The power of negative thinking.

In this issue of CJEM, Frank and colleagues report a randomized trial of magnesium administered intravenously (IV) for benign headache. They found that IV magnesium was no more effective than placebo, and had more side effects. Readers may notice that this article is unusual: It is uncommon these days to find an article reporting negative results. Journal editors shy away from negative trials, and this tendency gives rise to one of the significant problems with modern medical literature — publication bias. Emergency physicians were among the first to quantify “publication bias.” Moscati and colleagues found that only 15% to 16% of articles in leading emergency medicine and internal medicine journals reported negative results. Callaham and associates further demonstrated that positive abstracts were twice as likely to be accepted to an emergency medicine annual scientific meeting, and to be subsequently published. The second unusual aspect of Frank and colleagues’ article is that, with only 42 subjects, it is exceedingly small compared to today’s 5-figure pharmaceutical mega-trials. So why would CJEM decide to publish an article that, in addition to being negative, is “small”? Especially when there is pressure on editors to reject as many articles as possible. Esteemed journals such as JAMA are quite proud of the fact they reject over 91% of submitted articles. Not only do high rejection rates increase the apparent prestige and power of established journals, they are one of the criteria used by academic and indexing agencies to assess the quality of a journal. Despite a small sample size, negative outcome, and pressures to reject, the CJEM editors thought that publishing this article was the right decision, both from an ethical and scientific perspective. Here’s why.