Taking stock at The Green Journal.

Thomas S. Huddle, MD Nineteen ninety-six was the 50th anniversary of The American Journal of Medicine’s founding; in 1997 the editor’s chair moved to San Francisco, having been in Birmingham, Alabama, for 11 years. Both occasions offer an opportunity for reflection about where The Green Journal has been, and where it is going. The stated goals of the Journal at its founding in 1946 were to provide a forum for publication for an increasing volume of clinical research, to be a means of postgraduate education for practicing physicians, and to keep physicians aware of advances in therapeutics (1). For most of the Journal’s history, original articles, editorials, and reviews have been the means to those ends. Instruction has been further served by symposia and clinicopathological conferences. Politics, news, and miscellaneous pieces have been left to other journals, at least until recent years. One approach to assessing the Journal’s history is to compare the present with the past. The issues of 50 years ago offer an instructive comparison, as by 1948 the Journal had had 2 years to develop a distinctive persona. In physical terms, the 1948 Journal was different from its modern counterpart. At roughly 150 text-pages each, issues were half again as large as they are today. In spite of the extra space, they contained fewer clinical studies, generally 6 to 8 per issue. These commanded more text pages, generally 60 to 75, than the shorter clinical studies of the present, 8 to 10 of which are fit into 45 to 60 pages per issue. The rest of the extra space in 1948 was devoted to more reviews, clinical conference transcriptions, and meeting abstracts than the present Journal can accommodate. Clinical studies were written rather idiosyncratically, without the format that has become standard in the presentation of clinical research. Whereas as many as 4 authors were unusual in 1948, the typical paper of 1992 has 5 to 7. The affiliations of Journal authors have also changed substantially, reflecting its location and the predilections of Dr. Alexander Gutman, the first editor. In 1948, the Journal was a New York product. At least 2 New York authors were represented in every issue, showcasing the research departments of Columbia, Cornell, and Mount Sinai. The Journal was filled out with papers from prominent schools in Boston, Baltimore, San Francisco, Rochester, St. Louis, and Chicago. The modern authorship is much more diverse, with frequent international contributions from countries such as Canada, Great Britain, Japan, France, Germany, and the Netherlands. The Journal’s cumulative effect on its readers is perhaps most clearly suggested by examining those articles that have had the most impact, as measured by number of citations elsewhere. Thirty of the 50 most cited articles in The American Journal of Medicine between 1946 and 1992 are shown in Table 1. Although citation analysis offers a quantitative means of assessing the relative importance of a journal’s articles, it is not without pitfalls. Counting total citations emphasizes older papers that have had more time to be cited. Citation levels are indicators not of originality or even influence but of a paper’s ability to attract attention for whatever reason. Thus, frequent citations may be due to authors heavily citing themselves or to the ups and downs of academic fashion, sometimes directed by flows of research money. Original papers are not necessarily the most cited. Authoritative reviews may draw more attention. This is illustrated in the Journal’s list: Schwartz and Barrter’s initial report of the syndrome of inappropriate antidiuretic hormone (SIADH) in 1957 (#10) was followed 10 years later by Barrter’s comprehensive review of the subject (#9). The latter achieved more citations and continues to be cited at a greater level than the former. Brouet’s 1974 classification of essential mixed cryoglobulinemia (#13) has similarly drawn more citations than Meltzer et al’s elucidation of the syndrome 8 years earlier (#26). A much greater percentage of the most cited papers are basic science, and a substantial proportion of the rest are basic rather than applied patient-oriented research, as compared with consecutive samples of the Journal’s articles. That basic science papers attract more attention is perhaps not surprising. Therapy changes more quickly than the nosology of disease. Epidemiological papers are relatively uncommon in both the most-cited list and in consecutive samples of the Journal’s papers. The numberone ranked paper is thus even more noteworthy, both for its methods and for its number of citations given a relatively recent publication date. As a part of the Framingham Study, Gordon et al were able to confirm prospectively a hypothesis voiced 20 years previously, that highdensity lipoprotein (HDL) cholesterol levels were inversely correlated with coronary artery disease. The reasons why HDL cholesterol levels received less attention than low-density lipoprotein (LDL) cholesterol levels form a fascinating chapter in the history of lipid research. A correlation between low levels of HDL cholesAm J Med. 1998;105:131–134. From the Division of General Internal Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama. Requests for reprints should be addressed to Thomas S. Huddle, MD, University of Alabama at Birmingham, Division of General Internal Medicine, Department of Medicine, 621 Medical Education Building, 1813 Sixth Avenue South, Birmingham, Alabama 35294-3296. Manuscript submitted April 24, 1998 and accepted April 24, 1998.