Another pass of the torch

Peter Paré, Editor-in Chief

Katherine Thain, Editorial Assistant

It is with some trepidation and much humility that I take on the role of Editor-in-Chief (EiC) of the Canadian Respiratory Journal (CRJ). I have been passed the baton by a couple of Canadian legends in respiratory medicine: Dr Nicholas Anthonisen, the immediate past EiC and, before him, Dr Norman Jones, the inaugural EiC. A tough duo to follow!

Norman Jones was EiC between 1994, when the Journal was born, until Volume 8, issue 6 in 2001. He edited 47 issues of the CRJ and, in 2000, began a tradition I will not attempt to emulate – contributing an editorial to each issue. Nick Anthonisen has been the EiC since 2001, and has supervised the publication of 70 issues of the Journal contributing an editorial to almost every issue – a total of 61 editorials. The subject matter of these editorials was amazingly diverse and, among others, included the following: Canadian normal lung function values, transplant bronchiolitis obliterans, First Nations pneumonia admissions, the use of inhaled steroids in chronic obstructive pulmonary disease (COPD), management and outcome of malignant mesothelioma in Anatolia, Turkey, and the value of case reports in the medical literature.

That Nick was able to provide erudite, informed and entertaining commentary on such a wide range of subjects is a testament to his stature as a renaissance man in respiratory medicine. Nick has had a long and distinguished career in Canada after coming from Dartmouth College (USA) to join the Division of Respiratory Medicine at McGill University (Montreal, Quebec) in 1964. He was an active clinician investigator and my Respiratory Training Program Director at McGill in 1974, and subsequently took on the role of Respiratory Division head and, later, Dean at the University of Manitoba (Winnipeg, Manitoba), where he remains an active Emeritus faculty member and clinician. He has made major contributions to our understanding of the pathogenesis and management of lung diseases, particularly COPD, through his leadership in four of the most definitive and influential respiratory clinical trials ever conducted (1–4).

Under the leadership of Drs Jones and Anthonisen, the CRJ has grown in stature and has become an important means of communication and education for the medical community in Canada and internationally. How does one judge the stature of a medical journal? One metric is the impact factor (IF). The IF is a measure of how frequently original articles appearing in a journal are cited in the medical literature. The IF is derived by dividing the number of times articles published over the preceding two years are cited in the current year. For example, if a journal has an IF of 2 for the year 2010, it means that the articles published in that journal during 2008 and 2009 received an average of two citations in 2010; it could be that all of the citations were for only a few of the articles, so it is a measure of the journal’s impact, not the impact of individual articles or their authors. The CRJ’s present impact factor is 1.347 because in 2010 there were 101 citations of the 75 articles published in 2008 and 2009 (ie, 101/75=1.347). This is an increase from 1.0 in 2009. The CRJ ranks 36th among the 46 respiratory specialty journals listed on the ISI Web of Knowledge; the highest ranked are The American Journal of Respiratory and Critical Care Medicine (the ‘Blue Journal’) at 10.191, Thorax at 6.525, Chest at 6.519 and the European Resipratory Journal at 5.922.

The IF is easily measured, but has limited validity (5,6). Problems include marked variation according to discipline, ‘self citation’ – in which authors cite their own publications inordinately often – and gaming by journals to reduce the number of ‘citable’ articles that go into the denominator of the IF (for example, editorials are not considered ‘citable’, but review articles are and these can substantially inflate the IF).

A metric that would really measure the impact of a journal would be the product of how many people involved in patient care read the journal multiplied by the positive effect that the reading had on the care of the patients they serve. No such metric exists, but we do know the number of people who get the print copy of the CRJ. It is distributed to 13,000 health care providers in Canada. These include the 615 Canadian Thoracic Society (CTS) members (as a benefit of membership), an additional 370 practitioners who have respiratory expertise/interest, 700 with an interest in otolaryngology, 300 with an interest in Allergy, 650 with an interest in infectious disease, 500 emergency room physicians, 200 geriatricians and 9000 family practitioners who have, based on their prescriptions, an interest in respiratory disorders. The other way to access the CRJ is online. Up to May 2011, there were 14,173 page views, 4677 visits, 2413 unique visitors and an average length of visit of 3 min 42 s.

There is not, as far as I know, any metric to assess how the receipt and reading of a journal influences clinical practice. The CRJ has published an increasing number of clinical practice guidelines (CPGs) and one might expect that these publications reaching a large number of practitioners could have a substantial impact on clinical practice and patient care. However, despite the substantial resources that have been spent developing CPGs, there is a paucity of data measuring the impact of CPGs on the process of practice and on patient outcomes. A systematic review performed in Holland in 2009 (7) showed that 17 of 19 studies that assessed the effects of guidelines on the process or structure of care showed significant improvements, while six of nine studies in which measures of patient health outcomes were assessed showed significant but small improvements. If CPGs are to have an impact on changing behaviour, more effective implementation will be needed; a group from the College of Respiratory Therapists of Ontario have recommended guidelines for successful implementation (8).

Additional measures of a journal’s ‘performance’ include the time from submission to review, from submission to acceptance and from acceptance to publication. Norman Jones reviewed these data for the final two years of his tenure based on 161 submissions. The mean time from submission to review was 4.4±2.5 weeks, between submission and acceptance was 16±9 weeks and from submission to publication was 30±12 weeks. The difference between the latter two intervals – 14 weeks – is the delay from acceptance to publication (3.5 months). The rejection rate was 18%, and 26% of submissions were case reports.

Nick Anthonisen reviewed his first 18 months as EiC in June 2003. Over that time period, he received 84 original articles including case reports (56 per year). Of these, 66 were from Canada, with 18 (21%) from outside of Canada. The rejection rate was 25% and Nick lamented the delay of six months from acceptance to publication for an article.

Nick reviewed performance again in 2005. During 2004/2005, 70 manuscripts were submitted, 26 of which were of non-Canadian origin (37%) and 33% were rejected. The time from submission to review and decision remained remarkably short, but the average time from acceptance to publication had increased to six months. Unfortunately, this metric of performance has not improved. For 2010, the average time from acceptance to publication was seven to 10 months – this is too long.

When I started as EiC on May 1, 2011, the CRJ converted to a fully online submission process. As I write this (July 9, 2011), we have received 37 submissions (a rate of 190 per year). Of these, 75.7% are of non-Canadian origin and 14 are case reports (37.8%). It is too early to predict the rejection rate but with six issues per year and an average of eight to 10 items per issue, the rejection rate will likely be approximately 75%, a big jump since the 18% rejection reported by Norman Jones in 2001!

This brief history illustrates the following trends: increasing submissions and increasing percentage of submissions from non-Canadian origins (both good!), an increasing percentage of case reports (good?) and a lengthening of time from acceptance to publication (bad!). How are we to shorten this interval? There are two ways: increase the number of published articles or reject more manuscripts. The number of pages of articles that appear in the hard copy version of the Journal is limited and is based on the advertising revenue generated by Pulsus. It is largely this revenue that supports the substantial infrastructure necessary to edit and publish the CRJ. The current limit is 56 pages per issue. Contributors can ‘buy’ extra pages, and this is what the CTS does to publish its guidelines and position papers. Thus, increasing the number of published papers to shorten the time between acceptance and publication is not simply a matter of putting out a few extra thick issues to clear the backlog unless additional funding sources can be found.

However, there is the option to increase the number of papers published ‘online only’. The CRJ began this with the May/June issue (Volume 16, number 3) in 2009 and the percentage of articles published in this way has increased. There were 105 pages of ‘online only’ material in the 2010 CRJ with no advertising. Health Canada does not allow online medical advertising because the site is accessible to the general public as well as to the medical community. Our practice is to offer ‘online only’ publication to authors with the ‘carrot’ being more rapid publication. Surprisingly, most want to wait and have their articles appear in print. I find this surprising because it seems to me that the way the world is going is toward almost exclusive online publishing. I have given up all of my hardcopy journals – except the CRJ, of course! I receive notification of the table of contents of the journals I subscribe to, and access to the abstracts and articles via the journal websites or through my University library, which subscribes to most of the journals I read. Although it might seem obvious that a move to online only for the whole journal is the way of the future, it leaves the question of how this would be funded. With no online advertising, the only option is to charge the subscribers and/or the authors. Open-access, online-only journals pass the costs of reviewing, editing and running the journal’s web site on to the authors. The obvious advantages are rapid turnaround time and universal access, but many people still want the hard copy of journals so that they can send them to their mothers or read them in bed!

Clearly, the future of medical publishing is in flux. Our plan to decrease the delay between acceptance and publication is to work with Pulsus and the CTS to encourage more advertising (and thus more pages per issue and/or more issues per year), to continue to offer faster publication online only and to be more stringent in the quality of the articles that we accept.

The CRJ is the official journal of the CTS, which appoints the editors and determines editorial policy. In April of this year, I developed a vision for how I would enhance the CRJ as EiC and presented it to the Editorial Board. My philosophy and goals are summarized below.

I believe that the CRJ is an important instrument of communication and education for the Canadian respiratory community. I believe that it should primarily be a clinical journal dedicated to research, guidelines and clinical issues concerning human pulmonary disease and lung health. To increase the readership and the impact of the journal, aims for my editorship include the following:

1. Implement the online submission and review process.

2. Appoint a new slate of associate editors who have specific expertise in focused clinical areas, and who take an active part in the selection of papers for the Journal and write editorials and review articles in their area of expertise.

3. Appoint an editorial assistant who will work with the EiC and associate editors to facilitate the running of the Journal.

4. Increase the breadth of the contributing and reading community by forming partnerships with specific groups:

   1. Critical care community
   2. Respiratory sleep community
   3. Pulmonary pediatric community
   4. Thoracic surgery community
   5. Respiratory rehabilitation and respiratory therapy communities

5. Implement a clinical-radiological-pathological conference report that would regularly be contributed to by specific groups across the country.

6. Publish high-quality reviews by prominent Canadian clinician scientists on specific important and timely clinical issues of diagnosis and treatment.

7. Develop a pulmonary fellows forum in which experienced clinicians dispense ‘pearls’ for trainees.

8. Increase the role of the Journal as a vehicle for the dissemination of practice guidelines developed by the CTS and other pertinent sub-specialty groups.

Some of these goals have been acted on already, and I take this opportunity to introduce our new editorial assistant Ms Katherine Thain. Katherine, who is working part time with me and the associate editors, is a PhD candidate at the University of British Columbia (Vancouver, British Columbia) and is interested in determining whether a career in medical publishing is part of her future. We have appointed a new group of Associate Editors with specific expertise, which include the following:

• Asthma: Louis-Philippe Boulet, Laval University, Quebec City, Quebec

• COPD: Denis E O’Donnell, Queen’s University, Kingston, Ontario

• Interstitial Lung Disease: Charlene Fell, University of Calgary, Calgary, Alberta

• COPD and Respiratory Muscles: Francois Maltais, Laval University

• Pulmonary Vascular Disease: Evangelos Michelakis, University of Alberta, Edmonton, Alberta

• Rehabilitation Medicine: Dina Brooks, University of Toronto, Toronto, Ontario

• Tuberculosis: Kevin Schwartzman, McGill University, Montreal, Quebec

• Cystic Fibrosis: Liz Tullis, University of Toronto

• Pediatric Pulmonary Disease: Felix Ratjen, University of Toronto

• Environmental and Occupational: Catherine Lemiere, University of Montreal, Montreal, Quebec

• Lung Cancer: Stephan Lam, University of British Columbia

• Pulmonary Imaging: Jonathon Lepisic, University of British Columbia

• Interventional Pulmonology and Procedures: Alain Tremblay, University of Calgary.

An additional new Associate Editor, Dr George Rakovich from the University of Montreal, is drafting guidelines for a regular clinical-imaging-pathological educational forum that he will be in charge of and we will invite all Pulmonary and Thoracic Surgery Programs to participate. We have asked the executives of the Canadian Sleep Society and the Canadian Critical Care Society to recommend Associate Editors for these disciplines, and we are exploring more formal relationships between these Societies and the CRJ.

I want to take this opportunity to thank the generosity of ‘retiring’ Associate Editors and Editorial Board members, many of whom have served the Journal since its inception 18 years ago. These include Board members Margaret Becklake, Raymond Bégin and Moira Yeung, as well as Associate Editors, Art Slutsky, Zoheir Bshouty, Donald Cockcroft, Yvon Cormier, Mark FitzGerald, Richard Hodder, Michael Kay, Kieran Killian, Malcolm King, Jean Luc-Malo, Rob McFadden and Bruce Rubin, some of whom are staying on as Editorial Board members.

Finally, I welcome new Editorial Board members, Avrum Spira from Boston University (Massachusetts, USA), a displaced Canadian who is rapidly becoming the world expert on the genomics of COPD and lung cancer, Benjamin Raby from Harvard University (Massachusetts, USA) who is also a Canadian and a rising star in the study of the genetics of respiratory disease, and Greg King from the University of Sydney (New South Wales, Australia) who is an honorary Canadian and an expert in lung physiology and imaging. Nick Anthonisen has also agreed to join the Editorial Board to provide wisdom and perspective.

I am excited about taking on this important position and working with Pulsus and such an outstanding group of scientists, clinicians and educators.