Responses to Our Readership Survey

In May of 2005, I received the results of an Academic Medicine readership survey, prepared by Dataview Research, Inc., on behalf of the journal and Lippincott Williams & Wilkins, our publishing house. In April, the AAMC had e-mailed 1,697 invitations to deans and others who received complimentary subscriptions to the journal, asking them to respond to the survey; simultaneously, Dataview Research, Inc., sent 440 e-mail invitations to all U.S. subscribers for whom we had e-mail addresses. Follow-up e-mails were sent a week later. The response rates were 19.6% for complimentary subscribers, 38.8% for paid subscribers, and 23.3% for the total sample. A poor showing, admittedly, by our research authors' standards, but good by the standards of the readership survey and marketing industry. From this sample came a lot of data—more than 100 pages worth! But I flipped first to the open-ended comments respondents were invited to make in response to two questions: “What do you like most about the journal?” and “What do you like least?” While the two questions raised a number of “you say toMAYto, I say toMAHto” issues (where the same number of folks dislike something as like something), many respondents raised stickier issues, particularly, of course, in response to “What do you like least?” What follows is my attempt to address two of these more important concerns. Academic Medicine is too North American. It is extremely U.S. based, and doesn't take a more global perspective. In 2005 we published articles and research reports from Brazil, New Zealand, the United Kingdom, Israel, and, of course, Canada. Admittedly, these papers were few and far between, especially when compared to the number published in other journals in our field. But as we say in the FAQ section of our Web site “In general…the subject [of manuscripts submitted by authors outside the United States] must be in some way relevant or generalizable to U.S. medical education.” As the “official scholarly journal of the Association of American Medical Colleges (AAMC),” we feel some duty to serve our member schools in North America first and foremost. Because our medical education and training system is not universal, manuscripts from countries outside North America are often not relevant to the U.S. system. However, particularly as the journal moves in its new direction and focuses more on the “big issues” in academic medicine, I believe there will actually be more opportunities for those outside this country to weigh in. For example, I attended the annual meeting of the Association for Medical Education in Europe this past September and talked with representatives from a number of countries who are facing some of the same tough issues that institutional and educational leaders in the United States are grappling with: workforce shortages, admission standards, immigration concerns, conflict of interest, dramatic curriculum reform measures, and other pressing matters. And, of course, what our editor Mike Whitcomb calls “foundational research”—on how learners process information, how groups function in varied settings, and so on, especially in a technological age—knows no boundaries and never has. For papers focused on foundational research, quality is the only deciding factor in what gets published and what doesn't. I will be frank: too often, international manuscripts we have rejected are the same type that we have rejected from inside the United States: those that have described a small intervention at one institution among a small group of students with the only outcome measure being the self-reported satisfaction of the students. Or, alternatively, manuscripts that are meaningful only in the context of a particular institution or a particular country. But let me extend an invitation to those outside our borders by asking a few questions: What are the most pressing issues facing your country's medical education system? How are you dealing with them? Do you think they might be relevant to some of the issues facing the U.S. medical education system? For example, have you had to increase class sizes to accommodate workforce shortage concerns? Are you working on accreditation standards, perhaps looking to the U.S. model for guidance (or away from the U.S. model)? Are you concerned about “brain drain”—perhaps to the U.S. medical system? Are you undergoing significant curriculum reform efforts because of changing “real world” practice patterns or community needs? These and many other topics might be of interest to the journal. The editor arbitrarily dismisses and fails to send to reviewers topics that should be of interest to the AAMC and its readers but are not of interest to the editor. When an article is submitted, it should be reviewed by legitimate reviewers, not just the editor, who is currently able to reject manuscripts without sending them to reviewers. There were a number of comments about the journal's review process, in particular about what was perceived as arbitrary or narrow-minded decision making on the part of the editor about which manuscripts should be sent out for full peer review and which should not, with some clearly feeling that all manuscripts received by the journal should undergo peer review. As someone who has worked at the journal under two editors, learned from the work of many other editors via editors' listservs, professional groups, and conferences, and who has submitted work to journals herself (albeit in a very different field), I feel competent to address this in a fairly broad way. Let me give it a go. For better or worse, our review system is the same as that of other scholarly journals, from the largest and most prestigious to the smallest. I don't know of any scholarly journal that doesn't reject a significant number of manuscripts during a “prescreening” stage—that is, where the editor, either alone or in concert with some sort of internal review board, screens all manuscripts and decides which merit outside peer review and which don't. The more competitive the journal, the more manuscripts are likely to be rejected at this first stage. In relatively small fields like ours, we share a limited pool of volunteer reviewers with a number of other journals, and if we know up front that a manuscript is not one we want to publish, we simply don't want to take up reviewers' time with it. I am aware of how harsh this must sound; however, Academic Medicine, like most journals, has seen increases each year in the number of manuscripts it receives. We are now up to around 800 submissions a year in all categories, with the majority (about 740) being either Research Reports or Articles. Although we have over time increased the number of pages and manuscripts we publish each year, we still cannot review or respond personally to all of the manuscripts submitted. We do not have to worry about page limits; however, we do have to worry about how much work our staff can handle each month, and this means we can only publish about 13 to 15 manuscripts per issue, or 156 to 180 per year at the most. This means an absolute maximum of 25% of those 800 manuscripts can be accepted per year (a number that can be further diminished by the addition of articles for theme or other special issues). The editor typically rejects 60% after the first read-through, generally because the manuscripts' topics are not of great enough importance to make them candidates for that 25% that are eventually published. The reviewers (generally two per manuscript), the editor, and the editorial staff weigh in on the remaining 40%. Our general criteria? Will this manuscript be of interest to a large portion of the audience we are trying to reach? Does it make a significant contribution to the literature on the topic? And, of course, is the quality high—of the research, of the thinking, of the author's understanding of the topic at hand? It is in answering this last question that reviewers provide the most help, and their contributions are invaluable. In conclusion, we strive to do what we've striven to do since I came to the journal in 1989—and what I imagine my predecessors were aiming for, too: to bring the best articles to our readers on topics of critical importance to their work, articles that will help them do their work better and better achieve the missions of their institutions. We use a peer review system that (akin to the democratic system of government) is the worst system of judging the value of articles and research—except for all other systems that we know. We sometimes make mistakes and pass up articles we wish we hadn't and publish articles we wish we had passed up. If I'm sounding a little folksy here it's only to counter the sense I sometimes get that editors and their staffs are seen as being somehow against authors, conspiring to make their lives difficult. While we certainly endeavor to keep editorial standards high, we also know that authors are our bread and butter, and we enjoy working on manuscripts with them. Without the generosity of authors' submissions to our journal, there wouldn't be an Academic Medicine. Authors, peer reviewers, and the editorial staff work as partners to help create this journal. To work collegially, we have to communicate openly. That's one reason that everyone's responses to the readership survey were so valuable to me, and I thank all who participated. Lisa R. Dittrich, MFA

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