On the Occasion of the 20th Anniversary of the Founding of Academic Emergency Medicine
- The authors have no relevant financial information or potential conflicts of interest to disclose.
Culture & Knowledge Transfer In Medical Journals
January 1994 saw the launch of Academic Emergency Medicine (AEM) as the official journal of the Society for Academic Emergency Medicine (SAEM). Prior to that time, SAEM shared the Journal of the American College of Emergency Physicians (JACEP), which evolved into the Annals of Emergency Medicine (Annals). Although I assisted with the birth of AEM, the substance of this journal has largely been the work of those editors who have followed my efforts: Michelle Biros and David Cone.
We should briefly return to the birth of AEM and its associated labor pains. In 1990, while serving as SAEM president, like prior SAEM leaders, I helped renegotiate the affiliation agreement for SAEM's cosponsorship of Annals. It was clear to the SAEM board of directors that a culture clash existed at the time between the American College of Emergency Physicians (ACEP) and SAEM related to their cosponsored journal. Behind the culture clash of the practice arm of the specialty with the academic arm of the specialty was the reality that the major source of publishable material for Annals was the SAEM annual meeting, yet SAEM had little say in the content of the journal, its operations, or its finances. The Annals abrupt (albeit brief) change to a micro font size that challenged even those who had yet to require bifocals, and its increased emphasis on industry advertisements (and their placement within the journal content), both occurred without prior consultation with SAEM leadership. These actions reinforced to the SAEM leadership that it was time for change. Although Annals did not reflect the academic culture of SAEM, Annals and ACEP were increasingly benefitting from SAEM's increasingly popular annual meeting. Indeed, ACEP was demanding greater enforcement of Annals “right of first refusal” for manuscripts from work presented at the SAEM annual meeting.
An SAEM journal task force subsequently determined that independent publication of an SAEM journal that would reflect the organization's unique culture and academic values, highlight SAEM activities, and essentially help brand SAEM within the house of emergency medicine was quite doable. The SAEM board decided in 1992 to move forward with the formation of its own journal at the expiration of its Annals cosponsorship affiliation agreement. Interestingly, SAEM negotiations on a potentially lucrative contract with a major publisher were abruptly terminated when it was determined that ACEP had signed with that same publisher to assume future publication of Annals, and the publisher no longer desired affiliation with SAEM. Fortunately, there were other suitors for SAEM (some large publishers and some small publishers), and an agreement was made with Hanley & Belfus, a publisher composed of former editors from WB Saunders. In retrospect, the personal attention of these journal publishers was quite valuable to the birth of AEM, although SAEM would later revisit the journal publisher contract with Hanley & Belfus.
Although the transition from cosponsorship of Annals to sole sponsorship of AEM was challenging for SAEM, it was clearly necessary for SAEM to distinguish itself as the academic arm of the specialty of emergency medicine. Ironically, the accommodations and endorsement of academic freedom that SAEM embraced benefited both Annals and AEM. Historically, Annals had insisted upon the “right of first refusal” for all materials presented at the SAEM annual meeting. The SAEM leadership believed that presentation at its annual meeting should not be tied to a particular journal and that all journals should benefit from SAEM's scientific and educational forum. Although removing the restriction on journal publication site related to the annual meeting was the right action for SAEM to take, this action put the launch of AEM under greater pressure, as AEM would need to compete for the material presented at the SAEM annual meeting.
The approach used by AEM to compete for these annual meeting manuscripts was to emphasize the academic culture of mentorship. Authors were encouraged to work with the reviewers and editorial board members in a collaborative manner to help deliver their knowledge to the membership of SAEM and beyond. A new format for supportive peer review of manuscripts was undertaken, with a synthesized consensus review provided with every submission. This synthesized review guided the author should he or she choose to resubmit to AEM or elsewhere, rather than mirroring the often conflicting and overly critical reviews that were common with other journals at the time. Further, journal reviewers were given the synthesized review (a novel concept at the time) so that they could also benefit from their peers thoughts and the wisdom of the editorial board. Finally, AEM began to recognize its better reviewers—as based on quality with quantity of reviews—and this recognition was openly published and shared with the leadership of the reviewers respective institutions. Other journals have subsequently adopted these practices.
All new journals must prove their worth, and obtaining index status in Indicus Medicus such that articles will be electronically noted by the National Library of Medicine (NLM) is a major developmental milestone. Some predicted that it would take AEM a decade to be indexed in Indicus Medicus. Instead, this milestone occurred within 2 years of the launch of AEM—a near record achievement at the time. This achievement meant that the impact of AEM articles would reach throughout the NLM network. Further, this recognition was retrospective and went back to the original publication issue.
There were many reasons for the original and continuing success of AEM. Most importantly, AEM has always reflected the culture of SAEM. The journal worked hard to manage potential conflicts and avoid overcommercialization. The journal was launched with a stellar editorial board—at least five of the 14 original members have gone on to be honored as members of the Institute of Medicine of the National Academies of Sciences. Other editorial board members have served as SAEM presidents and in other major national or international offices. The first issue of AEM provided us the opportunity to showcase some journal innovations, including using a practical structured abstract format; highlighting study methods in a standard format; using a “further thoughts from the reviewers” section to capture valuable insights from the reviewers; using a separate “limitations” section to objectively note the limitations of our knowledge from the current study, given study realities; and using a “future questions” section to provide guidance to others seeking to extend the work of the authors.
The content of the first issue, whose table of contents is reproduced elsewhere in this issue, reflected the breadth of the SAEM annual meeting with both scientific and educational articles and publication of the invited Kennedy Lecture from the 1990 annual meeting. That commentary on health care rationing by noted ethicist Arthur Caplan was accompanied by a commentary from Oregon Governor John A. Kitzhaber on access to care, controlling costs, and the Oregon Health Plan. These articles are as relevant to today's debate on national health care as they were when first published. In the same issue were two articles demonstrating that early cardiac marker elevations were associated with ischemic complications in chest pain patients. Clearly, the findings from these studies helped launch a revolution in the evaluation of chest pain patients that continues today.
In reflecting upon my role in the development of the AEM editorial board, helping craft the journal's first policies and practices, and working with the entire membership of SAEM to bring about a journal that could bring pride to SAEM and reflect its values, this endeavor has been one of the most rewarding I have experienced in my short life. Yet, those authors who first submitted their knowledge to AEM and continue to reflect the academic and collaborative culture of SAEM deserve the most credit. Without their efforts, this journal that so aptly reflects SAEM's culture and essence would not have happened. It has been truly an honor to serve on the first leg of an editorial relay that will endure as long as SAEM endures.
Jerris R. Hedges, MD, MS, MMM
University of Hawaii–Manoa
The Second Phase
The tireless and dedicated efforts of the founding AEM editorial board created a strong foundation for SAEM's new journal. In 1998, I assumed the editorship of the journal. A healthy and energetic tone had been set through the leadership of Jerris Hedges and the support of the SAEM Board of Directors, and this continued in the next phase of the journal's development.
A number of key events shaped the second phase of the journal's growth. From 1998 to 2008, the publisher changed three times because of mergers, closures, and expansions within the medical publishing industry. While each change of publisher was a challenge, the long-term benefits were worth the aggravation. New publishers meant fresh ideas and a willingness to try new and better ways of creating the living document that we considered the journal to be. We acquired an electronic submission platform that eased the processing and tracking of an increasing number of manuscript submissions. We partnered with established distribution platforms such as the HINARI Programme, which allowed us to provide journal content to developing countries free of charge. We e-published abstracts from a variety of national and international scientific meetings that had no other means of disseminating their interesting content, and sometimes published the abstracts in their native languages. We developed a section called Dynamic Emergency Medicine that linked a static image and case presentation in the journal's print copy, to a dynamic image online, thus allowing for presentation of case studies in a unique way or procedural demonstrations relevant to daily emergency medicine practice.
The SAEM Board of Directors responded to the journal's growth trajectory by increasing support personnel, and Sandi Arjona and Kathleen Seal entered into their key supportive roles, where they both still remain. It is clear that without their enthusiastic support and loyalty, the journal would have foundered under the sheer burden of a rapidly and ever-increasing workload.
While it seemed intuitive that SAEM would always allow editorial decision-making to remain in the hands of the AEM editorial board, our editors witnessed events at other journals where political considerations of journal sponsors seemed to interfere with final journal content. With the encouragement of the SAEM Board of Directors, the AEM Editorial Independence Policy was developed, authored by Roger Lewis. The content of AEM has never been bound by any political constituents; the SAEM Board of Directors has wisely left the running of the journal to the capable hands of an outstanding editorial board. This has allowed for experimentation and innovation in journal content and management and has resulted in an outstanding final product.
During this phase, the journal took on a more visible role in the SAEM annual meeting and began to host a series of reviewer's workshops and didactic sessions on scientific writing, ethics, and research designs. The SAEM board and the program committee added the editor-in-chief as a designated moderator of the plenary session, along with the president.
Perhaps the most important event in the second phase of AEM was the development of the journal's annual consensus conferences. The concept (suggested by Jim Adams) was that our journal had a responsibility beyond the publication of original work; in addition, the journal should educate our readers about timely and controversial medical, social, and research issues in general, while stimulating thought and studying making these topics relevant to emergency medicine in particular. The consensus conference topics often (and serendipitously) paralleled topics currently under consideration by the Institute of Medicine, such as errors in medicine and disparities in care. The conferences have been organized by some of the most well-known thought leaders of our specialty, and the audiences often are the “who's who” of topic experts. A complete issue of the journal is dedicated each year to the proceedings of the annual consensus conference and related original work. Because of the timeliness of the yearly consensus conference topics, the conferences were able to self-fund within a few years of their initiation, with funding from U.S. and Canadian federal agencies and private foundations. Recent work by the current AEM editorial board has shown long-term and significant benefit of the AEM consensus conferences in terms of subsequent research efforts, publications, and funding. Again, a solid foundation had been set for the current phase of the journal's development.
Michelle H. Biros, MD, MS
Hennepin County Medical Center
The Current Era and The Next 20 Years
Twenty volumes ago, in 1994, the journal had a 14-member editorial board, six issues per year, and 592 pages of content. Currently, we have a 70-member editorial board, 12 issues per year, about 1,600 pages of print content, and several dozen more pages of electronic content each year. Why such a large editorial board? First, as noted by our founding editor above, a “consensus review” is created for each paper, rather than simply forwarding the raw reviewer comments to the author, as many journals do, leaving the author to sort out the often confusing or even conflicting reviewer comments. Our consensus reviews are more user-friendly. They allow authors to focus on the key issues and eliminate conflicting statements, but take substantially more time and effort on the part of the decision editor. Our large editorial board permits us to spread this workload around and also ensures that we have adequate breadth of expertise and a significant number of editors with “niche” expertise in specific topic areas or research methodologies. For example, every survey submission is screened by one of two editors with masters-level education in survey methodology, and only those papers meeting basic methodology standards are sent for peer review. Finally, the large number of decision editors helps us maintain our very rapid turnaround times, by ensuring that no editor is working on too many papers simultaneously.
Our diverse editorial board has also enabled us to add several unique sections to our journal in recent years, including our “Research Methods and Statistics” category, which provides detailed discussions of novel study methodologies and advanced statistical techniques that are likely not familiar to the typical reader; the “Biros Section on Research Ethics,” which celebrates the work of the previous editor-in-chief by providing a forum for work on the ethics of clinical research in emergency medicine; and our newest section, “Evidence-Based Diagnostics,” with articles that seek to answer diagnostic clinical questions on a single topic pertinent to most emergency physicians using a diagnostic systematic review. (An online tool is planned that will allow the reader to literally take the EBD to the patient's bedside to assist in real-time clinical decision-making.) Our new “Peer-Reviewed Lectures” (PeRLs) section is a joint effort of SAEM, the Council of Emergency Medicine Residency Directors (CORD), and ACEP, with an editorial subboard of education experts from all three organizations, offering clinician-educators an avenue to receive academic “credit” for high-quality lecture presentations. (We also have a number of peer reviewers from CORD who assist with the review of “Educational Advances” papers.) Finally, our editorial board is supplemented by a cadre of statistical reviewers (both quantitative and qualitative) who review all data-based submissions to help assure methodologic rigor.
I assumed the editorship of AEM in January 2009, fairly soon after we entered into a publishing contract with Wiley/Blackwell. Thanks to the efforts of Jerris Hedges in founding the journal and Michelle Biros in seeing it through adolescence into adulthood, I inherited a journal that was (and still is) running along quite nicely. With stable finances, a strong editorial board, and a supportive publisher, there were no major challenges or problems awaiting me, allowing me to focus on the growth missions that the SAEM board and the journal's editorial board had identified. Two of the most important of these areas of focus have been increasing the value of the journal to the international community (through Spanish abstracts and publishing the ICEM abstracts, for example) and advancing our electronic publication offerings. The medical publishing enterprise is changing rapidly, and as “early adopters,” we emergency physicians like to position ourselves on the leading edge of such change. We have already added several electronic publishing features to the journal, and more are planned in the next few years. Importantly, our publisher's “Article Anywhere” system is currently in beta-testing with a European chemistry journal, and we expect to be among the first of Wiley's medical journals to use this new platform, hopefully early in 2013. This format will provide a much more intuitive and usable electronic format for our papers—a vast improvement over simply reading the PDF on a mobile device. Our focus on global emergency medicine continues: we look to publish high-quality research papers from outside of North America, and our consensus conference this May in Atlanta will be entitled “Global Health and Emergency Care: A Research Agenda.”
The journal has come a long way since 1994—the year in which the father of a close medical school friend, who at the time was chair of gastroenterology at a large academic medical center in Washington, DC, opined over dinner one night that “academic emergency medicine” seemed an oxymoron. I was visiting his home while attending the 1994 SAEM annual meeting—still a resident and reluctant to challenge this very senior colleague. But even then, I knew that “academic” and “emergency medicine” go together well, and this journal is the proof. Our sponsoring society and our publisher are both vibrant, growing enterprises, and we will continue to work together to bring the best scientific content to our readers. Our superb editorial office staff of Sandi Arjona (Journal Manager) and Kathleen Seal (Peer Review Coordinator and Technical Editor) is available to assist editors, authors, reviewers, and readers at any time. But what can you do to help the journal advance SAEM's missions? First, you can send us your first paper and your best paper. We promise prompt turnaround, supportive reviews, and off-line assistance and mentoring, just as when the journal was founded. Second, you can help oversee and ensure the quality of the journal by serving as a volunteer peer reviewer. We are always in need of readers with at least one or two first-authored peer-reviewed papers under their belts to help us maintain the quality of the journal. Finally, you can strive to help advance all aspects of our specialty, in clinical practice, research, and teaching, so that even an old-school gastroenterologist won't think of Academic Emergency Medicine as an oxymoron.
David C. Cone, MD
Yale University School of Medicine