Ruminations on a (newly indexed) journal

Editorials / Commentaries

CJEM 2007;9(1):5-8

The National Library of Medicine (NLM), part of the National Institutes of Health in Bethesda, Maryland, is the world's largest medical library. In 1879, NLM began publishing Index Medicus, a unified international database of biomedical literature. Index Medicus has since evolved into MEDLINE, an online electronic database searchable by using PubMed; it remains the world's most important index for biomedical literature. In October of 2006, NLM approved the Canadian Journal of Emergency Medicine's application for MEDLINE/PubMed indexing, catapulting CJEM into the ranks of top-tier journals like the New England Journal of Medicine, Lancet and the Nippon Dental Review. Indexing in MEDLINE/PubMed is a huge step forward for CJEM and it will have a significant impact on our journal's future.

The origins of CJEM

Two decades after Emergency Medicine (EM) became a recognized Canadian specialty, Canada still lacked an emergency medicine journal; the Canadian Association of Emergency Physicians' official journal was the San Diego-based Journal of Emergency Medicine. In October, 1998, the CAEP Board voted unanimously to upgrade its newsletter, CAEP Communiqué, into a full-fledged scientific journal. The Board's first step, selection of an editor-in-chief, was a thoughtful and protracted process that required a national search to find an emergency physician foolish enough to accept the position. Fortunately they found one.

After accepting my new role as the editor of this prestigious international scientific journal, I quickly determined that I was only 3 months from the first issue deadline and facing a number of important challenges — most notably that CJEM had no staff, no office, no infrastructure, no one who knew anything about journal publishing, and no articles to publish. Facing these challenges head on, I attacked the most important problem first — determining the right colour for the cover. I chose teal green — favoured by journal colour consultants for its embodiment of right-brain sensitivity, environmental awareness, business-like weight, and scientific credibility (coincidentally, also the colour of the Seattle Seahawks' football helmets). My second critical action was to conscript my wife, Heidi, as CJEM managing editor, a task she joyfully added to her day job as a teacher, and to secure CJEM head office space (we found a perfect spot between our furnace and storage room). My third critical task was to assemble an editorial board made up of the top clinical and academic minds in the country.*

Launching a new journal

Realizing that the first issue would be much stronger if it contained actual articles, I sent out mass emailings to potential authors, announcing that CJEM was open for business. I begged everyone I knew to write something for the new journal. Fortunately, several of them came through, and the April 1999 debut issue included 2 editorials,1,2 one randomized controlled trial,3 6 invited commentaries,4-9 2 EBM reviews,10,11 2 International EM articles,12,13 a review of Canadian EM training,14 a chest pain evaluation strategy,15 a pediatric case report,16 a Diagnostic Challenge,17 2 book reviews,18,19 and 2 Humour and Humanity articles — the latter representing the low point (or perhaps high point, depending on your perspective) in our journal's history.20,21 Twelve of the 21 first-issue articles were authored by former or current editorial board members.

But even before the first issue went to press, an unforseen problem loomed. Our lawyers advised us that, for reasons involving potential copyright infringement, we could not use the name "Canadian Journal of Emergency Medicine." Some of our more discerning readers may remember that, because of this, our first issue was titled CJEM: Canadian Journal of Emergency Medical Care. Subsequent issues were simply titled CJEM, with fine print under the cover photo clarifying that CJEM was the "Journal of the Canadian Association of Emergency Physicians." For 18 months we cowered in fear but, at our second annual meeting, the editorial board concurred that: a) the legal advice was absurd and, b) there would be little point in suing a journal that has no actual money or cash flow. In January of 2001 the Canadian Journal of Emergency Medicine emerged from the closet.

Early on, the CJEM board agreed on several guiding objectives: to publish high quality scientific and educational articles; to promote the development of academic EM in Canada; to increase the visibility of Canadian emergency medicine; and to produce a credible, peer-reviewed internationally respected EM journal that people actually read (the latter, we felt, would distinguish us from other medical journals). We realized that, to achieve these goals, CJEM would have to attract and publish high quality articles — a requirement that pitted us against a medical journal's version of Catch-22: that authors are unlikely to submit high quality work to a journal that is not indexed in MEDLINE, and that it is impossible to get indexed in MEDLINE without high quality content. With this in mind, MEDLINE indexing became a primary objective, essential to assure the future growth, impact and credibility of CJEM.

Building market share

We agreed upon several strategies to attract readers and authors.

• To maximize national and international visibility, we send CJEM hard copies not only to subscribers and CAEP members, but to all Canadian hospital and medical school libraries, all Canadian and US Emergency Medicine residency programs, and to a handful of international EM opinion leaders.
• To maximize reader interest, CJEM adopted a less formal tone incorporating measured doses of humour. This was short-lived however, and in 2001, the editorial board, using valid scientific methodology, determined that in the stuffy world of medical publishing, humour (particularly my humour) posed a significant threat to indexing — perhaps even to international security.
• Recognizing that emergency physicians appreciate clear succinct writing (and have the attention span of an armadillo) we edit manuscripts aggressively to maximize clarity, brevity and readability.
• To increase international exposure for CJEM authors and manuscripts, and to enhance the likelihood of attracting top-tier articles and authors, the board endorsed a free online access policy, and we remain the only EM journal to offer full text online access without user charges.

Our growing international submission rate suggests that these strategies have paid dividends. Currently, 20% of CJEM authors and 18% of subscribers come from outside Canada. In 2005, the CJEM Web site received 16.6 million hits (an average of 1.4 million per month), with 57% coming from outside Canada: one-third from the United States, 12% from Europe, 9% from Australasia, 2% from Central and South America, 2% from the Middle East and 1% from Africa. Internet search engines such as Google Scholar have clearly reduced the importance of indexing, but MEDLINE/PubMed is still the most important medical database; hence NLM indexing remained a primary goal for the journal.

In preparation for our first indexing application in 2003, we conducted a national readership poll and were pleased to find that the journals read by the largest proportion of physicians practising in Canadian emergency departments were the Canadian Journal of Emergency Medicine (96.6%), the Canadian Medical Association Journal (83.6%), and Canadian Family Physician (58.6%). Figure 1shows that US EM journals are less widely read in Canada and that other recognized top-tier journals such as the New England Journal (34.7%) and Journal of the American Medical Association (17.5%) had relatively poor penetration among emergency physicians. Regrettably, the NLM did not weigh our readership poll heavily in their 2003 decision. They suggested we should enhance our research and educational content, and invited us to apply again in the future.

Success and change

In a 2006 survey, CAEP members identified CJEM as the #1 benefit of membership, suggesting the journal remains relevant to its primary audience. Over the last 5 years, submissions to the journal have increased in quantity and quality. Of the over 200 submissions per year, 92% are unsolicited and these manuscripts face a 60% rejection rate — an unavoidable consequence of growing popularity. CJEM has increased from 4 to 6 issues per year, and our editorial board has expanded. During our first 8 years of operation, 48 emergency physicians have served as associate editors, an academic opportunity and experience that, in many cases, they would not otherwise have had. A core of them have been with us from the beginning; others have come and gone, but all have made important contributions. Hundreds of others across the country have served as peer reviewers and authors. It is safe to say that CJEM has played an important role in the evolution of academic emergency medicine in Canada, and in building academic capacity within our specialty. Having accomplished so much, it is hard to believe now that CJEM head office was once a 60-sq-ft room in my basement (in 2006, we expanded into a new luxurious 90-sq-ft converted bedroom on the main floor).

Editorial workload has grown with the journal, and in recent years, Jim Ducharme and Riyad Abu-Laban have shouldered an increasing amount of senior editor work,^† making the editor-in-chief job almost doable. In 2005, after 6 years of managing the journal, Heidi turned over her responsibilities to Penny Gray-Allan, who has continued her excellent work.

The future

NLM indexing will bring greater visibility, greater credibility and higher submission volumes. This means increased editorial workload, higher rejection rates and, perhaps higher page counts, if justified by manuscript quality. All of these will drive costs upward. In an era of falling journal revenues, CJEM, like all other journals, will have to review its editorial, publishing and business processes, striving for greater efficiency without compromising quality and integrity. Publishing costs, editorial independence, editor remuneration, organizational support levels, advertising and revenue generation, electronic submission systems, and the balance between hard copy and electronic publication will be critical issues for future editors and editorial boards.

After successful indexing, the time is right for me to hand the journal over to someone with fresh vision and energy, and I have advised the CAEP and CJEM Boards of my intention to step down as editor-in-chief in mid-2007. In doing so, I must thank the CAEP Board for the opportunity to help create something important, and to all of the volunteer editors, peer reviewers and authors who made it possible and made me look good. I'll end this with the autotext footer that now graces all of our email communications:

Canadian Journal of Emergency Medicine
NOW INDEXED WITH THE NATIONAL LIBRARY OF MEDICINE AND PUBMED

References

1. Innes G. Ruminations on a new journal [editorial]. Can J Emerg Med 1999;1(1):14.
2. Dickinson G. A new EM journal? [editorial]. Can J Emerg Med 1999; 1(1):17.
3. Innes GD, Macphail I, Dillon EC, et al. Dexamethasone prevents relapse after emergency department treatment of acute migraine headache: a randomized clinical trial. Can J Emerg Med 1999; 1(1):26-33.
4. Shuster M. Who should write admission orders? [editorial]. Can J Emerg Med 1999;1(1):21
5. Allen T. Commentary: Chest pain evaluation in the emergency department [editorial]. Can J Emerg Med 1999;1(1):62
6. Christenson J. Acute coronary syndromes: We must improve diagnostic efficiency in the emergency department [editorial]. Can J Emerg Med 1999;1(1):22-5.
7. Murray M. Another milestone. Can J Emerg Med 1999;1(1):11.
8. Rhine D, Bullard M. Our evidence-based future. Can J Emerg Med 1999;1(1):41.
9. Frank J. A voice for future EM physicians. Can J Emerg Med 1999; 1(1):47.
10. Edmonds M. Are inhaled corticosteroids useful in the emergency department treatment of acute asthma? Can J Emerg Med 1999; 1(1):38-9.
11. Rabin E, Bullard M. Chest pain observation units for patients with unstable angina. Can J Emerg Med 1999;1(1):39-41.
12. Dickinson G. African drumbeats: a first conference on emergency medicine. Can J Emerg Med 1999;1(1):44-6.
13. Cheng I. Career planning . . . International EM? Can J Emerg Med 1999;1(1):48-50.
14. Moore K, Lucky CA. Emergency medicine training in Canada. Can J Emerg Med 1999;1(1):51-3.
15. Mutrie D. A new chest pain strategy in Thunder Bay. Can J Emerg Med 1999;1(1):57-61.
16. Sellens C, Morrison L. Accidental injection of epinephrine by a child: a unique approach to treatment. Can J Emerg Med 1999; 1 (1): 34-6.
17. Hollohan K. Chest pain? Again? Can J Emerg Med 1999; 1(1): 63; 71.
18. Worster A. Randomized controlled trials [book review]. Can J Emerg Med 1999;1(1):72-3.
19. Berringer R. Spine trauma [book review]. Can J Emerg Med 1999; 1 (1): 72.
20. Moser M. Taking time to talk to the roses. Can J Emerg Med 1999; 1(1):66.
21. Huber A. The CJEM quiz: What kind of emergency physician are you? Can J Emerg Med 1999;1(1):64-5.