A. Herxheimer*

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 by "outsiders".

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 patient.

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 important.

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 important details.

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.