When physicians disagree with medical journals [PODCAST]

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Join infectious disease physician Sami El-Dalati as we delve into the complex issues surrounding medical literature and clinical guidelines. Sami sheds light on the challenges faced by medical providers in delivering patient-centered care, particularly in the context of substance use disorder and endocarditis treatment. We explore the implications of biases and limitations within prominent medical publications and discuss strategies for promoting evidence-based discourse and advocating for optimal patient outcomes.

Sami El-Dalati is an infectious disease physician.

He discusses the KevinMD article, “When your letter to the editor is rejected or ignored.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. We welcome back Sami El-Dalati. He’s an infectious disease physician. Today’s KevinMD article is “When your letter to the editor is rejected or ignored.” Sami, welcome back to the show.

Sami El-Dalati: Thank you for having me.

Kevin Pho: So I was just looking back, Sami’s been on almost three and a half years ago, and it’s wonderful that he’s still writing and he’s back on again. You’re an infectious disease physician. What’s your practice?

Sami El-Dalati: I am an infectious disease physician. I primarily see patients who have infective endocarditis. We’ve been very hard hit by that here in Kentucky as a result of the opioid epidemic. We see a pretty large number of patients with that condition, so we have a dedicated consult service and multidisciplinary team that helps to care for patients with endocarditis, particularly those with substance use disorder. So that’s a lot of what I see. And then I also see a little bit of general ID and patients living with HIV.

Kevin Pho: Now, from your lens as an infectious disease physician, tell us some of the challenges that you face seeing infective endocarditis in that patient population.

Sami El-Dalati: Yeah, a lot of different challenges. I think first and foremost, endocarditis is just a really complicated disease that requires a lot of interdisciplinary communication and coordination of care. So whether the patient has substance use disorder or not, they often need to be seen by infectious disease, cardiology, cardiac surgery, maybe neurology, neurosurgery, and the list goes on and on. So one struggle is just getting all those people to communicate and get on the same page. That’s where the multidisciplinary team concept comes in.

I think, as you hone in a little bit more on patients with substance use disorder, some of the challenges relate to the stigma that those patients experience as they come into the hospital. A lot of people, including health care providers, view it as a self-inflicted disease, and sometimes the compassion that we might have for other individuals is a bit lacking in those situations. And certain treatment options might be limited as well for those patients.

And then there are just a lot of structural challenges within our health care system, and just our overall social system, for caring for these patients, many of whom are unhoused, have significant comorbid mental health disorders. And so we can take care of the infection in the hospital, but then the patient is going to be going right back out into perhaps a very chaotic social situation, and they’re not really set up to do well long term. So we’re trying to navigate all these things, and that can certainly be challenging.

Kevin Pho: All right, your KevinMD article is titled “When your letter to the editor is rejected or ignored.” Now, for those who didn’t get a chance to read that article, tell us what it’s about.

Sami El-Dalati: Yeah, so it’s about two previous letters to the editor that I’d written. One was back in 2021, to the New England Journal of Medicine. The other was in 2022, to the American Heart Association journal Circulation.

The first piece, the New England Journal piece, started as kind of a poll where they would ask, would you treat a patient with substance use disorder with oral or IV antibiotics? And then they had sort of a point counterpoint. At the time, this was something I was doing in my practice, I was treating a lot of patients with substance use disorder with oral antibiotics, and I just felt like the position that was taken, even on the pro-oral side, really didn’t capture a lot of the decisions that we were weighing on a daily basis, and didn’t really take the patient perspective into consideration. I felt like that was a pretty big missing piece. So I tried to write and highlight that, and also highlight some of the missed opportunities in terms of citing literature.

Similarly, the 2022 Circulation article was a position statement about treating endocarditis in persons who inject drugs. It was a much needed article, but one of the things that was concerning to me is they had a section on oral antibiotics and they provided some recommendations for treating MRSA endocarditis, and they miscited the largest paper on this topic, the POET trial, and gave these recommendations and said it was based on evidence when it really wasn’t. And that was pretty alarming to me, because we run into patients with MRSA all the time, we struggle to know how to best treat them with oral antibiotics, because the data is just not there.

So I’d written letters to both journals, and the first, New England Journal, at least wrote back to me, but Circulation just completely never responded. And the article was born out of a little bit of that frustration. One, there’s sort of this misinformation that’s out there, and then two, the fact that there’s really not a discourse that’s happening. So when a powerful journal like this puts something out there, they can kind of just double down and ignore the people who are trying to reach out and highlight some of the challenges.

Kevin Pho: Now, as far as you know, did any other physician reach out and express a similar viewpoint to yours, and did the journal accept that view?

Sami El-Dalati: To my knowledge, I didn’t see anything come out along those lines. Didn’t see anything published related to those articles, or any kind of retraction or alteration to the pieces.

Kevin Pho: And when you received the reply from the New England Journal of Medicine, did they give any reason as to why they didn’t publish your letter?

Sami El-Dalati: They said just that they receive a number of requests for correspondence, and that they just had too many and wouldn’t be able to accommodate mine. That kind of boilerplate language.

Kevin Pho: So for those who aren’t familiar with letters to the editor in academic journals, tell us about that process.

Sami El-Dalati: Sure. So most journals will have on their website a submissions page for authors, and one of the article types is a letter to the editor. They’ll have specific criteria about what you’re allowed to include. It’s usually somewhere around 250 to 500 words, that’s probably on the long side, and they really want you to just focus specifically on what the issue was with that article. And usually there’s a limit on the number of authors, two or three in my experience.

And then you submit it to the journal just like you would submit any other article that you’re hoping to get published. It goes through an online submission system and you just kind of wait to get a response. Now, in these cases, rather than it going through peer review, it’s just reviewed by the editor, and then they ultimately make the decision.

Kevin Pho: So in terms of the letters to the editor that do get published, do you notice any particular trends or biases to the letters that do get published in general in these academic journals?

Sami El-Dalati: That’s a good question. Personally, there’s not something that I would say I’ve noticed. I will read letters to the editor from time to time, but I don’t know that I’ve read enough examples of correspondence to be able to pick out a pattern.

Kevin Pho: So now, with the advent of social media, and now you’re on this platform, podcast, what do you think about the relevancy of letters to the editor, because there are so many ways that you can express your viewpoint without going through that system now?

Sami El-Dalati: Right, for sure. Yeah, I think it’s a great point, and your forum sort of gave me an opportunity to express my viewpoint when the letters were not published. So I think it’s good to use these other avenues, for sure.

But I also think that change often comes from within, and so trying to work a little bit within the structure and the system that they have, and make very scientific, well reasoned arguments, I think is important. My approach was sort of, I’m going to give them the opportunity to respond in the typical format, and then if they don’t respond, then I’ll go and pursue another avenue to try to get the message out there. So that’s my perspective. Everybody’s probably a little bit different. I don’t really use a lot of social media, so for me that’s not an avenue I usually go down, but obviously lots of people do.

Kevin Pho: All right, so you have a platform here, and you’re an expert in infective endocarditis. So tell us your perspective and your viewpoint that these studies and the academic journals may be missing.

Sami El-Dalati: Yeah, so with respect to the Circulation article, one of the things I tried to touch on in the piece was that there is pretty good data for using oral antibiotics to treat infective endocarditis, particularly if it’s caused by specific organisms. So methicillin susceptible Staph aureus, streptococci, coagulase negative staph. There’s randomized controlled trial data that shows that that approach is non-inferior to IV in clinically stable patients.

But what I’ve seen is that there has not been a significant practice change despite that data being available. And so where I think we need the society and these large journals, we need their help to a certain extent, is to highlight that even though the data is out there, people aren’t changing their practice. We really need to be asking ourselves, why is that, and pushing people to try to use evidence-based medicine. I think we talk about it a lot, but then in practice it’s not always taking place.

So that is one piece of it. I felt the position statement really missed an opportunity to highlight the ways in which we could improve the care for this patient population, and update it so that it was more consistent with the literature that’s out there. And instead the article really didn’t cover those things, and not only that, maybe supplied some incorrect information.

I think, as you want to change the approach toward marginalized patient populations, having that evidence and that scientific background behind what you’re doing really goes a long way. You can speak to people’s compassion, to their hearts, I think that’s important of course, but having the data behind you also really helps. So trying to tie those two things together is important for me.

Kevin Pho: Now, for those non-clinicians who may be listening to you, talk about the role academic medical journals have when it comes to changing physician practice.

Sami El-Dalati: Yeah, so a few different ways. One is that these journals are going to publish the newest studies, often on hot button issues, or things that are pertinent to people’s clinical practice. So if it’s an infectious disease journal it might be a study about oral versus IV antibiotics, but if it’s oncology it may be about a cancer treatment or what have you. So that’s a big part of what they do.

The journals have different impact factors, essentially an assessment of how widely read the journal is and how much of their content is being disseminated. And so some of these large journals may be the only journals that a lot of physicians read, the New England Journal, or if you’re a cardiologist, perhaps Circulation.

The other thing that they do, particularly Circulation, is they produce guidelines on the management of certain disease states. So Circulation has produced an endocarditis guideline going back over 20 years. It hasn’t been updated since 2015, but that guideline document ends up being what virtually all infectious disease and hospital physicians are using to treat patients with endocarditis in the United States.

Because endocarditis is a heterogeneous disease, there’s a lot of literature out there, so people are going to try to go to a trusted source for how to manage these patients. So the document that they put together is going to be what a lot of people use. And so from my perspective, if you’re going to do that, you have a certain level of accountability, to make sure that the right information is getting out there, because it’s going to affect real people and patients downstream.

Kevin Pho: Now, other than social media, are there any other forums where a physician can express a criticism or a dissenting opinion to a study that’s published in an academic medical journal?

Sami El-Dalati: Yeah, I think outside of social media, writing the letters. Sometimes at a conference, potentially, you may be able to have that opportunity, if you submit a project that maybe has some data that’s contrary to what the journal published. But again, a lot of the same organizations that put on the conferences are the ones that publish the journals, and so you’re kind of running into the same people as you’re trying to raise dissent.

I think there are opportunities like your blog and this podcast, other podcasts in general, that are perhaps different than social media. And then of course there’s the lay media, trying to get things out to them as well. But then that carries some risk. My experience has been that a lot of physicians might be nervous having those types of conversations, because of how that might be perceived by the hospital they work for, the institution they work for. And so I think that limits some of the options.

So there are some things, but I think it’s hard, and I think people feel the pressure to not pursue some of these avenues because of the consequences that they might have for their careers.

Kevin Pho: We’re talking to Sami El-Dalati. He’s an infectious disease physician. Today’s KevinMD article is “When your letter to the editor is rejected or ignored.” Sami, we’ll end with some of your take-home messages to the KevinMD audience.

Sami El-Dalati: I think a couple of things. One, with patients who have substance use disorder, just encouraging people to be aware of the stigma that’s out there, and perhaps some of their own inherent biases that may come across toward that population. I think historically we’ve operated a little bit through a provider perspective on these patients, and trying to move to a little bit more patient centered is one thing.

With respect to reading a journal article or reading a guideline, I think just remembering that those are guidelines. So, one, it doesn’t mean that what’s in them has to be set in stone and you absolutely have to follow it. These guidelines are often based on expert opinion, or maybe very small retrospective studies. So knowing that it’s there is important, but also taking it with a grain of salt.

And then I think just being analytical and critical of what you’re reading, and saying, OK, so this guideline says this, but what does that come from? And going to the primary literature. Because you can start doing that when you’re a medical student, when you’re a nursing student, you can do that early on, and just having that critical lens, so you’re really getting at the underlying information and not what’s being filtered to you.

And then I think the last piece is just that there’s room for more discourse with respect to academic medicine, and hopefully we can find some more forums to have those discussions, and there’ll be more opportunities to give feedback to journals.

Kevin Pho: Sami, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Sami El-Dalati: Thank you for having me.

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