Epilepsia and the rough seas of medical publishing


In this, our last editorial as Editors-in-Chief of Epilepsia, we would like to offer some thoughts about the task of navigating the journal through the sometimes turbulent seas of academic medical publishing. We have served as Editors-in-Chief for almost 8 years, and have greatly enjoyed being at the Journal's helm. During this time, we have come to appreciate many of the complexities of the academic medical journal publishing world, and in this our swan song, we have taken the liberty to muse upon issues that have occupied us in our task.

Academic publishing is going through a time of unprecedented change. As the research enterprise becomes more complex, and as electronic innovations alter the way in which information is communicated, complications—and opportunities—arise for authors, editors, publishers, and owners of journals. At the heart of these changes is the challenge of the rapidly increasing scope of online facilities made possible by the worldwide web. For a journal to thrive in this changing seascape, it must be flexible and responsive to change. To ignore these developments will imperil any academic medical journal. We focus here on a few of these new developments that must be addressed by the International League Against Epilepsy (ILAE), and by the publishers of Epilepsia, and its next editors-in-chief.

Editorial Independence

A critical issue in today's publishing environment is the need to retain editorial freedom from the interests of advertisers, the publisher, and journal owner. This issue is not new, but it has become more complex as the academic journal publishing enterprise has grown more complex. In the rarified atmosphere of academic medicine, one might imagine that this bedrock of publication practice is not a problem, but sadly this is not the case. There are increasing pressures, and journal editors need to hold the line—in sometimes difficult circumstances—against lobbying groups, political influences, and peer pressure. As emphasized by the Committee on Publication Ethics (COPE), editorial independence is the overriding principle to be preserved; notwithstanding the economic and political realities of their journals, editorial decisions should be made on academic grounds and quality and suitability to the readership and not be determined by financial, political, or personal considerations. Epilepsia has adhered strongly to this principle.

Serving Our Readership

In the best of worlds, a journal could be all things to all people. For some of the larger, general topic journals, this goal might be realistic. For a subspecialty journal such as Epilepsia, however, serving our readership is a tricky business. Epilepsia is primarily a research journal, and we have striven to publish the best work in the epilepsy research field. But this effort is not straightforward. For example, the majority of our readers are clinicians who are not active researchers, but who simply want to keep current with major research advances, and thus focus on clinical reports. However, we have felt it important to include top-quality basic bench research in the Journal, since this research is likely to provide the basis for eventual improvement in clinical treatment. In addition, we have found it difficult to decide the degree to which we should include case reports or clinical observations; although these papers are generally not of hypothesis-driven research, they can assist clinical practice. The trick to producing a journal with an appreciative readership is to find a balance among all of the facets that make up our field.

A related thorny issue is determining the scope of the Journal. For instance, like many high-profile academic journals, Epilepsia is “international”; not only is it owned by an international society, but it also draws manuscripts from an international group of authors and appeals to readers from around the globe. To what extent, then, should our journal (or any journal) seek to be internationally representative? Especially given that Epilepsia is the journal of the International League Against Epilepsy (ILAE), we recognized the need to encourage the activities of emerging research programs by offering a publication outlet. However, the current reality is that the research enterprise is just developing in some regions, and the general quality of work is not as high as in, say, the United States or Western Europe. For Epilepsia, as for any top-tier academic journal, scientific excellence has remained the overriding criterion for publication.

Online versus Print

The future of print edition is another pressing issue for medical journals. It is clear from numerous surveys and publishing statistics that journal articles are increasingly accessed not on the printed page but via electronic download. Furthermore, library shelves worldwide are buckling under the weight of only occasionally read journal back issues. From almost every point of view, it would seem that journal print issues will inevitably disappear, with publication moving to an exclusively online edition. Newspapers are doing it—and so are increasing numbers of academic journals. There are, to be sure, downsides associated with this change. People tend to browse printed journals and therefore see many articles of interest; in contrast, the online search focuses on individual articles, ignoring the remaining (and potentially relevant and rewarding) content of a journal issue. Published material such as editorials (like this one) and news items, and journal sections such as Gray Matters in Epilepsia, would probably not be read widely. For some, there is also the convenience and enjoyment of picking up the latest print issue, to peruse on the bus or train on the way to work or while drifting off to sleep in bed at night. Of concern, too, is that in the future, with the evolution of online technology, our current online systems may not be supported (remember documents written only 10 years ago by word-processing programs that are now redundant and impossible to read), thus making previous online articles inaccessible. For book lovers like us, the end of the print edition would be a matter of considerable regret, and this attachment to print is not just sentimental. It is important to remember that a printed journal is more than simply its content—it has historical, cultural, and esthetic significance. We sincerely hope that even as the regular print edition disappears, a small print run is maintained, for reference libraries kept for “heritage” purposes.

The Process of Editing

To edit a journal successfully, the steps and procedures have to be well organized. In the last 10 years, this process has come to be carried out almost entirely online, and these electronic systems are remarkably efficient. The submitted manuscript is now uploaded with various metadata used as tags and for indexing. Preliminary decisions (direct reject or not), instructions to Associate Editors, the identification of and communications with referees, reading and assessing peer reviews, and decision making and correspondence with authors are all tasks performed exclusively online. Journal statistics, searches, and reports can be generated “automatically” in electronic format. When an accepted manuscript is finally passed to the publisher, here too the process tends to be primarily electronic. This electronic processing has without doubt prevented mistakes (e.g., the bane of previous editors' lives—the forgotten manuscript mislaid under a pile of papers). The electronic nature of editing goes someway to mitigating the effects of the rapid increase in manuscript volume, but the amount of work required continues to grow. It is sometimes with heavy heart that the computer is powered up early on a Sunday morning to see what new tasks are requested by the online manuscript handling systems. Furthermore, the automation cannot obscure the essentially personal nature of publishing. Authors invest an enormous amount of work, time, and effort—as well as considerable emotional value—in their manuscripts. Rejecting articles (and/or requiring major revisions) and resisting lobbying pressures carry the risk of alienating colleagues and sometimes friends. Communication with authors (and publishers and owners) has to be personal and sensitive.

The Motivation to Publish

As we have gained more experience in editing Epilepsia, we have become more convinced that the motivation for publication in medical journals has changed dramatically over the past few decades, and certainly within the scope of our professional lives. It would be nice, but naive, to think that the main function of medical publishing is to advance knowledge in some significant way (which is what the lay public largely believes). It is our strong impression that much of what is published in the ever-expanding medical literature is of little intrinsic or enduring value in this sense. Increasingly, authors publish with the primary goal of enhancing their CVs or chances of promotion. The publication itself, and not the advance in knowledge, has become the primary goal; the disease of “publish or perish” has certainly reached epidemic proportions. A recent analysis of 300 papers published in epilepsy journals found that 71% of papers were of “no enduring value” and only 4% were of “high enduring value” in terms of their contribution to the topic (Gregoris & Shorvon, 2013). One might have hoped that there would be other methods of assessing an individual's academic quality and potential beyond simply counting the number of articles he/she has published.

Perhaps even more critically, this drive to publish also encourages fraud and exaggeration, and journal editors have to be increasingly watchful to avoid these practices. There is a strong tendency for authors to publish the same data multiple times, and to make overinflated claims for their work. Many published studies turn out to be simply wrong (and/or cannot be replicated); how much of this error is due to ineptitude and how much to deliberate manipulation of data is unknown, but the latter certainly occurs. The ethical issues in publishing are of increasing concern, leading to the development of editorial software to check manuscripts for plagiarism. Another excellent service is provided to journal editors by COPE; a perusal of the “cases” on the COPE website provides an insight into the dense ethical web within which journal editors may find themselves entangled (http://www.publicationethics.org). One reaction by journals to these problems of publication ethics has been to produce extensive “conflict of interest declarations,” but the declarations (e.g., “having a practice in which I see patients with epilepsy”) can be simply conceit and miss the point completely. Such statements are not going to deter or reveal the most serious aspects of unethical practice.

The Impact of the Impact Factor

A remarkable feature of the current publishing landscape is the growth in the number of online-only journals. This growth is totally uncontrolled and we are in danger of being swamped by poorly produced, badly reviewed articles of low quality. This situation has arisen, at least in part, because of the easy profit made by a publisher who does not care about quality and whose costs associated with online-only publication are small. It is partly in response to this danger, that citation metrics, such as the “Impact Factor,” have assumed such great importance. A journal's Impact Factor now serves as a surrogate measure of worth or quality. Unfortunately, as a quality mark, these metrics are unreliable. Some types of research and some areas of research are inherently much more likely to be cited than others, and these features may have nothing to do with research quality. Some types of articles may be widely read (or downloaded), but not cited. In the past, an author would submit his/her manuscript to a journal most suited to the topic or nature of the paper, to be read by the most appropriate target readership. But now, increasingly, Impact Factor has become the first priority. The resultant skewing of research output is regrettable, often giving rise to a situation in which choosing a journal which caters for the appropriate audience for a particular research report becomes an irrelevant consideration. Furthermore, to improve their Impact Factor rating, journals and publishers (and editors) have found ways to manipulate article type, reference lists, timing of article publication, and type of publication. This manipulation is, from the scientific and academic point of view, disappointing—but is now a fact of everyday life.

Open Access, Journal Finances, and the Role of the Publisher

Finally, an issue of growing significance is that of “Open Access”—the idea that papers published in a journal should be available to any reader, anywhere he/she has access to the internet, without cost or subscription. Open Access is a complex issue, and presents significant problems for journal owners and publishers. The arguments in favor of Open Access are based on the simple and indisputable fact that publically funded research should be freely available to the public. And indeed, funding agencies such as the National Institutes of Health (NIH) in the United States, and the Wellcome Trust and Research Councils in the United Kingdom have mandated that research published with their support should be freely accessible to anyone—although these agencies had allowed journals/publishers to restrict access to subscribers for a limited period (currently 1 year by NIH). The fact that the Wellcome Trust and Research Councils in the United Kingdom have recently mandated that free access be available immediately upon publication has moved the discussion to a new level. Open Access policies are being considered and adopted by an increasing number of universities/institutions, directing their faculty to publish their work in Open Access format wherever possible.

The issue of Open Access has been aggravated by growing awareness that academic publishers make very large profits from their journals. For example, between 1998 and 2003 the average price of an academic journal in Britain rose by 58%, and Elsevier (the largest of these publishers) reported a 37% profit in 2011 (Economist, 2004, 2012) based on what many view as excessive subscription costs. These charges, in turn, have compromised the ability of research libraries/institutions to pay for the publications that their faculty need for their research. Given that the journal articles are provided by their authors to journals/publishers without charge, and that the work of peer review and academic editing of these journal articles are also generally unremunerated (as is the case for Epilepsia), it is not surprising that there should be a significant push back against the idea of excessive publisher profits.

There is certainly an argument to be made by the publisher in this discussion. If a publisher provides a well-formatted and well-produced journal as a vehicle for the authors' work, that effort clearly incurs a significant cost, as does marketing and distribution. Some publishers are now also producing enhanced articles (with links, videos, commentaries) and improved websites with all sorts of attractions. These welcome value-added features have been offered as editors look for enhancements to their journals and readers demand more information. Whether these new features warrant the high financial charges claimed by the publisher is arguable. Many journals—including subscription journals—now offer Open Access publication to authors who are willing/able to pay a fee for the Open Access option; indeed, this option is currently available in Epilepsia. And there has been a proliferation of Open Access journals in which publication is financed by author fees; in this model, the author pays for publication rather than the reader/subscriber. To encourage this author-pay Open Access model, some funding agencies and institutions provide authors with support for publication. But for those authors who do not have access to such support—and particularly for authors from poor countries with just-emerging research enterprises—this author-pay requirement imposes a considerable barrier to publication.

Given these financial considerations, some have questioned whether publishers are necessary at all. Some authors and institutions have begun to take advantage of the possibility of making their manuscripts freely available without journal publication; toward that end, there has been a proliferation of “repositories” of articles on institutional and personal websites. While inexpensive, this approach draws number of criticisms and questions: absence and/or quality of peer review, the lack of professional editing and page typesetting, and the significant difficulty of “distribution” (i.e., how to get people to find and look at your manuscript). And some societies have opted for self-publication. A key issue in such considerations is the need to have the journal's articles indexed on the large databases such as Medline or PubMed, but these have their own sometimes-opaque rules of inclusion, which in turn encourage further gamesmanship.

The Open Access issues are essentially economic. For a journal such as Epilepsia, owned by an association (in the case of Epilepsia, by the International League Against Epilepsy) that employs a publisher, there are also major economic implications for the society. For example, the ILAE earns annually over a million dollars from the publication of Epilepsia—a sum that does not include the profits taken by our publisher, Wiley-Blackwell. What will happen to these profits if/when Open Access models are adopted is not yet clear.

In Conclusion

The battle lines are not yet fully defined, and the shape of future medical publishing is uncertain—but the future landscape is likely to differ markedly from today's environment. Major change, although often difficult, brings opportunity. If guided wisely, ILAE and Epilepsia have the potential to thrive in this changing environment. Adventurous policies are needed in order for Epilepsia to move forward “in front of the curve”; this is no place for the faint-of-heart.

The above paragraphs illustrate some the complexities and difficulties of academic medical publishing. But we would be remiss to give the impression that there is only doom and gloom out there. All in all, we have found our tenure as journal editors to be challenging, yet hugely rewarding. Although there is a great deal of relentless and routine process work involved in keeping a journal afloat, there is also much that is interesting and important. Editorship carries a responsibility to the subject area, to the contributing authors, and to the publishers and owners of the journal. It is an interesting intellectual task that requires insight and judgment and a broad overview of the field. Finally, editorship requires a balance to be maintained between keeping the journal focused on its true course in the rough waters of modern medical publishing and being submerged in so much detail that the direction of travel becomes obscure. It is vital to keep a hand on the rudder when the tidal wave of manuscripts, lobbying, and interference threatens to swamp the ship. Whether we have achieved this goal as editors of Epilepsia is for others to decide, but we have greatly enjoyed the ride. We extend to the new editors of Epilepsia our very best wishes in their journey, and Godspeed.

Disclosure of Conflict of Interests

PAS has no conflicts of interest to disclose. SDS has received travel grants, speaker honoraria, advisory board honoraria, and/or research grants from Eisai, SAGE, UCB, GSK, Bial, Viropharma, and Sun pharmaceuticals.

We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.