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What’s the future of medical journals?

10 Jul, 16 | by scarley

The future of medical publishing

I had the pleasure of joining a panel discussion at the recent SMACC conference on the future of medical journals. I was delighted to share the stage with some real big hitters such as Richard Smith (ex editor of the BMJ) and Jeff Drazen (current editor in chief of the NEJM), together with some amazing researchers such as Sara Bassin Flavia Machado, Kathy Rowan, John Myburgh, Simon Finfer and Kath Maitland.

As with all panel discussions there was a degree of entertainment generated by our host Simon Finfer, but this is a significant matter. Journals and the publishing process have a huge role and influence on the conduct, funding and dissemination of science. The panel was assembled with deliberately discordant views to challenge the status quo and to look to what may be a fabulous, or perhaps a more dystopian future.

Richard Smith is a vociferous proponent of a post journal world and you can read his thoughts here. It’s really worth a read as a challenge to how we deliver knowledge from primary research out to those that actually need it and then out to practice, and more importantly to those that will benefit from it i.e. our patients.


I found myself at one end of the on stage sofas with Rob MacSweeney who many of you will know from the Critical Care Reviews website, and with whom I share many views. I think we played our role as challengers to the status quo pretty well. Rob in particular is a fantastic exponent of getting research to the bedside in an ethical and fair way. If you’re not following his blog, and getting his newsletter at critical care reviews then follow the link and think about joining in.

There was too much on the day to summarise here, but I’d ask you to have a think about some of the ideas raised on the day. Right or wrong the panel were challenged on the following.

  1. Publishing in high impact journals is a key to academic promotion. Should it be?
  2. Universities are using a proxy measure (impact factors) to determine promotions. That’s outsourcing a really important measure to a system that has huge flaws.
  3. Similarly, funding organisations measure success in terms of publications in high impact journals. Journals thus have a huge influence on research funding priorities and success. Is this right?
  4. Peer review has been repeatedly shown to have huge flaws, fails to detect fraud, fails to detect poor quality and is prone to interpersonal bias and politics. Can we find a better way?
  5. Social media has the potential to produce post publication review, but is it any good, and can we collate it?
  6. Should we have open publishing, followed by widespread open peer review and then publication, and would this be better at detecting fraud, bias and error?
  7. Some journals make their papers open access after a period of time (e.g NEJM) and this is a good thing, but it would be better if it was sooner. Should all funding agencies demand open access (as many now do)?
  8. The relationship between researchers seeking publication, impact factors, promotion and future funding is complex and arguably at risk of a ‘mutualism’ relationship that does not directly benefit patients. How do we break that relationship (and do we need to)?
  9. Many journals believe that they are providing a service by filtering the poor quality out and only presenting research that is worthy of attention. The question was raised as to whether we need ‘other people’ to do this for us. Do we really need journal editors to be our filters and guides or can we do it for ourselves?
  10. Patients enter trials on the understanding that they will benefit healthcare in the future. Is it therefore unethical that that information is behind a paywall and not widely distributed?

We covered many more topics and I’d recommend a listen when it is eventually released from the SMACC website. For me, straddling the traditional world of journals as an EMJ editor, and also as proponent the new world of #FOAMed it was fascinating. I think it’s increasingly difficult to see how journals can survive in their current format with the rise of easy e-publishing and the ability to engage with a much broader audience across the internet. However, thinking that journals will remain as they are and not adapt to a changing world would be similarly naive. Journals will have to adapt and change and I’m sure they will.

My thoughts are that the role of journals as sole publishers of original research will diminsh, taken over by an open publication, hive-mind reviewed, open multi peer review process (I can dream). This will not mean that journals will die. Arguably there will be an increasing need for the  collation and interpretation of science, and arguably this will be a more effective and useful service for readers. The signs of such a change are already here. For example the BMJ has changed format over the years and now serves original research in a more summary style within the paper version. The detail is available, but not in the paper copy. It seems that accessibility, engagement and interpretation are increasingly valued, and that’s no bad thing. Here at the EMJ the primary survey and the podcasts serve a similar purpose and they are popular.

What then is the future of medical publishing? I’m not sure but I’m fairly confident that the status quo will not continue. What do you think?



EMJ Editor and Editor at St.Emlyn’s virtual hospital, blog and podcast.

PS. The debate was fuelled by some rather fabulous on stage drinks. The 25 year old Bushmills as recommended by Rob was truly stunning.

Primary survey Highlights from the January 2015 issue. Mary Dawood, Editor

16 Jan, 15 | by scarley


A mask tells us more than a face (Editor’s choice)
As ED clinicians we often pride ourselves on recognising the sickest patients by how they look, this skill is tacit and one that is the result of experience and longevity in emergency care. Our psychiatric colleagues have long accumulated significant research into disturbances in affect recognition in patients with mental illness, so I was intrigued to read in this issue a study by Kline and colleagues from the US which explored the variability of facial expression in patients with serious cardio pulmonary disease in emergency care settings. They found that patients with serious cardio pulmonary disease lacked facial expression variability and surprise affect. They suggest that stimulus evoked facial expressions in ED patients with cardiopulmonary symptoms may be a useful component of gestalt pre-test probability assessment. So, there may be some substance in one of the many satirical remarks made by Oscar Wilde that “A mask tells us more than a face” though I doubt his context was clinical.

It’s not the age that matters
Accurately measuring weight in children presenting to the ED is essential and particularly crucial in resuscitation situations where interventions and drug dosages are calculated by weight. The APLS formula, 2× (age+4) has been widely used in western ED’s, but as obesity in our young people is becoming more common and children are taller than previous generations , this formula may fall short in terms of accuracy and patient safety. An alternative formula (3×age)+7 by Luscombe and Owens (LO) has been suggested as more accurate than the APLS formula. Skrobo and Kelleher in Cork University Hospital Ireland undertook a retrospective study of 3155 children aged 1–15 years comparing both formulas to identify which one best approximates weight in Irish children presenting to the ED. They conclude that the LO is a safe and more accurate age based estimation over a large age range. Maybe it’s time to review our practice but do read this paper and weigh up your own thoughts, no pun intended!

Not all suffering is pain
Pain is the commonest reason patients attend the ED. Our sometimes lack of appreciation and subsequent under-treatment of pain is often a source of distress and dissatisfaction which can result in uncharacteristic behaviour. However not all suffering is pain and we may find ourselves wanting when the cause of distress is emotional rather than physical. This issue features a prospective cohort study by Body and colleagues in Oxford which sought to describe the burden of suffering in the ED. Of the 125 patients included in the study many reported emotional distress particularly anxiety as well as physical symptoms. Indeed only 37 patients reported that pain was causing their suffering. It should not come as any surprise that being seen, information, reassurance, explanation, care by friendly staff and closure were the key themes reported as relieving suffering. This approach just represents best practice but in the mounting pressures of ED’s worldwide it is all too easy to lose sight of the person and their need for compassion and understanding. Dismissing emotional suffering as perhaps someone else’s problem is detrimental to our patients and ultimately ourselves. Do read this paper; it is a timely and salutary reminder of what we should be about, why we do the job we do and what patients expect of us. There is also a podcast with the Editor in Chief and the author. Find this online alongside this issue.

Best evidence or clinical acumen (Readers’choice)
As demands for emergency care and acuity of patients presenting continues to rise globally, ED clinicians are increasingly faced with making decisions to discharge patients from high acuity areas of the ED. Patient safety and well being should govern any decision to discharge a patient but many cases are complex and weigh heavily on clinicians making such decisions. Calder and colleagues in Canada conducted a real time survey of experienced ED physicians to determine how they perceive their discharge decisions and the impact on adverse events. The authors concluded that ED physicians in their study most often relied on clinical acumen rather than evidence based guidelines and that neither approach was associated with adverse events. They recommend further research which focuses on decision support solutions and feedback interventions.

The greater good
Pulmonary embolism (PE) is a leading cause of death in pregnancy and the post partum period and a devastating event for mother and baby. When accurately diagnosed and treated the risk of an adverse outcome is low. In this paper Goodacre and colleagues explore the options for imaging and discuss the evidence for using clinical features and biomarkers for the selection of women for imaging. Their review of the literature suggests that the harm of investigation with diagnostic imaging may outweigh the benefits but that clinical predictors could be used to identify women at higher risk who could be appropriate for imaging. They also state the need for further research around clinical predictors and particularly the use of D-dimer at a pregnancy—specific threshold.

Pearls of wisdom
There is little doubt that the emergency department is a quite unique environment that offers abundant opportunities for learning. Seizing and exploiting these opportunities is not always as straightforward as we would like it to be. The constant pressure to manage multiple patients and make decisions to refer, admit or discharge against the backdrop of a ticking clock often mitigates against the teachable moment however genuine our desire or commitment to teaching is. It’s easy to feel impatient and exasperated by the seemingly slow pace of some learners when you are trying to maintain safety in a crowded department. On the plus side, however, learning in such an environment can instill a sense of urgency, something that cannot be learnt from a textbook. Nonetheless teaching and learning is integral to all our roles and so it was refreshing to read in this issue “Top 10 ideas to improve bedside teaching in a busy emergency department” by Green & Chen from California. We have probably all used some or all of these methods to teach in different circumstances but the authors imaginative use of a framework, of ‘mnemonics’ and easy to remember names such as “Aunt Minnie” and “Snapps” is amusing and lighthearted. In reading this paper, you may just find that pearl of wisdom for the next teachable moment.


Mary Dawood

How Are We Accelerating Knowledge Translation?

21 Apr, 14 | by rradecki

In contemporary medicine, the first exposure to new evidence comes first in abstracts and conference presentations, filters through peer-review into journal publication, and, finally, into textbooks. Then, the process of translating knowledge into practice change takes place, slowly percolating into the current physician base through guidelines and expert recommendation, followed by trainees indoctrinated into the latest evidence during graduate medical education. Efforts to speed this process have improved markedly in the decades since the advent of the internet, but remains an ongoing challenge.

However, the rise over the past few years of prominent FOAM resources is leading to a revolution in this process, resulting in sea change to traditional means of dissemination and scholarship. A fantastic recent example can be found in a recent post on Academic Life in Emergency Medicine. As part of a recurring Global Journal Club series, the moderator Brent Thoma compiled a list of prior FOAM discussion of a recent publication regarding therapeutic hypothermia.

Within a handful of days of publication, no fewer than 18 experts in emergency medicine and resuscitation had provided commentary, whether through blog posts or podcasts. A sampling:

All this expert commentary is disseminated freely through the internet – and these experts are universally available through their blogs for further critique, discussion, and debate.

This is accelerated knowledge translation. No more waiting for professional societies and committees to process & regurgitate – nor must authors’ conclusions be taken at face value. Any healthcare worker willing to put the effort into keeping up to date has any number of excellent resources from which to draw. All of this expert commentary is, however, essentially, opinion. The peer-review and vetting process is crowdsourced and not evenly applied to all content – and may be non-existent. The reliability of each contributor is left to the individual read to discern, with few resources available to validate.

Regardless, it’s a leap forward in how practice change is influenced – and one we can all participate in, globally.

Tweeting Locally, Reaching Globally

3 Feb, 14 | by rradecki

The necessity of providing emergency care is not restricted to the world’s wealthiest countries. The lucky few living in settings with access to 24/7 emergency care, staffed by physicians educated in rigorous, structured settings, benefit from the resources disproportionately available. These clinicians have the support of their hospital physician education programs, may be funded for access to costly Continuing Medical Education, and belong to professional societies that provide further educational content. These issues are further exacerbated when publishers like Elsevier draw revenues of £2.1 billion and aggressively defend their profits with copyright crackdown lawsuits – further stifling the dissemination of medical knowledge.

How can the developing world – arguably in even greater need of support – bootstrap itself up without these resources?

That answer may present itself in a movement over the last few years to generate free, openly-accessible content. Entitled FOAM – Free Open Access Meducation – “Medical education for anyone, anywhere, anytime”, this movement spans the clinical spectrum. Frequently published by internationally-renowned expert, subjects range from core emergency medicine to advanced critical care, with all manner of knowledge translation in between.

A sampling of highlights:

  • The WikEM, a growing resource of practical point-of-care clinical knowledge.
  • EMCrit, critical care content and podcasts “bringing upstairs care downstairs”.
  • The Poison Review, critical appraisals on medical toxicology.
  • Life In the Fast Lane, aggregated Emergency Medicine education, upside-down.

Even commercial sites, such as eMedicine have valuable core content available in many specialties. However, care must be taken to evaluate each article for sources of bias, considering the revenue they derive from pharmaceutical sponsorship.

Unfortunately, much of this content is English language-only; Google Translate and other similar technologies ameliorate this barrier, but it remains an imperfect solution. Regardless, physicians in developing nations have access to an ever-increasing wealth of of experts – with nothing more than an internet connection.

Discover more through the most active social media platform, Twitter, using the #FOAMed hashtag.

Ryan Radecki


Associate Social Media Editor EMJ


All change at the EMJ….

23 Dec, 13 | by scarley

Ellen Weber

Ellen Weber

The New Year brings many changes to the EMJ. Not only do we have a new cover, we have a new editorial team too. For the last 7 years Geoff Hughes and Kevin Mackway-Jones have developed the EMJ into a scientific journal with real impact across the emergency medicine and pre-hospital care communities. They have done an amazing job for the EMJ and its readers and although they have handed over the reigns of the journal they will still be around to manage the ever popular commentaries and BestBets sections.

So, who’s in charge now and where do we go from here? If you have access and want to hear the full story then head over to the EMJ Editorial for a full introduction by clicking here.

Ellen Weber takes over as the Editor. This will be the first time that the EMJ is solely edited by a non-UK physician reflecting the international reach and aspirations for the journal. Ellen is an emergency medicine professor at the university of California, San Fransisco and has a broad research and editorial background with interests in overcrowding, triage and our beloved 4-hour target. Ellen’s thoughts and aspirations can be read in this month’s journal with a theme running through to make the journal something for readers to value, enjoy and use. This may take some time to mould and Ellen aspires to experiment in order to get this right. Quite what those experiments will be I’m not sure, but further forays into the world of social media are certainly on the agenda.

Two deputy editors continue from the old regime with Steve Goodacre (Sheffield, UK) taking on responsibilities for acute medicine and Ian Maconochie (London, UK) overseeing paediatric emergency medicine.

The associate editor team has an international flavour with Terri Reynolds tackling global health (from Tanzania and the USA) and Paul Middleton covering prehospital care and resuscitation (from Sydney, Australia). Back in the UK, Mary Dawood (Emergency Nursing ) and myself (social media) complete the team.

So, it’s not just the cover that’s changed. The new look for the journal also means a new outlook for readers and authors alike. As always, we want to know what you think so keep in touch via the blog or by using our twitter feed and let us know what you think – as Ellen tells us….’The journal should be for the reader…….’.


Simon Carley

Associate Editor EMJ

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