The violation of editorial independence at the CMAJ

Several of the Open Medicine team members were involved in editing the CMAJ in the period leading up to the highly publicized firing of CMAJ editor-in-chief John Hoey and senior deputy editor Anne Marie Todkill on 20 February 2007. The dismissal of the two editors, who had been working with the journal since 1994 and 1996 respectively, was the culmination of the growing tension between the journal’s editors and its publisher, CMA Holdings, which is the business arm of the Canadian Medical Association (CMA), representing somewhat more than 60,000 physicians in Canada.

Under John Hoey’s editorship, the CMAJ had developed into the fifth most-cited journal among general medical titles. The journal was receiving 100 submissions a month, with close to 70,000 subscribers (including the membership of the CMA). At the same time, the CMAJ had on more than one occasion published papers and editorials that had noticeably upset the CMA. As an example, a CMAJ editorial that was critical of new Québec legislation on hospital emergency-department staffing (CMAJ, 2002) pointed a finger at the doctors in a Québec community who had failed to keep an emergency department open, resulting in the death of a patient and this legislative intervention. In response to this editorial, Dana W. Hanson, president of the CMA, published a letter in the CMAJ calling for a retraction of the editorial’s judgement that the tragic incident at that Québec hospital represented a breakdown in the trust so important to the patient–doctor relationship (Hanson, 2002).

As a result of this and other instances in which the CMA took exception to what was published in the CMAJ, as John Hoey and Anne Marie Todkill explained in a 2003 CMAJ commentary, ‘in September 2002 the Canadian Medical Association’s board of directors agreed to put in place a Journal Oversight Committee as a mechanism for resolving the association’s rare but sometimes strong disagreements with the editors of its wholly-owned journal CMAJ’ (Hoey and Todkill, 2003: 287). Hoey and Todkill envisioned the committee’s duties to include, among other things, ‘protecting the journal from undue influence by its publisher and owner’ (ibid.). The oversight committee was not to prove very effective in this capacity.

Three years later, on 12 December 2005, the CMAJ published an editorial entitled ‘The editorial autonomy of CMAJ’, in which editors flatly stated that they had ‘a transgression to report’ (CMAJ, 2005: 9). They went on to describe how the publisher had interfered in the publication of an investigative journalism piece (Eggertson and Sibbald, 2005), at the behest of the Canadian Pharmacists Association. The article described how Canadian pharmacists were engaging in invasive questioning (dealing with sexual histories) of women who were seeking to purchase the emergency contraception drug known as Plan B, an over-the-counter drug in Canada. The article was based on the experiences of 13 women who had been recruited by a reporter for the CMAJ to approach pharmacists across the country. In order to run the piece in the CMAJ, the editors had been forced by the publisher to remove any references to the women’s experiences with the pharmacists, ostensibly on the grounds that the reporter’s procedures did not constitute a proper research method for a medical journal. In response to this interference, the editors stated in the journal’s editorial on this incident that they had established ‘an advisory group’ made up of medical editors and a health reporter ‘to examine CMAJ’s editorial autonomy and governance structure’ (ibid.).

On 7 February 2006, the CMAJ posted a news story on its website with the headline ‘Two-tier Tony Clement appointed new Minister of Health’ (CMAJ, 2006b). The press had previously nicknamed the minister ‘two-tier Tony’ because of Mr Clement’s stated interest in permitting private health plans, which was widely seen to undermine support for the country’s public health system. Once more, the editors of the CMAJ were pressured by the publisher to revise one of their papers, reducing its critical aspects and replacing the original title with ‘Tony Clement appointed as Canada’s new Health Minister’, while retaining the CMA president Ruth Collins-Nakai’s endorsement of Tony Clement’s appointment (Kondro and Sibbald, 2006).

It was later that month, on 20 February 2006, that John Hoey and Anne Marie Todkill were dismissed by Graham Morris, president of CMA Holdings and CMAJ publisher, who told the press that he ‘just felt that it was time for a fresh approach’ (Webster, 2006: 720). By way of further explanation, Ruth Collins-Nakai, president of the CMA, commented later and somewhat more candidly in a letter to the journal that it was ‘a case of irreconcilable differences’ (Collins-Nakai, 2006). While denying that the firings had to do with any particular article, she points more than once in her letter to tension between ‘on the one hand, the rights of the editor for independence and, on the other, the responsibility of the publisher to protect the organization’s legal, financial and liability interests’ (ibid.). Collins-Nakai’s letter was in response to the publication in the CMAJ of the report on editorial autonomy that Hoey commissioned (Kassirer et al., 2006; more on this below). For their part, Hoey and Todkill were contractually constrained from talking about the incident.

The firing of the two editors was covered by the Globe and Mail (Curry, 2006) and the New York Times (Austen, 2006) among other newspapers, as well as by medical journals The Lancet (Webster, 2006) and the New England Journal of Medicine (Shuchman and Redelmeier, 2006). In each case, it was made clear that editorial autonomy was the probable cause of dismissal; as the Globe and Mail’s Helen Branswell put it: ‘The firings are believed to be the culmination of an ongoing struggle between Dr Hoey’s team and the journal’s owners over the editorial independence of the publication’ (Branswell, 2006: A7). In a ‘perspective’ piece on the incident for the New England Journal of Medicine, Shuchman and Redelmeier (2006: 1339) concluded that the political nature of the medical profession should not be minimized:

A week after Hoey and Todkill were dismissed, acting editor Stephen Choi resigned from the journal after the CMA refused to accept his proposed editorial governance plan for CMAJ, which sought to ensure the ‘absolute’ independence of the editor (see Kassirer et al., 2006).

Not long after this, the committee that Hoey and Todkill had announced on 12 December 2005, which had been charged with examining editorial independence at the CMAJ, issued a highly critical report, first released by the CMAJ on 28 February 2006. The brief, ‘Editorial autonomy of CMAJ’, stated that ‘despite claims by the CMA … the editorial autonomy [of the CMAJ] is to an important degree illusory’ (CMAJ, 2006a: 950). The report did fault the journal editors, including Hoey, for their willingness ‘to respond to pressure from the CMA by modifying a report slated for publication in the journal’, while saving their major criticism for the CMA ‘for blatant interference with the publication of a legitimate report’ (ibid.: 247).

Meanwhile, the resignations continued at the CMAJ, with 15 members of the 19-member editorial board stepping down on 13 March 2006, reflecting an overall loss of trust in the CMA’s ability and willingness to preserve the autonomy and intellectual integrity of the journal (Ubelacker, 2006). This loss of trust was not to be restored by the CMA’s formation of an outside governance review panel, whose 25 recommendations for ensuring editorial independence at the CMAJ were accepted by the CMA when the report was published on 14 July 2006 (Gandhi, 2006). The governance review panel, headed by Dick Pound, recommended in its report that, for example, the CMAJ mission statement ‘enshrine, as a specific goal and objective of the CMAJ, the principle of editorial integrity, independent of any special interests’ (Pound, 2006: 36).

By that point, however, the dismissed and deserting alumni of the CMAJ had become convinced that what was needed, on the part of the CMA, was something more than the acceptance of a series of well-intentioned recommendations. There needed to be recognition on the CMA’s part that something had gone terribly wrong in the mix of professional-association politics and medical research publishing. Failing this recognition on the part of the CMA, the former editors and editorial board members pursued the possibility of establishing an entirely independent journal in the field of general medicine – a journal that did not have to depend on a careful set of checks and balances to minimize the inevitable conflict of interests. This was not, after all, the first time that a publisher had interfered in the editorial content of a medical journal. And before considering the role that open access can play in the formation of independent journals, it is worth considering the larger pattern of undue influence and interference that has beset medical journal publishing in recent times, as to do so will make apparent the reasons this concept of editorial independence is particularly critical in medical publishing.

A brief history of editorial interference in medical journal publishing

In 1992, the Annals of Internal Medicine published a paper on pharmaceutical advertising that concluded that ‘many advertisements contained deficiencies in areas in which the FDA has established explicit standards of quality [for medical advertising]’ (Wilkes et al., 1991). As a result of publishing this study, several large pharmaceutical companies withdrew an estimated US$1.5 million in advertising from the journal. Ensuing tensions between the journal’s co-editors, Robert and Suzanne Fletcher, and its publisher, the American College of Physicians, led to the editors’ resignation in 1993. A subsequent survey of North American journal editors found that 12 per cent observed conflicts between editorial decisions and advertisers’ wishes and almost one-quarter had no control over the advertising that ran in their journal (Wilkes and Kravitz, 1995). As Robert Fletcher later put it, ‘The pharmaceutical industry showed us that the advertising dollar could be a two-edged sword, a carrot or a stick. If you ever wondered whether they play hardball, that was a pretty good demonstration that they do’ (cited by Tsai, 2003: 759).

The political side of biomedical publishing came into the glaring light of press coverage on 15 January 1999, when George Lundberg, editor-in-chief of the Journal of the American Medical Association (JAMA), was dismissed after he published a paper by Stephanie Sanders and June Reinisch (1999) examining college students’ perception of what constituted ‘having sex’, based on Kinsey Institute data, which included the results that nearly two-thirds of the students did not count oral sex in their definition. The paper was published just as President Clinton was publicly asserting that he did not have sex with Monica Lewinsky. The American Medical Association (AMA) executive vice-president, Dr E. Ratcliffe Anderson Jr, claimed that Lundberg’s publishing of the paper ‘threatened the historic tradition and integrity of [the journal] by inappropriately and inexcusably interjecting JAMA into a major political debate that has nothing to do with science or medicine’ (cited by Hoey et al., 1999: 508).³

Later that same year, Jerry Kassirer, editor-in-chief of the New England Journal of Medicine (NEJM), was forced to resign in a conflict over how the NEJM ‘brand’ was being used to start new publications for doctors and the general public by the journal’s publisher, the Massachusetts Medical Society (Altman, 1999). Kassirer felt that such use of the ‘brand’ was inappropriate, given that these materials would not go through the same level of scrutiny and review; he had asked in an earlier annual report, ‘Does the society want to become a business?’. It might be said that any journal which generates US$15 million in profits on US$75 million revenue (estimates for 2005), even if it is for the non-profit Massachusetts Medical Society, is very much a business already (Smith, 2006). That Kassirer’s resignation as editor-in-chief was followed by the appointment of Jeffrey Drazen, who had a history of strong ties to the pharmaceutical industry, only served to further affirm the financial orientation of the journal.

Pharmaceutical companies placed US$448 million worth of advertisements in medical journals in 2003, making it possible for the AMA to reap a US$40.7 million profit from its journals in 2004 (Fugh-Berman et al., 2006).⁴ In addition, pharmaceutical companies purchase millions of reprints to distribute to physicians whenever a paper reflects well on their medications, just as they are known to provide physicians with sponsored subscriptions to The Lancet, NEJM and other journals. Finally, studies have shown that authors conducting clinical trials have far too often held consulting contracts with the participating pharmaceutical companies (Perlis et al., 2005).⁵

Clearly, medical journals are in a financial class of their own compared with journals in any other field within scholarly publishing. By the same token, medical journal editors have taken special steps to protect the integrity of their journals. It is now standard practice, for example, to ask authors for a statement of competing interests (financial and otherwise; see note 2 on p. 350 for a statement from the authors of this chapter), with many journals requiring the same for reviewers and editors (Lee and Bero, 2006). In addition, the International Committee of Medical Journal Editors (ICMJE) adopted a policy in 2004 that called for all clinical trials to be registered before the results would be published, in a move that would prevent drug companies from burying unfavourable studies (De Angelis et al., 2004).

Open Medicine as an independent medical research journal

In light of this history, the editors of Open Medicine are not only committed to adhering to the safeguards that are now becoming common practice for medical journals, but have also made it a policy neither to seek nor accept sponsorship from professional associations nor to accept drug or medical device advertising. They are inspired, in part, by the example of the editors of PLOS Medicine, who do not accept medical advertising as they are determined not to become ‘part of the cycle of dependency … between journals and the pharmaceutical industry’ (Barbour et al., 2004).

The editors at Open Medicine also ensure papers are published as soon as they are ready, and that the journal does not engage in the common practice of sending out ‘advance articles’ to the press with an embargo ensuring that any press coverage is withheld until the journal publishes the paper, a practice that Vincent Kiernan argues does more to direct and control press coverage of medical research issues than to serve public interests (Kiernan, 2006).

The editors of Open Medicine were also committed to establishing a journal with open access in ways that went beyond John Hoey’s original initiative with the CMAJ, which had made the online edition free to readers while restricting reprints and other use of the content. With Open Medicine, authors are not asked to turn over the copyright for their work to the publisher. The published paper is placed under a Creative Commons licence that enables its reuse and further distribution, as long as it includes proper attribution to the author and journal, and on the grounds that access will continue to be open. The Creative Commons licence enables others not only to freely access papers but also to utilize the work in new productive ways through such bioinformatic innovations as data mashups and information mining (Good et al., 2006; Hodgkinson, 2007). The rise of open access in scholarly publishing is proving critical to the formation of independent and innovative journals, and this new approach to the circulation of knowledge needs to be considered in more detail.

The open access model

Open access represents, above all, the use of the Internet to extend the circulation and sharing of knowledge. That extension is not to everyone everywhere, certainly, in light of the considerable and persistent digital divide, but open access does represent an extension that goes well beyond what was proving possible with print journals. As should be clear by this point, open access is not taking any one form, neither in terms of economic models nor conditions of access to a journal’s content. Open access is part of an important new chapter in the long historical process of opening up science and scholarship to a wider world. That chapter includes open data initiatives (Uhlir, 2005), open source biology (Maurer, 2003), open encyclopedias and a variety of ‘open science’ projects (David, 2004).

Among open access journals, there are those that have been born-digital and free, which have risen to the very top of their fields in a relatively short time, such as the Public Library of Science’s PLOS Biology, and there are highly ranked éminences grises, such as NEJM, which makes each issue free to readers six months after initial publication. In addition, most publishers in the biomedical field also support the World Health Organization’s HINARI programme and other initiatives that provide free online journal access to research libraries in low-income countries, although the implementation of this support by the commercial publishers has been questioned (Villafuerte-Gálvez et al., 2007).

Scholarly societies are also finding ways to contribute to this greater openness without jeopardizing the subscription revenues on which they depend. For example, among medical societies using HighWire Press, a division of Stanford University Libraries, for their online editions, one finds titles whose contents are freely available (CMAJ) or delayed by a matter of months (NEJM), adding up to the free availability of 1.7 million papers drawn from HighWire’s collection of more than 1000 journals. Among the funders of biomedical research, the Wellcome Trust insists that all grant recipients deposit copies of their published work in the open access PubMed Central (PMC) six months after publication, while the National Institutes of Health in the US requests a similar form of deposit. This sort of open access mandate for grant-funded research has been taken up or is under consideration by a number of funding bodies.⁶

Yet up to this point, the argument for open access among libraries, journal editors and researchers has been about increasing access to research for researchers, professionals (such as physicians) and the public (Willinsky, 2006). At issue has been the human right to know what is known, and all the more so, surely, when that knowledge has been funded by public and philanthropic sources. There is yet another side to the access question, however, which has to do with who is able to participate in the circulation of knowledge and on what terms. This is the point at which, as we have learned through our work with Open Medicine, open access provides a means of defending and furthering academic freedom.

Academic freedom and open access

The concept of ‘academic freedom’ took shape during the twentieth century as a way to protect the right of faculty members to pursue independent lines of research and scholarship, with this work judged solely on its scholarly quality and contribution. A critical incident in the formation of this concept, for example, came when Edward Ross was dismissed by Stanford University in 1901 because his ideas about economic reform met with the disapprobation of Jane Stanford, wife to Leland Stanford, an act followed by the resignation of seven professors in protest. When John Dewey became the first president of the American Association of University Professors (AAUP) in 1915, he formed a committee to examine the state of academic freedom and tenure; the committee included Arthur O. Lovejoy, one of the professors who had resigned at Stanford (Pollitt and Kurland, 1998). The standard statement in the field of academic freedom from the AAUP, known as the 1940 Statement of Principles on Academic Freedom and Tenure, states as its first principle that ‘Teachers are entitled to full freedom in research and in the publication of the results’ (AAUP, 1940).

While the concept of academic freedom has typically involved undue interference in a faculty member’s ability to pursue research and teaching that otherwise meets common academic standards, we take the editorial independence of scholarly journals to be a natural extension of this concept. We see this editorial independence as no less necessary for the realization of faculty members’ academic freedom, given that this freedom depends on their work receiving a fair hearing and opportunity for wider circulation. The journal editor, in this sense, is the handmaid of academic freedom. The editor creates opportunities and guidance for the publication of innovative work, nurtures authors’ work and mediates differences between reviewers and authors to ensure that the work receives a fair and critical reading (at least in principle).

Certainly in the humanities, journal papers are where trial balloons are floated and new ideas given their first run, with authors not infrequently going on to fully develop their papers into book-length manuscripts. The journal is also where new and old ideas are most readily and immediately contested. Books and papers are subject to extensive public review in journals, in addition to the closed peer review. This closed and open review process is particularly important to academic freedom, as it is not simply an instance of free speech or a civil liberty (Slaughter, 1980). And the peer-reviewed journal is the best available device – though by no means perfect (cf. Horrobin, 1990) – for providing the level of review and scrutiny needed to ensure that academic freedom can continue to make its contribution to the generation of knowledge.

Journals are also where disciplines define themselves – where the old guard, as editors and reviewers, carefully maintains traditional definitions of the field and its boundaries. By the same token, new journals are often about the formation of new disciplines. Consider how the emerging field of women’s studies was marked by the launch of Women’s Studies Quarterly in 1972, with Signs following in 1975 and Feminist Review in 1979 (preceded in biomedical publishing by the Journal of the American Medical Women’s Association, founded in 1947). It seems fair to say that these journals made a significant contribution to the academic freedom of scholars working in what was then a new area. The journals, with their interdisciplinary titles, provided a vehicle for work that challenged entrenched disciplinary approaches and boundaries. They created a sense of possibility for going with one’s work where others had not gone before.

If the journal can serve as one of the great defenders of academic freedom, then the ability to start a journal that is able to establish its intellectual, as well as financial, independence from forces and traditions that might otherwise compromise that freedom becomes all the more important. Among the factors today inhibiting the initiation of new titles is the corporate publishers’ practice of licensing to research libraries bundles of hundreds, if not thousands, of titles at a single price, which locks down a growing proportion of those libraries’ serial budgets into multiple-year and no-cancellation contracts. Prior to 2003 when Cornell University cancelled its bundle of 900 Elsevier titles (Elsevier now has 2000 titles), it had been paying 20 per cent of the library’s serial budget for 2 per cent of its titles through this bundling process (Cornell Chronicle, 2003). With the journal market squeezed by the major publishers – the six leading publishers now control 60 per cent of peer-reviewed titles and a much larger portion of libraries’ serials allocations given the much higher pricing of commercially published journals (Bergstrom, 2002; Crow, 2006) – it has become that much harder for a new journal or a journal that is not part of a major organization to secure library subscriptions. Enter the many forms of open access in scholarly publishing. Open access enables a new journal to become part of the larger academic community immediately, without first having to convince a major corporation or organization to sponsor it, or without having to assemble sufficient resources to sell initial subscriptions through some combination of advertising and agents. (One estimate sets the price of securing 500 subscribers in the first three years at roughly US$50,000 [Page et al., 1997].)

Open access enables journals to establish a global presence online to reach readers worldwide. In addition, open access versions of scholarly indexing, such as Google Scholar, PubMed and CiteSeer, enable readers to find this work and in some cases to track who has cited the work and in what context. This improves the ability to appreciate how new developments in research are taking root long before the ideas become well established enough to be picked up by citation indexes such as the ISI Web of Science. Finding a way into libraries and, even more challenging, being picked up by the major indexes – once necessary for a journal to begin to offer its authors a fair and widespread reading – no longer stand as major barriers to a new journal’s ability to serve the cause of academic freedom.

The new-found support for academic freedom afforded by open access is also being realized by universities in low-income countries. It has long been a challenge for new journals in such settings to gain recognition and circulation for local research initiatives. Yet work that is made open access can turn up in the same search results as work from the leading journals. In addition, open access is serving the emergence of regional initiatives, with journal hosting programmes such as African Journals Online (http://www.ajol.info) and Bioline International (http://www.bioline.org.br/), indexes like SciELO (http://www.scielo.org/) and Latindex (http://www.latindex.unam.mx/), and individual open access titles, whether they are the born-digital African Journal of Biotechnology (http://www.academicjournals.org/AJB) or the 85-year-old East African Medical Journal (http://www.ajol.info/index.php/eamj).

The opening ahead

Open access may enable immediate presence, but it still leaves in question the longer-term sustainable economic model for publishing the journal. In the case of Open Medicine, the editors who had been working with the CMAJ had come off a multi-million-dollar annual budget devoted to publishing a biweekly, highly ranked journal with a full-time professional production and management staff. They are now engaged in an all-volunteer professional editorial effort – except for some limited funding for copy-editing support – which allows ongoing high-quality publication as well as editorial processes and a flow of manuscripts that enable it to publish papers on an as-ready basis (weekly to biweekly). Open access made it possible to establish a journal with an immediate presence, visited by tens of thousands of readers in its first month, while attracting press coverage from across Canada. It enabled Scientific American (Mims, 2007), as well as a number of bloggers, to pick up one of its initial papers, which compared healthcare expenditures and outcomes in the US and Canada (Guyatt et al., 2007), and it continues to attract ongoing media interest. At this point, the Open Medicine team is considering a variety of economic models aimed at sustaining and expanding this open access journal. A number of donations have already been made to the journal, and the team charges nominal publication fees. It welcomes non-medical advertising and has received support from various university research libraries in Canada, but at each point it remains committed to realizing and reasserting the basic principles of scholarly publishing in the medical field. It does not pretend to be unique in taking this principled stand, as PLOS Medicine, which was first issued in 2004, remains very much an inspiration in its open access policies and independence in terms of professional associations and medical advertising. But Open Medicine has been able to demonstrate how this reassertion of scholarly principles can happen on a far more modest and immediate scale, born of an urgent national need for an alternative model in general medicine.

Open Medicine was able to mount a peer-reviewed journal from scratch with a first issue of ten articles in less than a year, through the dedicated commitment and experienced professionalism of its editors. But these tireless efforts were also facilitated by parallel developments in the field of software and publishing systems. What enabled the editors and board members to collaborate across Canada (and with Sally Murray in Australia) was another open development, this time in the form of open source software for journal publishing. The journal uses the freely downloadable Open Journal Systems (Willinsky, 2005) to manage and publish the journal (just as the open access archives in many libraries use the open source EPrints and DSpace systems to enable authors to archive their published work).⁷ In addition, Tarek Loubani, a recently graduated emergency medicine physician and part of a new generation of physicians with technical savvy, has used the open source Drupal to establish the journal’s OM Blog, which Dean Giustini initiated and Carly Zwarenstein now uses to bring immediacy to the journal, and a wiki to help organize editorial meetings. It is that particular combination, then, of open access to research and open source software that has become the new enabler of academic freedom in an age in which access to knowledge can otherwise operate like just another commodity market. It may be fair to say that Open Medicine has yet to arrive at a long-term financial model (although, for that matter, the New York Times is also still searching for a stable model for online publishing, judging by the array of initiatives with which it continues to experiment). But given the commitment of everyone involved in Open Medicine, it is very unlikely that it will back away from its open access principles. While we cannot predict which economic model will prevail with this journal, or with the field of online journal publishing generally, what is clear is that people are finding innovative ways of increasing access to this body of knowledge.

Yet it is also fair to claim that Open Medicine has raised the stakes for open access by demonstrating how this combination of open access and open source can be used today to reassert editorial independence, intellectual integrity and academic freedom. These principles of scholarly communication, as this critical incident in the development of scholarly publishing also demonstrates, are never entirely secure from the competing interests of a knowledge-based economy in biomedical journal publishing. Constant and critical vigilance are needed to protect research principles from undue influences, and only innovation and experimentation will provide corrective measures and a way forward. Fortunately, such critical and innovative work is the stock in trade for the academic community, even if this critical sensibility is seldom applied to the communication practices at work in our own particular corner of the knowledge economy. It takes a critical incident to help us realize which principles underwrite this form of communication and to test our commitment to them.

The first five years at Open Medicine

We initially wrote this chapter during Open Medicine’s first year of publication, and we have included, for the second edition of this book, the original chapter updated and this additional section after five years of successful publication. This is a sizeable achievement on the part of everyone involved, most of whom have been with, and stayed with, the journal from the beginning. In those first five years of publishing, the journal has taken a number of additional steps both in technical innovations and editorial direction, all the while giving back to the open source software system as well as the open access scholarly publishing community. It has not been easy, by any means, to manage and edit the journal on a largely volunteer basis, while pursuing various strategies to obtain sustainable publishing support. We also remain committed to staying fully open access and are currently the only open access general medical journal in Canada.

Among the technical advances and experiments that Open Medicine has been engaged in is the development of additional code to optimize the commenting system for the articles and to customize a program designed to help render the journal’s articles suitable for submission to PMC which requires meeting National Library of Medicine standards. All of this was accomplished through the use of free and open source software (Loubani et al., 2008; Murray et al., 2008). In addition, Open Medicine is the first refereed journal to publish the content of a scoping review (Deshpande et al., 2009) and a systematic review with meta-analysis (McIntosh et al., 2011) in a wiki format. Both articles were peer reviewed, revised and edited prior to publication on our site in HTML and PDF format. We concurrently created a wiki version of these reviews in order to push the boundary of publishing content as ‘living documents’ to be edited by the scientific and broader community. We have contributed to the learning curve in this form of publishing, which has been successful in many areas outside of biomedical publishing, and have outlined the process, issues and responsibilities involved in turning a research article into an open access wiki in an editorial (Murray et al., 2009). These technological innovations have paid off: web traffic indicates increasing readership of the journal. The Open Medicine website had 8092 unique site visits and 181,971 hits in March 2009; corresponding figures for March 2010 were 17,174 unique visits and 350,554 hits; and, for March 2013, 23,559 unique visits and 383,942 hits. Since our launch we have received 542 manuscript submissions and have published 168 individual articles (as of June 2013), including in-house editorials.

In terms of editorial direction, Open Medicine has remained committed to editorial independence. This position allowed us to provide frank commentary and analysis on conflict-of-interest issues concerning the appointment of Dr Bernard Prigent (Pfizer Inc. executive) to the Canadian Institutes of Health Research Governing Council (Ghali et al., 2010; Lewis, 2010) and concerning the position of Barbara McDougall, who was chair of the board for the International Development Research Agency and simultaneously on the board of Imperial Tobacco (Todkill, 2010). Both situations sparked national and international discourse, with Open Medicine actively contributing to the expressions of concern. We believe that Open Medicine provides an independent forum to debate issues related to medical practice and research and health policy, for the Canadian and international medical communities.

Our independence has also allowed us to address fluidly current issues in biomedical publishing. As examples, we have revised our editorial policies and author guidelines and published supporting editorials on policies such as ghost-writing (Murray et al., 2010b), financial conflict of interests (Rochon et al., 2010a and b) and systematic review registration (Palepu et al., 2011). We have endorsed and implemented the recommended reporting guidelines from the EQUATOR Network, which are intended to improve the quality of reporting of health-related research (Altman et al., 2008). We request that authors complete the appropriate checklist and revise their manuscripts to adhere to the appropriate reporting guidelines for accepted manuscripts. In addition, we ask our peer reviewers to use the appropriate checklists in their peer review. Open Medicine participated in the simultaneous, broad publication of the PRISMA guidelines (for systematic reviews and meta-analysis) in 2009 and the CONSORT 2010 update (randomized controlled clinical trials) as a step in increasing the uptake of these guidelines among authors and editors.

Open Medicine fosters a student peer-review group based at the University of Calgary. Under the mentorship of editors based in Calgary, a group of graduate students in the Department of Community Health Sciences has been involved in the peer-review process for the journal. The group meets on an ad hoc basis to review manuscripts submitted to Open Medicine; the students independently review the manuscript before meeting to discuss their comments and reach a consensus on recommendations for the editors. Students rotate the responsibility of writing up their review and presenting it at the weekly editorial meeting. Overall, the students have found this experience rewarding because it gives them an insight into the peer-review and editorial process, helps them develop their critical appraisal skills, teaches them about aspects of health research that may be beyond their current domain of study and refines their own manuscript writing. The Open Medicine editors, for their part, find the student reviews to be thoughtful, thorough and of benefit to the review process. The student peer-review group has published an editorial on the Open Medicine site describing their experiences (Lail et al., 2011). The journal also supports the Open Medicine Clinical Audit Prize at Notre Dame University in Australia. The winner is able to work with an Open Medicine editor to develop their clinical audit report for publication in a peer-reviewed journal, is supported through the peer-review process, and can attend an editorial meeting to learn how and why manuscripts are selected by a journal’s editorial team.

From 2008 to 2011, Open Medicine has published an annual supplement of the complete abstracts of the Royal College of Physicians and Surgeons of Canada’s annual International Conference on Residency Education. This was a positive project for the journal, serving to raise Open Medicine’s profile in Canada’s academic community and affirming a link with a national medical association focused on medical education, as well as allowing the abstracts to be published in an open access format.

The path to financial sustainability

In July 2009 Open Medicine was officially accepted into PMC and began to be indexed in MEDLINE in August 2010 (Murray et al., 2010a). We deposit the full text of each article in PMC, ensuring that it complies with the National Library of Medicine’s exacting standards for XML markup. As a result, our content can be found through MEDLINE and accessed from PMC. This indexing and inclusion in the PMC archive has been made possible through the tireless effort of Tarek Loubani and the use of Lemon8-XML developed by MJ Suhunos. While these steps may appear trivial for biomedical journals, the process requires time-consuming and detailed technical diligence.

In addition to overcoming these hurdles, Open Medicine continues to experiment with strategies for financial sustainability. Despite a slow and steady flow of modest funding from library partners, medical schools and generous individuals, the bulk of the editorial team’s time is volunteered. In March 2010, we instituted publication charges (sometimes referred to as article processing fees) to offset the cost of copy-editing and layout for publication: we initially charged US$1200 for research and review articles and US$500 for unsolicited analysis and commentary articles, and we continue to provide editorial services free of charge to authors who remain unable to pay (ibid.). After we were accepted into MEDLINE, we increased the publication charge to US$1500 for research and review articles and US$750 for analysis and commentary, which does not completely cover the costs of copy-editing and production. Open Medicine will continue to champion the assurance of equitable, accountable, free access to research findings in a context of fiscal responsibility to our authors, editorial team and board.

The next five years

Going forward, Open Medicine’s editorial team seeks to balance our editorial values with the need to achieve a stable and sustainable financial model. The landscape of open access publishing has expanded greatly in the time since Open Medicine’s inception: there has been an influx of support for open access publishing among many top-tier academic institutions as well as encouragement from funders to ensure research findings stay in the public domain. In response, there has been an increase in open access journals and a move for traditional journals to provide, at a cost to authors, free or open access options. In addition, new models of publishing are emerging as seen with the explosion of publications in PLOS ONE, a journal aiming to rapidly peer-review and publish all articles of sound scientific merit, leaving the assessment of novelty and impact to the scientific community through post-publication tools. Given this myriad of open access publication options for scholars, the editorial team at Open Medicine must be intentional in determining its role, responsibilities and even its necessity in the world of biomedical publishing.

Acknowledgements

This work has been supported in part by the Pacific Press Endowment in the Faculty of Education, University of British Columbia. This chapter was originally published in 2007 in the Canadian Journal of Communication 32(3).