New Journals, New Societies, More Meetings—Do We Need Them All?Who Can Do It All?

Increased specialization, new technology, and fields of interest lead to an increase in journals, books, organizations, meetings, and courses. Are they all necessary? Do we need an American Board of Minimally Invasive Surgery? There is an International Society for Minimally Invasive Cardiac Surgery and their journal, Heart Surgery Forum. In 1999, Organ reviewed the problem of overlapping societies, memberships, and costs and called for a moratorium on further expansion and contracting.¹ Now the problem has intensified. Organ cited Billroth: "It is a most gratifying sign of the rapid progress of our time that our best textbooks become antiquated so quickly."¹(p1344) How many societies today would Billroth join, how many journals would he subscribe to, and how many textbooks would he buy?

Has a society or a journal ever announced that it has done its job and is packing it up? Why not? Many complex issues are involved—prestige, "honor" of membership, desire (honor) to be officers, and the pleasure of meetings. Of the 13 societies listed by Organ, at one time I belonged to 8. One of them kicked me out for not attending the annual meetings for 3 consecutive years. Surgeons in practice join regional societies—the New England Surgical Society to the Pacific Coast Surgical Society and the American College of Surgeons. Academicians join the American College of Surgeons, the Association of Academic Surgeons, the Society of University Surgeons, and finally, the American Surgical Association and subspecialty societies. The American Surgical Association was described by its president at its recent meeting as the oldest and most prestigious of surgical societies. Many societies serve exemplary educational needs. The American College of Surgeons' postgraduate courses are helpful and often filled to capacity. Specialty societies and their journals provide current information. The question is what is needed, worthwhile, and perhaps necessary, and isn't there too much?

For thoracic surgeons, the prestigious senior society is the American Association for Thoracic Surgery. When a society for all trained, certified, and reputable thoracic surgeons was needed, the American Association for Thoracic Surgery did not let everyone in; therefore, the Society for Thoracic Surgery was formed. Both have annual meetings and journals. The 50-year-old Southern Thoracic Surgical Association combines camaraderie, a social program, and academics. It meets in November at a pleasant watering hole in the South. What is a striving thoracic surgeon to do—probably belong to all of them, if invited, or could they merge? Some societies are old boys' and now old girls' clubs as well, such as the Halstead Society and the Society for Clinical Surgery. This is not a put-down. They are wonderful groups. Once, when I was on the Yale faculty, my residents introduced me as one of the better visiting professors of the year. Societies multiply to fill the need for those who support a cause or wish to be part of that world (Table 1).

Who can go to all of these meetings? How often can you go to a meeting in Cancun, Mexico (a favorite watering hole)? Many courses and meetings are held in attractive resort areas with programs for spouses. Academic physicians now have limited bud gets and cannot afford all the meetings, all the journals, and all the clubs. Physicians in private practice do not have the time. The number of regional, national, and international meetings and courses is overwhelming.

How does this begin? A local group with similar interests meets to talk about common pursuits. They suggest a regional or state get-together that decides to become a national get-together. It may begin with those working in a new field of medicine or science such as "The big-bang's effect on sexual function" or "Hubbell's Law of an expanding universe and global warming." Invasive cardiology, angioplasty, and stent therapy are examples of an exciting new specialty with its own organizations (the New England Society of Cardiovascular and Interventional Radiology) and journals. Colleagues from abroad and the pleasures of international travel suggest an international society and meeting. New developments, that is, interests, specialties, and technology, develop organizations and a journal. To an extent, this is healthy and necessary. Is there a limit? Teaching a course or sponsoring a program may also be a way of advertising by showing off the clinical stars of the sponsoring center. The unwritten, unspoken message is "refer your tough cases to us." It is also a way to establish a national or international reputation—if I invite you to be on my program in Brussels, Belgium, then you will invite me to be on yours in Trieste, Italy, or Munich, Germany, or Miami, Fla.

Over 100 years ago an article in JAMA titled "The Multiple Occasion of Books" stated, "The real literature is on the point of being buried beneath a mass of cheap trash. This excessive literary production is characteristic also of medicine. The number of journals, etc is simply overwhelming."²(p.894) America is characterized as the land that flows with ink and money, so what is new 100 years later? Ravitch, in an editorial in 1978, stated "Why another journal?" for the new journal Resident Staff Physicians and repeated it in 1985 for Surgical Rounds. "It is all in the interest of education,"³(p4) he said.

New boards, societies, journals, and textbooks are dependent, in part, on individuals' need to become officers, editors, and authors. Publishers contribute to the proliferation of textbooks and journals. Many publishers want a journal and book of their own on most subjects. Some physicians do not want to be part of a large organization or publication and want their own expression. These reasons may be cloaked in "the need of patients to have better specialty care." Special interest groups may insist on their right to express themselves independently or to have their own club of buddies and friends. Some new organizations or activities are calculated to seize a piece of the action from an established activity. Some of these are worthwhile. Others are political and powered by personal ambition or ego trips.

The biggest problem that I see is the explosion of journals (Table 2). Who can read them all? Are they all needed? I think not. How do we deal with this? Library funds are exhausted. They cannot afford all the journals they presently subscribe to. Some libraries cancel the subscription if the journal is on the Internet. Most of us cannot subscribe to all of the journals in our fields of interest. How do new journals begin? First, a publisher studies if they can get a piece of the market with a new journal. They approach an expert in the field who is not an editor. Who can turn this down? The editors of the major surgical journals do their jobs as labors of love but with high visibility. They receive expenses and a very modest honorarium. Editorial board members receive nothing other than their name on the masthead. Editorial boards become interlocking directorates. Take a look at how many surgeons are on how many boards. Is there money plus notoriety in some of the newer, more commercial publications? The new editor writes to his friends:

I am developing a new journal on critical care (or whatever) and invite you to be a member of the editorial board. The new journal will serve a unique purpose and will have papers online quickly. It would be a great pleasure for me if you would be part of this enterprise.

I know of an editor who agreed to be on the editorial board of a new journal competing with his own journal.

An example of how journals spin off is the Surgical Infection Society (SIS). Many years ago when the SIS was formed, I agreed to publish their program in the ARCHIVES. The first years were tough because not all of the material presented at their early meetings warranted publication. Years later the SIS became more basic than could be justified in a clinical journal so the SIS published their papers in the journal Shock. This proceeded until Maryanne Liebert, Inc decided to launch a new journal, Surgical Infections, which publishes the yearly program of the SIS. It sounds like a perfect fit–Surgical Infections–SIS–fortuitous? Planned? What will be next? This journal will compete with the journal Sepsis, developed by Marshall.⁴ Marshall launched this journal in 1997 (Kluwer Academic Press) as a review journal of the host inflammatory response.

Many surgical journals publish the discussions of papers presented at meetings. Other specialties do not do this. When I was with the ARCHIVES, the editor of JAMA asked why surgeons do this? I replied that we are gregarious, like to talk to each other, discuss things, and see our names in print. There may be other reasons as well. When I was on the faculty of the University of Pennsylvania, the Chairman, the late Jonathan Rhoads, told us that he learned from his Chief, Isadore Ravdin, to always discuss the first paper at the meeting. Then if you are called away, everyone would know that you had been there. Jonathan always did this. Discussions of papers are often stylized according to the society–some just ask questions, some say, "I rise (you can't discuss sitting down) to compliment the authors on an excellent presentation, or an important message, or a nice study or whatever." No one ever says "this is terrible," or "I don't believe it," or "I totally disagree."

Vascular surgeons are an example of splitting off. I grant that bypassing a femoral artery blockade is a bit different technically from a thyroidectomy or a cholecystectomy, but there is still a lot of basic surgical discipline involved. Years ago we published the program of the International Cardiovascular Society in the ARCHIVES. The Vascular Society papers were published in the journal Surgery. The vascular surgeons wanted their own journal. The specialty was growing in numbers and capability. They could easily get a publisher. There are now a number of vascular surgical or related journals. Vascular surgeons now seek an independent American Board of Vascular Surgery separate from the American Board of Surgery. I won't go into that.

And what about authors? Where do all these articles come from? Is it publish and/or perish? Is it a means of getting your way paid to a meeting if you are on a medical school faculty? Clinical experiences can be important if they represent something new—a better operation, better care, better results. Tell us why they are better. We do not need a review of 162 cases of esophageal cancer. A case report should be published only if it describes a new clinical entity. We do not need a report, "This is the 15th reported case of Tsutsugamushi disease." If an interesting case (a fascinoma) is presented at Grand Rounds, the resident may be asked by an attending "Why don't you write it up?" The real questions are (1) Is this a new, unique, or landmark experience?⁵ (2) Is it a new disease, or operation, or observation that will now or could in the future change what we do? Before writing, ask yourself if you have something worthwhile to say and is it important enough to share with others?

The more journals there are, the more authors are needed. An overload of review articles does not help. A new disease of the "literati" has been described by Mexal.⁶ It may apply to medical writers as well. It is called the Jane Auel syndrome or mad writers' disease. Writers' subsequent books become longer and longer. Auel's first book in 1981 was 495 pages. Her fourth book in 1991 was 880 pages. Tom Clancy's first book Hunt for Red October in 1984 was 276 pages. His recent book The Bear and the Dragon in 2000 has over 1000 pages. Stephen King and J. K. Rowling followed suit. Medical journals limit the length of each article. This can lead to duplicate publication or publishing separately pieces of a study that should be published together. Broad called this "the least publishable unit" in a paper titled "The Publishing Game–Getting More for Less."⁷ There is no limit for multiauthored books other than that what publishers will allow and a reader will buy. I sometimes think some of these books are sold by the pound. Be careful not to drop one or it will break your toes. Dr Michael Alberts of the journal Chest wrote about too many journals, too many pages, and too little time.⁸ He described Chest going from 120 pages per issue in 1980 to 309 pages in 2000. He instituted a new section, a brief review of the 10 best papers in the last 2 years picked by an expert on a subject.

Another phenomenon recently is one person designated the editor-in-chief and another person the editor. I do not understand this relationship. JAMA frequently publishes a list of organizations of medical interest occupying 6 pages of small print.⁹ It also publishes meetings of medical interest occupying 5 pages for meetings from only August 2000 to January 2001.¹⁰

When is enough, enough? I have reached emeritus status and scientific programs are not as interesting, but the receptions to see friends are most enjoyable. The beat goes on, involving personalities; egos; publishing and/or perishing; academic prestige; and affluence and money from drug, equipment, supply companies and publishing interests. The need for surgeons to be organizers, editors, officers, invited speakers, members of boards, and attendees is pervasive. New journals are needed by publishers, editors, societies, and specialties. It is human nature at work. Hopefully, some good comes from it. I have described the problem. I wish I had a solution other than restraint by surgeons. Is restraint by surgeons an oxymoron? Organ asked for a moratorium.¹¹ Did anyone listen? Could there be mergers of journals and societies. Hom, Organ, and Twomey¹² recommended mergers and name a number of possibilities such as a merger of the SIS, the American Burn Association, and the American Association for the Surgery of Trauma with 1 journal. Wouldn't we all be better off? Perhaps decreased reimbursement for operations and other monetary factors will produce retrenchment. The Harvard Law of Experimentation is "Under controlled conditions, animals and people (and organizations and publishers) behave as they damn well please."

Corresponding author: Arthur E. Baue, MD, Box 396, Fishers Island, NY 06390.