Raising the standard of surgical reporting to increase its impact

The surgeons patiently practised a laborious and unnecessary ritual for the sake of the better results.”1 The quote is not about the surgical safety check routine but about the introduction of Listerism by Thomas Roddick to the Montreal General Hospital. The observation was made by William Osler in a report published in the Canadian Medical Association Journal (CMAJ) regarding the 1912 funeral of Joseph Lister in Westminster Abbey. Osler concluded that as “with everything that is worth preserving in this life there has been evolution, but from the great underlying principle on which Lister acted there has been no departure.” CMAJ had been founded a year before through the amalgamation of the Montreal Medical Journal and the Maritime Medical News, both of which had been established in 1888. Canada had a robust medical publishing industry with multiple journals competing for a relatively small audience. As a young graduate Osler contributed articles and editorials to Canadian journals. He continued his contributions throughout his career in the United States and England. His article on Lister was 1 of 16 that Osler published in the early years of CMAJ under the banner “Men and Books.” Just as the New England Journal of Medicine started life as the New England Journal of Medicine and Surgery, the early Canadian journals addressed both sides of the medical house. Medical publishing was initially dominated by surgery until overtaken by medical articles in the 20th century. In 1957, the Canadian Journal of Surgery (CJS) was founded to redress the imbalance. Just as Osler helped CMAJ establish roots, leaders of Canadian surgery published frequently in the CJS. In contrast, I was told recently that the young presenter of a very modest project declined the opportunity to publish in CJS because it would be considered the death knell of his research. The comment must be analyzed, not dismissed. The impulse that established the CJS was essentially protectionist. Medical articles were preferentially published in generalist journals because they were of higher quality. CJS was to be a safe place to publish surgical articles especially from Canada. For a while, we tried to rationalize that surgery required a different reporting format than medical science. The impact factor (IF) for CJS diminished to a nadir of 0.5; only 1 of every 2 articles published in the preceding 2 years received a single citation. From the beginning, CJS has been a professionally produced, perfectly copyedited journal. It has observed improvements in style as they were developed, such as standardized formats for references and standard units of measurement. The journal introduced authorship regulation and participated in programs to eliminate bias and fraud. Low-impact articles, such as case reports or historical essays, were refused. The number of citations generated by CJS articles has quadrupled over the last decade but the journal’s IF remains resolutely in the second tier of surgical journals at 1.5. While subspecialty surgical journals tend to have a higher IF than generalist journals, the current score does not reflect the quality of Canadian surgery. In recent years the journal has concentrated on its Canadian impact rather than its IF. The founding collaboration between the Chairs of Surgery, the Royal College of Physicians and Surgeons of Canada and the Canadian Medical Association has been revived. Subscription has been supplemented by an institutional academic program generously supported by the founders and specialty societies led by the Canadian Association of General Surgeons. This has allowed the circulation to grow so that every surgeon in Canada receives the journal. Articles are publicized widely via social media and are available by immediate open access via direct links on scientific registries, such as PubMed, and popular search engines, such as Google. Important developments in Canadian surgery, such as the impact of resident work hour restrictions2 or the future of generalist general surgery in Canada,3 are highlighted. A process to develop and report consensus has been developed by the journal.4 To answer the challenge made by our young colleague, the only factor limiting the impact of articles published in CJS is the content of each report. The next phase of development will be to raise the standards for reporting surgical research. Reports will only have an impact if they are transparent, accurate and convincing. CJS will promote compliance with the reporting guidelines of the EQUATOR network (www.equator-network.org), an international initiative that seeks to improve the reliability of health research reporting.