentless.

Eric Rubin:: That’s right. It’s kind of relentless.

Joe Elia: Yes. So, have you been inundated with research reports?

Eric Rubin: We have. I will say it’s gotten a lot better, but at its peak, we were getting more than 200 manuscripts a day, 7 days a week, for a while, just on COVID-19, on top of really a pretty normal volume otherwise.

Joe Elia: Yeah, my gosh. So, electronics have helped you distribute that workload, I guess, but that’s a lot of reviewers to find.

Eric Rubin: It is. We have to filter, before we send out for review, pretty severely, and finding reviewers is also problematic because the reviewers that we want to use are also quite busy. They’re the people taking care of the patients with COVID or setting the policy.

So, people, I think the reviewers have been very generous, but it did mean that we took a rather severe cut when things came in, thinking, you know, “This just is not likely to make it, and the authors are better off going somewhere else, where they can get a real serious look.”

Joe Elia: Yeah. You know journals have often been called universities without walls, but now, a lot of information, especially biomedical information, is being swapped around on social media, but they are kind of universities without constraints. What’s your feeling about this — this kind of swapping of information that’s going on?

Eric Rubin: You know I have mixed feelings. On one hand, I like the fact that information is being democratized and anyone can see it and comment on it, and that’s certainly true of COVID-19, where we and many of our fellow journals are making everything available immediately for free access right away, immediately, so that everyone can read the same things that the experts are reading.

When I look at social media, though, there’s a real mix. There’s really learned commentary, and there’s real misinformation, and it can be hard, I think, for people to sort out what’s real from what’s not.

Joe Elia: Can journals then offer a kind of healthy skepticism and peer review? Is that what they can bring to the table?

Eric Rubin: I think for sure. There’s no question that we make a lot of changes in every manuscript that comes to us. We work together with the authors, but the final product generally looks a lot different from what was submitted and different from the preprint that’s been posted.

And some of those changes — a lot of them — are cosmetic. A lot of them are messaging questions, making them more understandable or more accessible or being very clear about what the investigators did, but a lot of them are substantial.

For example, it’s not unusual to change the conclusions of a manuscript and sometimes change them to the opposite of what the authors had said originally, and that’s a pretty big change, and it is.

So, I think we’re still playing a role in communications that is very important, and we do that, certainly, with the very big help of our peer reviewers.

Joe Elia: So, those changes, Eric, are made with the — of course — with the consent of the authors. I mean they’re not just made and published. I just want our listeners to understand that.

Eric Rubin: Absolutely. This is a collaboration with our authors.

Joe Elia: Yeah.

Eric Rubin: When we accept a paper, we’re a little bit different from many scientific journals. We generally decide, after peer review, immediately, we’re going to take this or we’re not. It’s very unusual for us to send it back and say, “You know, if you did some more experiments, we’d reconsider.” Generally, we write a letter that says “We’d like to publish this, but as long as we can work with you to make the changes that we think are necessary,” and those are — can be — very extensive.

Joe Elia: This pandemic is an event that’s affecting culture, in some ways in the same way that the AIDS epidemic did, and by which I mean that, you know, human interactions and politics as much as creating an urge to solve the problem biomedically, but would you agree that the pandemic has become unusually politicized?

Eric Rubin: It is. It’s very strange but absolutely. I think the parallel that you point to with HIV is a good one, and back when HIV was in its heyday and treatments were not so good…not that HIV’s gone away. I don’t mean to suggest that.

Joe Elia: Right.

Eric Rubin: But back when there weren’t many therapies and there was a very strong advocacy movement, it was a very frustrating time, and that led — and people may not recall this — but that led to a lot of sort of crackpot theories that got propagated very widely in the community and were ascribed to by a lot of people, and that really undermined, I think, their confidence in the system.

Now, in the case of HIV, what brought confidence back was having effective therapies. It really was a technical fix. It wasn’t a political fix. Now, we’re in an even more difficult situation, I think, because our most effective means for controlling the virus are simple. They’re social engineering, in a way. They’re wearing masks and social distancing and all the standard sort of stuff, and yet we’re not really able to implement them, in the US at least, as widely as we should because of this politicization of the questions.

Joe Elia: You know Rudolf Virchow, back two centuries ago, said that medicine is a social science, and these simple, you know, measures that you mentioned are part of the social science — probably — that needs to be done.

Eric Rubin: Well, you know, and I think that goes back, again, back to HIV. I think it’s a really good point. In HIV, all we had originally were control measures, and those control measures meant people had to change their behavior in ways that they didn’t want to change, and it was very difficult. The uptake of that was difficult, very parallel to today, and what made the difference was actually not a social intervention but a technological fix, and I think, once again, we’ve come to rely on technology that we’re incredibly reliant, right now, on the idea that a vaccine will be successful.

Joe Elia: You know, speaking of HIV, when I was at the journal, a long time ago, at the Shattuck Street offices, we had a telephone call from Michael Gottlieb in Los Angeles in 1981, and I happened to be the senior person in the office at the time, I think Bud Relman was off on one of his trips, and he [Gottlieb] said, “Gee, I’ve got four cases of something, how soon can you publish an article?” and I said, “Well, you know, 3 to 5 months is what we’ve got.” So, I said “What is it?”

And he said, “Well, you know, it’s this kind of infectious thing that’s predominantly among gay men,” and I said “Do you think it’s a public health problem?” And he said, “I do,” and I said “Go to MMWR [Morbidity and Mortality Weekly Report (from the Centers for Disease Control)] and submit it there.” And he did.

And the next day, Bud Relman was back — the editor of the journal in those days — and he called Gottlieb and said, “Yeah, go to MMWR and we’ll publish the whole thing later.” And we did in, I think, December, like something like 6 or 8 months later, we published his article.

So, I mean, Randy Shilts and his book “And the Band Played On” says, “Oh, you know, Gottlieb went to the journal and the journal pooh-poohed it.” But it’s not true, but it makes it…

Eric Rubin: And the journal had the first report, I have to say, in a medical journal of HIV back then. Technology is better now so that we can publish things much more rapidly, and we can get them online instead of in print.

Joe Elia: Yeah.

Eric Rubin: Like we had to do back then but that it still requires people, and that is still the resource that’s most difficult for us. We put a lot of hours into every article, and we’re still putting in the same hours. They’re just compressed into a weekend.

Joe Elia: Yeah. Early in the pandemic, the journal published a letter about asymptomatic, or yes, presymptomatic transmission, for which it was…it got some criticism. Turns out that it was correct, that the letter was correct, but that.. You’re on the firing line, a lot, aren’t you, as the editor? You can be accused of saying, oh, you know, the journal is trying to be first, and it’s not always…that’s…

Eric Rubin: Yeah. I think that’s right, and I think we should be criticized when we make mistakes, and we should act to try to rectify those. In that case, we happened to be right, and we were vindicated by subsequent studies, but you know that was a case of politics as much as anything. That was a message that people didn’t want to hear and they were very resistant to at the time.

You know it’s no surprise that the biggest subsequent issues, in general, in medical journals have been about hydroxychloroquine, which has a very faithful following, and when anything gets published, we have a lot of people who object if it…and we would have people objecting on either side if the article suggested that it worked or it didn’t, and we’re also in the position, put in the position…we get a lot of people writing, saying “Why didn’t you do this?” We didn’t actually do the study, so it’s a little hard for us to…but they’ll criticize our characterization of the study as positive or negative, and I think we’re doing the best we can, and it’s very fair to second guess us. That’s part of the interchange, but it can get a little personal.

Joe Elia: So, when you think about your role, Dr. Rubin, do you see yourself as a teacher, a referee, a ringmaster? When you think about your audience, who is it?

Eric Rubin: Well, that’s a really good question. We like to think of our audience as clinicians, as people who are taking care of patients. The truth is that we publish a range of things, some of which are aimed at practicing clinicians and are very practical. They can be the videos in clinical medicine which show you how to intubate a patient or how to do any given procedure or the CPCs, the various clinical series we have where discussants develop a differential diagnosis and come up with management plans for patients. The research articles, we try to characterize, at least in summary, in ways that anyone, that any clinician could understand the message. Now, the truth is, we do have, and we have more and more of what I guess I’d call experimental medicine, which is something that’s not yet ready for primetime.

It can be phase I studies. It can be first-in-man studies, occasionally, of new drugs or new techniques, and I still think that’s important because a clinician can see what’s coming next, what do we have to look forward to? This may or may not be a breakthrough, but it could be, and we’d like to get those out to our audience.

Admittedly, some of what we publish is very technical and is aimed at a subspecialist or occasionally really a researcher community, but we’re trying to serve everybody to some extent. Our goal is to make a difference in how people are treated, and I think we try to think of the audience that matters for making that sort of impact.

Joe Elia: If you considered yourself a ringmaster, how do you get the lions and tigers to behave?

Eric Rubin: Well, so, I guess that requires a little description of the process we go through to make decisions on manuscripts. Essentially, all the editors sit in a room, at least until we shut down the office. Everyone shows up. There are 30 people in a room, and every manuscript that’s gone through peer review and has some chance of being accepted gets presented. Actually, it’s very old-fashioned. The editor who’s handling it Xeroxes all the figures, hands them around, and then presents the papers if it’s a journal club, and then there’s a very interesting discussion where the experts in the room or the people of opinions in the room, or of educated opinions in the room, will bring up any aspect of it, was the design correct, are the statistics correct?

We have several PhD professors of statistics sitting in the room. Was it ethical? Was there equipoise? Could you do this study? Almost any aspect of it gets discussed, and at the end, we make a decision. It is kind of a strange position to be in to be the final decision-maker because so many people in that room know more than I do, but it comes to a balancing act of what do we think people really need to know, and what’s going to move the needle? And I think that gets discussed all the time. In fact, one of the key questions that comes up repeatedly is, “If we publish this, is it going to help or hurt patients? Are people going to take this incorrectly and potentially do harm, or is this really going to make a difference?” And if it’s really going to make a difference, we’ll definitely publish it. So, it’s a fascinating process. You know it’s the world’s best journal club.

Joe Elia: Well, I want to thank you, so much, Dr. Rubin, for speaking with me today.

Eric Rubin: Thanks, Joe.

Joe Elia: That was our 273rd episode. We come to you from the NEJM group. Our executive producer is Kristin Kelly, and I’m Joe Elia. Thanks for listening.