Two seemingly disparate papers published in this issue raise some interesting points and require wider discussion.
The first paper is about our favourite subject in Canadian surgical practice: wait-lists. To some degree, wait-lists have become the canary in the cage for the success or otherwise of the provision of nonurgent health care surgical and other procedures for the Canadian population. The paper from Gaudet and colleagues1 has come to a strikingly original conclusion that should bolster the orthopedic profession: in the arena of restricted resources, patients who are waiting for a total hip replacement are prioritized according to their need, not according to their place in society, age or the other demographic factors described in the paper. Why is this seemingly mundane fact so important?
Because, unfortunately, wait-lists have spawned an industry of their own. Researchers, opinion makers, patient pressure groups and even the legal industry have made their mark. Too many policy and administrative career civil servants, researchers, social policy analysts and others now want to take the issue of wait-lists out of the surgeons’ hands and organize even more complicated methods of assessing and running wait-lists. More money is being poured into studying the wait-list problem. The paper by Gaudet and colleagues1 should be read as the needle that will puncture this unnecessary effort, as it is quite clear that, when given the resources, surgeons are capable of treating patients according to their need. When those resources are constrained by outside influences, surgeons continue to behave in a professional manner and still treat patients according to their needs, with the most urgent patients having their surgeries sooner. Those participating surgeons in Québec, the province with the lowest provision of health care services for its populace, deserve high kudos for their professionalism.
Too many voices want to lay the blame for wait-lists at the feet of surgeons and imply that the problem is too big for surgeons to solve. The paper by Gaudet and colleagues1 should be used by all departmental chiefs of surgery to show administrators and civil servants that the only issue that needs to be addressed is the provision of adequate resources to let surgeons do the job. The more pressing issue for the surgeon and for the provider is how to measure the outcomes of the intervention, to address points raised by Wright and colleagues, where they questioned whether patients receiving elective operations actually do as well as expected.2
The second paper comes from the epidemiological research machine of McMaster University, where Bhandari and colleagues3 looked at citations of papers in the The Journal of Bone and Joint Surgery. American volume (J Bone Joint Surg Am) and drew inferences about the types of papers that are most likely to result in subsequent citations by nonrelated authors. The hypothesis was that the more often a paper is cited, the better the science or methodologies that supported that paper. Statistical analysis of the 137 papers studied supports that hypothesis. However, there is a larger problem here that deserves some exploration. It can be argued that, if the true purpose of a journal is to disseminate information, then is a subsequent citation index a broad enough measure of a particular journal’s ability to do this? The use of an impact factor that measures the number of articles in a journal over 1 year and divides that number into the number of times those articles are cited elsewhere is now more commonly used to measure both the author and the journal.4 However, this is not necessarily a methodology that captures how a journal is supposed to alter the practice and behaviour of surgeons on a day-to-day basis. Are there papers that significantly impact on the way that doctors practice medicine that do not get high subsequent citation indices? There needs to be recognition that surgeons are also practical people whose changes of practice and improved scientific behaviour may not be adequately captured if they are not in the business of preparing papers for scientific publication. This is a very real issue, as the cost of publishing journals continues to rise, and the justification of these journals is often based on an outcome such as the citation index. It is my personal belief that a citation index is a very useful tool for those whose occupation is primarily based on scientific activity as measured by scientific paper presentation and publication. It is not an adequate measure for a publication whose appeal is broad and whose subscribers are engaged in the practical application of surgical skills based on their diagnostic acumen. In this situation, a more detailed evaluation of subscribers’ opinions may need to be undertaken to measure the success of the journal as a whole. It is my suggestion to the readership of this journal that they support such efforts when asked to provide opinions regarding this publication’s efforts, so that the editors can continue to make changes. I also think that academic journals need to better define their target audience; a journal that is filled with complex science is not likely to be read by an audience more practically engaged in the surgical arts.
Footnotes
Competing interests: None declared.