In February 2014, after appearing in print for 40 years, this journal became strictly an online publication. We knew that having a complete issue in hand was preferable to, and more appealing than, reading the material piecemeal online. Nevertheless, financial constraints left us no choice. The change caused me to reflect on what it takes to be successful in the highly competitive field of medical publications. As a widely published author and, at times, an active editorial board member of several nationally prominent medical journals, I feel qualified to comment with authority on this matter.

Crucial Components

Financial Security

As with any business enterprise, medical journals need sufficient funding to function effectively. Until a financial situation forced us to discontinue print copies, I never fully realized or appreciated how expensive it can be to publish a large number of printed issues. Although we were regularly producing and mailing 50,000 copies per issue, we had only 1,000 paying subscribers and essentially no advertisers. By canceling our 6 printed issues per year, we have saved over half a million dollars annually. And, thanks to the online network, we have greatly expanded our worldwide audience. Other major medical journals—some with much larger mailing lists and weekly or biweekly publication—undoubtedly have enormous production costs as well. To some extent, their expenses might be defrayed by having many more paying subscribers and advertisers than we do.

In addition to direct publication costs, there are in-house expenses. These include salaried staff members, consultants' fees, legal charges, equipment updates, utility bills, office space, and office supplies.

An Ample, Competent, and Experienced Editorial Staff

Heading this vital group is the Editor-in-Chief. This person should be decisive and a firm-but-fair leader who knows the rules of the game, who is always accessible to his or her team, who demands the best from them, and who treats everyone involved with respect. And because this person is ultimately responsible for the finished product, his or her job is to ensure that the articles published are timely, accurate, easy to read, and free of grammatical mistakes and typographical errors.

Unfortunately, no editorial process is flawless. Even the best-known and most highly regarded medical journals occasionally publish articles that harbor bad writing or bad editing. I have studied “dizzy medical writing and editing” for the past 33 years and have written extensively on that subject.1–12  Although the causes are many, several warrant emphasis. With many notable exceptions, physicians are bad writers. Most spend no time writing manuscripts, and few ever learn how it should be done. Consequently, even if they do read their page proofs (which many obviously don't), they can't catch their own mistakes, much less those of the editorial staff.

A colleague and I explored this matter by sending detailed questionnaires to the editorial staffs of 70 prominent American medical journals.6  Thirty-two of the staffs responded. Most blamed their mistakes on lack of time and personnel to do the best job possible. Our survey also found that many journals hire inexperienced manuscript editors and fail to give them the time and intensive on-the-job training that they need and often want.

At the Texas Heart Institute Journal, we try hard to present manuscripts that are well-written, easy to read, and error-free. To do that, we make certain that each accepted manuscript undergoes 3 separate readings (with corrections) by 3 different senior manuscript editors. If the article contains figures, a graphics expert approves them for accuracy and clarity. Then, when this in-house process is complete, we send the final version to the corresponding author for approval. This routine is tedious, time-consuming, and often difficult. Yet it benefits our authors and readers and maintains our commitment to clarity and accuracy.

Reliable Manuscript Reviewers

A few manuscripts are accepted by the Editor-in-Chief upon receipt and review. Others, such as letters and solicited articles, undergo quick evaluation in-house. And a sizable percentage—half or more—of the unsolicited manuscripts are rejected without further review.

The remaining manuscripts—those deemed to have possible merit—are sent to at least 2 outside experts for detailed evaluation. This review process is critically important both to the authors and to the journal because, if done correctly, it yields specific recommendations for improving or reasons for rejecting the article. Not infrequently, manuscripts receive mixed reviews. In such cases, the Editor-in-Chief renders the final decision.

Basic to all such reviews is the need for fairness and objectivity. To help achieve this goal, some journals attempt blind reviews, wherein elements that might identify the authors or their institutions are removed from the manuscript to diminish or eliminate bias.

The Quality of Submissions

It is human nature to want one's work published in a prestigious journal. Consequently, the top-rated journals are deluged with submissions—some terrible, most ordinary, and a few really admirable. The sheer volume of submissions, however, increases the relative number of high-quality manuscripts, and that pool appears never to run dry. No wonder the top journals can reject up to 90% of their submissions.

Responsive Readers

Most first-rate medical journals have a section for letters or correspondence wherein responsive readers can voice their opinions about the journal itself, about a recently published article in that journal, or about their own observations (research-related or otherwise). Moreover, as mentioned earlier, letters to the editor are accepted or rejected in-house and can appear in print within weeks of their submission.

Perhaps the best-known and most widely read letters appear weekly in the New England Journal of Medicine. They typically offer lively discussions regarding the pros and cons of studies recently published in that journal. Occasionally, the letters present brief case reports, new physical findings, preliminary research results, or important drug reactions and other patient-safety concerns. In reference to the letters in that journal, the late Franz J. Ingelfinger, its venerated editor in the 1970s, wrote the following to me*: “. . . I am convinced that the Letters to the Editor section is one of the most thoroughly read parts of the New England Journal of Medicine.” His statement is as true today as it was 43 years ago.

Conclusion

We are proud to report that, in 2016, readers visited PubMed Central (PMC) 1.75 million times for articles in the Texas Heart Institute Journal.** Whether you are a reader, an author, or a researcher, you can be part of our success. So pick up your pen—or crank up your computer—and start writing. We look forward to hearing from you.

*Personal correspondence, F.J. Ingelfinger to H.L. Fred, 1 March 1974.

**Texas Heart Institute Journal statistics, from PubMed Central, 4 January 2017.

References

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Addendum

Dr. Fred recently received the prestigious John P. McGovern Compleat Physician Award for 2017. Established in 1993, this award is presented annually by the Houston Academy of Medicine and Harris County Medical Society to one physician in the United States whose career has been founded on the Oslerian ideals of medical excellence, humane and ethical patient care, writing, research, and harmony between the academician and medical practitioner. The award brings with it national recognition, an honorarium, and a beautiful plaque featuring a specially cast medallion. Dr. Fred joins a distinguished group of previous winners from across the country, all of whom have made extraordinary contributions to medicine and humanity.

One other point. Dr. Fred's academic career of 66 years ended on 31 December 2016. Nevertheless, his service to the Texas Heart Institute Journal will continue unabated.

Author notes

Dr. Fred is an Associate Editor of the Texas Heart Institute Journal.

Reprints will not be available from the author.