Drug bulletins aim to provide independent information of good quality, to help
prescribers make better treatment decisions and pharmacists to work more effectively with
prescribers. They come in all shapes and sizes, from four to 80 pages and in many
languages. Some are published every two weeks, others only quarterly.
Bulletins differ in two important ways from other methods of providing drug
information. First, they are not and cannot be comprehensive, so they are quite unlike
formularies, compendia or databases. Second, most drug information which people in
hospital or in information centres provide is in response to questions. For example: how
should drug X be given for disease Y in a child? Can drug A cause side-effect B, and if so
how frequently, in what circumstances, and what should one do when it occurs? Drug
bulletins on the other hand choose the questions that they deal with, and that includes
some that doctors ask and others that no-one has yet asked, but which are important.
To choose the questions that are important to a large number of health workers needs an
understanding of their problems, their existing practice and their knowledge of the
relevant scientific data. Investigation of existing methods of practice and health
workers' knowledge of a subject is apt to be considered intrusive, especially if attempted
It needs the combined skills of practising doctors, clinical pharmacologists and
pharmacists to formulate and answer all these questions. None of these groups can do it
alone. For some issues the pharmacist is the most important, for others a clinician, for
yet others the clinical pharmacologist. For example the oncologist's contribution will be
the most important in assembling the information that doctors need to treat a cancer
Importance of teamwork...
There is another aspect to drug bulletins: the way the information is presented once
you have decided what is relevant. Not only must answers be made attractive, interesting
and clear, but the reader must also be persuaded early on that the questions are
Drug bulletins differ from other periodicals in that they look at therapeutic problems
and drugs from the prescriber's point of view. That means they are concerned with
comparative effectiveness, hazards, therapeutic strategies and how to optimise treatment.
They also have to assess the quality and strength of the evidence - is it solid, or thin
and speculative? If there is doubt, they should say what questions need to be answered.
For most readers this is merely a signal to keep an open mind on an issue, but perhaps a
few will try to find answers themselves.
Drug bulletins also differ from medical, pharmaceutical and review journals in the way
the articles are produced. This is usually by teamwork. Someone who knows about the
subject writes the first draft, which is criticised by other experienced people and
revised in the light of their comments. This is one reason why articles in some bulletins
are unsigned. The editors and referees must ensure that the articles are balanced and
reasonably complete and that important points get more attention and space than less
In a general medical journal, like the British Medical Journal or Lancet,
the editor's job is to ensure that everything is clear and correct, but the author has the
final responsibility for the article. These journals have a correspondence column where
readers can express disagreement with what an author has written. With drug bulletins it
is the other way round. The discussions, disagreements and sometimes fights go on before
publication, and the published version embodies the results.
A sense of perspective...
A third difference between drug bulletins and other journals is their crucial need for
independence. There are several powerful parties who want to provide drug information, to
reach the prescribers, the decision makers. First of all, industry has to sell its
medicines, and it is by far the biggest provider of information about medicines in the
world to prescribers and pharmacists. Second, licensing authorities, which are responsible
to society for regulating the medicines market and must represent the interests of the
consumer, the industry and the professions, have to be impartial, like judges. When such
an authority has decided to license a drug it does not expect anyone to question the
decision. Third, health services and social insurance systems carry enormous financial
burdens. No country has enough funds for health services. The cost of medicines can be
identified much more easily than most other components of the health budget, and the
message that providers want in bulletins is how to be economical, how to save money.
Fourth, influential doctors can, by strongly expressed opinions, persuade their students
and colleagues to use treatments even when the evidence of their value is weak. Bulletins
have the task of putting such messages into perspective and giving weight to the evidence.
Finally, professional associations of doctors or of pharmacists tend to be conservative.
I have listed all these groups to show how desirable it is to be independent of them in
terms of organization and funding, although this may not always be possible for financial
or other reasons. However, it is essential that bulletins have guaranteed professional
independence of expression. Of course writers and editors do depend professionally and
scientifically on the information produced from these sources. That leads to another
point: pluralism. None of us can find the truth on our own. We need discussions,
arguments, disagreements, to find out how close we have got to the truth. Two or three
bulletins discussing the same subject may well differ on some points; that is normal and
healthy and should lead to progress.
To sum up, the role of drug bulletins is to bridge the gap between science and practice
- for all forms of treatment, but especially for drug treatments.
* Dr Andrew Herxheimer is consultant to the Cochrane Centre, Oxford, UK and former
editor of the Drug and Therapeutics Bulletin, UK.