The Ingelfinger Rule

Does it strangle the flow of medical news?

One article reports that a widely acclaimed ulcer drug called cimetidine is actually less effective than ordinary antacids in treating seriously ill patients suffering from gastrointestinal bleeding. Another presents evidence that the incidence of hepatitis A is greater than normal in homosexual men and is related to their sexual practices. These are just two of the articles in last week's New England Journal of Medicine, a weekly that has been making news practically from the time it was founded in 1812.

Many significant firsts in medicine have been revealed in the Journal's pages, including the use of ether for anesthesia during surgery (1846), and an operation to remove a ruptured disc from the spinal column (1934). So important are the literate, well-edited and often controversial articles that hardly a week goes by without some mention of the magazine in the press. Now the Journal itself has become news, a target for reporters who charge that its editorial policies delay the revelation of medical developments to the public.

Articles submitted to the Journal are routinely forwarded to at least two experts for review and comment and then discussed by the staff at a Thursday lunch, after which papers may be sent back to the authors for revisions and, often, rewriting. Says the Journal's editor, Dr. Arnold Relman: "The conclusions have to be not only warranted but also readable." So exacting is the process that only 10% to 15% of the 4,000 papers received each year are printed. No one objects to that meticulous procedure. In fact, it has helped make the Journal the world's forer most medical publication.

But there is another aspect of the magazine's editorial policy that is not so widely applauded. Under the direction of Dr. Franz Joseph Ingelfinger, the Journal began refusing to publish papers that had received substantial coverage elsewhere, in either the general or medical press. Dubbed the Ingelfinger Rule, the policy has been extended by Relman. It now forbids researchers submitting articles to give interviews on their findings to reporters before the articles are published in the Journal. This restriction applies even when the results have first been presented at medical meetings open to the general press. Relman argues that such a policy avoids misleading stories based on fragmentary and often preliminary data. Says he: "Until work has had peer review and has been published in full in a professional journal, it is half-baked." He insists that the policy also permits doctors to learn about new developments before their patients do and thereby be in a better position to answer anxious inquiries. But Relman admits that the rule is self-serving; it guarantees that the Journal will be the first to publish important medical news and thus be credited when the stories are repeated elsewhere.

Reporters charge that Relman's policy has had a chilling effect on relations between the press and medical researchers; critics call it a throwback to the 19th century, when journals were the only source of medical news. Relman brushes these complaints aside. Says he: "We don't get any protests from either doctors or authors, so I really believe our position is supported by the great majority of scientists." But his detractors contend that medical scientists, especially those on the way up, are intimidated by the Journal's power. And it does have power. Notes Alexander Langmuir, former chief epidemiologist at the Center for Disease Control: "The Journal is probably the one place young physicians and researchers aspiring to an academic career would rather publish than anywhere else in the world. The people who are making the decisions about jobs and tenure are reading the New England Journal."

Some examples of the rule's impact:

-- Houston Oncologist Jordan Gutterman, upon arriving at a Manhattan medical conference last May to deliver a key paper about the effect of interferon on cancer, requested no press coverage of his talk. Reason: he hoped eventually to publish his findings in the Journal. > A report by Allen Steere, a Yale University internist, giving the first full scientific details of a newly discovered tick-borne disease called Lyme arthritis, was rejected in 1976 by Ingelfinger. Reason: Steere's findings, presented at a scientific meeting, had been picked up by the New York Times, which expanded the material with an interview and printed a story. Properly chastened and again in the Journal's good graces, Steere now accepts reporters' inquiries only if they go through the Yale Medical School press office. -- A 1977 paper by Stanford Epidemiologist Ralph Paffenbarger, already accepted by the Journal, was yanked at the last moment by Relman. Reason: the paper, which indicated that vigorous exercise cuts down the incidence of heart attacks, was presented at an open meeting of the American Heart Association and was reported by the press.

Last September reporters and editors from several medical publications met in Relman's Cambridge, Mass., offices to discuss the Journal's policies. Relman remained adamant, though all the other editors argued against his position. Says one of them, Dr. Edward Huth, editor of the Annals of Internal Medicine: "In an open society with open scientific meetings, with thousands of people from the profession attending, when a new development is announced in an oral paper, it immediately becomes potential news. The game that was played in the 19th century can't be played any more." -

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