Looking back, looking forward

This editorial marks both the 25th anniversary of the journal and the handover of the role of editor in chief from Geoff Norman, the founding editor for the journal, to Rachel Ellaway. We have written this editorial together to mark these milestones, and we take the opportunity to reflect on where the journal has been and where it might go from here.

The thought of being the editor in chief calls up Hollywood clichés of green eyeshades and sleeve garters, and shouting across a smoke-filled room to ‘hold the front page’. Or more recently, the espionage-like drama of All the President’s Men or Post. We can attest from personal experience that academic editors aren’t quite as exciting a bunch as that. What an academic editor does need to do is more prosaic but also more reflective and constructive.

The past few months, where we have both engaged in a handover has caused us both to reflect on what it’s all about, from the mundane, like adding up page counts for the next issue to the strategic, reflecting on how the journal and the editor’s input have influenced the field generally. There is a production side to things. We construct issues, oversee the processing of submitted papers, and adjudicate what does and does not get accepted for publication. Below is a very attenuated job description:

We nurture the journal as a whole, and the many individuals who contribute to its working—our Deputy Editors and Associate Editors, and our many peer reviewers.

We write on and for the journal, leading and challenging thinking through editorials and through the directions we give to the journal.

We maintain standards and integrity—at least we try! Stewards of the science and scholarship, and occasionally a policing role too—not only does this mean careful attention to peer review and quality monitoring, it also involves checking for academic misdemeanours—our recent paper on self-plagiarism and salami slicing as an example (Tolsgaard et al. 2019).

We develop and innovate—new formats, special editions, new and emerging ideas and thinking.

We market and promote the journal through venues like the Editor Roundtable sessions at meetings.

We interact with editors of other journals in our field to share ideas and innovations and to discuss areas of common concern.

We provide guidance and feedback to authors (and occasionally reviewers and editors), regardless of whether the submission is accepted or rejected.

We sometimes assume a therapeutic role, dealing with everything from tardy editors to angry authors.

All this on 100 shillings a week! And there’s much more to the role on top of this …

In any case, this is a time for reflection on more than just the job description. It’s time to cast a long vision over the past 2.5 decades and a tentative glimpse back to the future.

Where have we been?

I (GN) can hardly believe that it’s been 25 years. If you were to drop me into the Washington Hilton, I’m sure I would have no problem locating the little table in the coffee shop where Peter de Liefde (Springer), Henk Schmidt, and I plotted the backbone of this new journal. There were two basic aspects that might set it apart from the other mainstream journals in the field like Medical Education and Academic Medicine. First, it was to involve all the health sciences. This was not intended as a political statement, but rather as recognition that the educational issues were pretty well common across professions, so it made little sense to be exclusively medicine.

Now, in a sense this is, or at least it was, a political statement, for two reasons: (1) Some of the journals did publish papers from other disciplines, although having words like Medicine and Medical in the title inevitably must be viewed as a deterrent. Second, it remains the case that for whatever reason, the majority of submissions do arise from medicine. Undoubtedly the reasons are multiple and interactive, but the outcome is the same.

The other basic tenet was that the focus was to be on both theory and practice. In all honesty, this was an overt bias I had, based on my background in physics and my career interest in experimental cognitive psychology. I saw little value in demonstrations that some new curriculum or teaching module or simulation “worked”; what mattered more in advancing the field was understanding why it worked. This separation of intents has been elegantly discussed by Cook et al. (2008), but the idea, less well articulated, was in the design of the new journal from the outset. Again, this intent departs from other journals more in degree than kind. It’s not difficult to place the journals on a sort of continuum of theory orientation, but there remains considerable overlap among journals.

What remains mysterious to me was how we got from the idea of a journal to the actual journal. At an instrumental level, it is difficult to see how the editor in chief can actually influence policy. I strongly believe in peer review, consequently I cannot and should not ever reject a paper simply because it does not align with my preconceptions. I have always read every paper that was peer-reviewed (about 60% are rejected at the time of submission by the deputy editor). But I only overturn the decision of the associate editor if, in my reading, I uncover fatal errors—“trap doors”—that the reviewers missed. There have been a few occasions where I really did not want to accept a paper, but deferred to the judgment of the reviewers and associate editor. And other occasions where I had the dubious honour of rejecting my own paper (it helps to have multiple personality disorder). So, in my view, an editor in chief who accepts or rejects papers unilaterally is not just heavy-handed, they are unethical.

Somehow journals do end up reflecting the personality and preferences of the editor in chief, but I think this arises through somewhat covert processes, where associate editors, reviewers and authors may decide to submit to a journal because the work lines up with the expressed interests of the journal editor.

There are two areas, however, where the guidelines of the journal do explicitly affect submissions: literature review and analysis. I have no statistics on this, but my sense is that about half the articles that are rejected suffer this fate because the authors have not laid out a case that the study truly represents a contribution to knowledge. As to analysis, statistics is one place where things can be right or wrong, and I have always insisted that authors use the correct approach.

It does seem that AHSE has created a niche for itself. Number of submissions has grown steadily over the years (See Fig. 1 below) and has had a recent growth spurt, which I will return to in a minute. It may well be all the journals would report a similar steady increase; no easy way to tell. As to indices of quality, our Impact Factor remains a consistent 3rd place among the general health sciences education journals, behind Academic Medicine and Medical Education. Anecdotally, it appears that the journal is valued for those aspects we intended—theory-based high quality research that fairly consistently represents real contributions to knowledge.

Fig. 1

Number of submissions to AHSE by year

Where are we now?

Boy, that’s a hard question to answer succinctly. I do think the field has matured in 25 years. How could it be otherwise? But how has this played out? I think we see fewer “how to” papers, although they would be unlikely to end up in AHSE anyway, and fewer papers using satisfaction surveys; but again, that is explicit in journal guidelines. Regrettably, we see fewer psychometric studies. Several plausible reasons—maybe assessment research is a “degenerative research program” to use Lakatos’ term. But I think it also reflects the declining influence of national agencies like the National Board of Medical Examiners, the Medical Council of Canada and the American Board of Internal Medicine, which used to dominate the RIME conferences and also created grant programs to support assessment research.

We also see a realignment of power. When I began, the field began and ended in the U.S. THE conference to be seen at was RIME, and an acceptance of a RIME paper was a massive achievement. The dominance of the US has, I believe, declined. The AMEE conference in Europe probably draws as many North Americans as the RIME conference. For that matter, for some time Canada has been greatly overrepresented in the RIME proceedings. When you look at awards, citations, and so on, it is very clear that they field is now dominated by Canada and the Netherlands.

Why this is the case remains to be seen. In an article I published a few years ago, I conjectured that this may be a consequence of the role of Maastricht and McMaster in research innovation related to PBL in the 1970s and 1980s (Norman 2012). A negative influence may be that educational research can only thrive in medical schools with steady funding support, both internal and external, and stable funding in the US, particularly internal, is not easy to achieve in a health care environment that is driven by for-profit organizations.

One last change comes to mind. After decades of qualitative research being the poor cousin, the tables appear to have turned. Perhaps when I get to the retirement home, I’ll do a bibliometric analysis. But for the moment, it seems to me that the proportion of qualitative papers in our journals has steadily increased. Whether my perception is real or not, it was one contributor to my decision that now was about the right time to move aside, and put the journal in the capable hands of Rachel Ellaway.

Finally, we inevitably ride the coattails of the publishing industry. The move to open source and online publishing is inexorable. How it will play out is not for me to say. Hopefully the egregious excesses of the predatory publishers have been reined in. One innovative approach has been taken by Perspectives on Medical Education, which is open source and the entire cost of publication is underwritten by the Dutch national association. That, of course, is not a model for AHSE, which has no linkage to any other organization.

Another is MedEdPublish, published by AMEE and now 3.5 years old. It is open peer review, meaning that editors ensure that it is written well enough, has no ethical issues and is within the scope of medical education. It is then published with reviews by 2–3 panel review members, then registered readers can contribute reviews. I have concerns about this approach. My sense is that there just aren’t that many high-quality submissions. We publish about 12–14% of submissions, not because of any quota, but because 12–14% warrant publication. Moreover, I think the review process is rigorous, and I see one of my critical roles is to maintain vigilance over the process. I see no advantage in handing responsibility over to people who are not skilled in the area. On the positive side, they encourage author responses so some “back and forth” can develop.

Aside from the niche we’ve established, there are two other specific innovations that, I believe, have advanced the field. The first, in Year 1, was that we never imposed a word count. The mantra was “as may words as it takes to tell the story”. A consequence was that over the years some other journals have adopted a more liberal view of word count. In hindsight, perhaps we should have adopted Einstein’s dictum and said it slightly differently, “As many words as it takes to tell the story and no more”. The constraint is not cost of paper, it’s patience of reader. And some tome-like papers do try our collective patience.

The other innovation, which just came in the past couple of years, is the Fast Track option. I described this in detail a few issues ago (Norman 2018). Basically, we encourage authors of studies that have been turned down elsewhere to submit them with the previous reviews and tell us how they’ve responded (or not). We’ve had nearly 100 Fast Track submissions over the past 2 years. We’ll be describing the process in more detail next issue.

Finally, it’s hard not to sound trite, but the success of the past 25 years was truly a team effort. My contributions pale alongside all the many hours contributed by dozens of editors and hundreds of reviewers over the years. When I read one of the many extensive and thoughtful reviews, I wish I could personally thank everyone. Somehow nice words don’t seem up to the task.

So to continue the sport metaphor, it’s time to pass the baton. Over to your capable hands, Rachel.

Where are we going?

I (RE) am not so foolish (I hope) as to make sweeping predictions of the future of health sciences education. Not only do we rarely get these predictions right, doing so feels like an attempt to lock things in so that the predictions must come true. A journal such as AHSE represents the collective thinking of a community of scholars and like any conversation it should be free to reflect how thinking changes over time and how the circumstances for thinking also change. To that end I see my role as facilitator of the conversation; maintaining the standards and opening the conversation for others to join and help it grow. Change is the only prediction we can make with some confidence.

For instance, Geoff notes that qualitative methodologies are in ascendancy in AHSE and across the field. There is much to support that perspective. But it is not just a matter of quantity; the standards of qualitative inquiry have risen, the variety of approaches in qualitative inquiry has grown, and the expectations regarding the utility of qualitative inquiry have increased over time. Perhaps the bigger picture is that our field has expanded and deepened the range of philosophies and methodologies that can and are used and that can advance our science as a whole.

We might equally say that we have expanded our focus [as Streiner and Norman (2009) encouraged] to include issues of effectiveness as well as efficacy. This reflects a more pragmatic perspective focused on exploring and critiquing what works, and how we can make things better (Cook et al. 2008) Rather than a seesaw of one philosophy of inquiry going up as the other goes down I see this as a maturing of a field around a mixed- and multiple-methods philosophy. Indeed, this plurality of approaches is a key characteristic of an applied field such as ours; it is the role of AHSE to create a space for these pluralities to be expressed and explored. And yet this cannot be a free-for-all. We are also charged with setting and maintaining standards in health sciences education, primarily in appraising and reviewing submissions, and advancing thinking about these standards in our field. As a journal, and as the editor for that journal, the role of steward (maintaining standards and quality) is as important as that of enabling and supporting the expanding discourses of health sciences education. This I see persisting independent of the kinds of science we pursue.

A challenge that all journals have faced (and continue to face) is the speed and depth of change in academic publishing. Journals are increasingly read online rather than on paper, articles are identified through searching Pubmed or other databases rather than by reading an entire edition of a journal, and open-source and other disruptive approaches have been added to traditional subscription-based business models. More worryingly, there has been a growing tension between publishers and academic institutions over costs and ownership. There is no prospect that this is going to be tidily resolved any time soon, my only other prediction is therefore that, while I do hope there will be a 50th anniversary editorial, the means by which it is produced and accessed are unlikely to be the same as those we use today.

A final concern, and one that may reflect my future imprint on the journal, is attention to equity and justice issues in the work we do and the conversations we have. The focus of this journal, like many others, is international in scope, and yet approaches to medical education and academics from the Northern Hemisphere and from high income countries dominate the discourse. While we do not assume that Western-style academic health sciences are superior any more than we assume that research originating in medicine is superior to that from other disciplines—something that Geoff ruled out in founding the journal—we could do better in how we represent different models of and approaches to health sciences education. Of course, we can only publish what is submitted and everything we publish needs to meet the quality standards required of our field. How we respond then is not just a matter of more of this and less of that, but one of encouraging and nurturing a nuanced and inclusive discussion about the sciences of health science education in all their varieties.

Advances advancing

Clearly, while some things have changed (the breadth of approaches to conducting science, the way we publish and consume academic knowledge), others have not (the importance of setting and maintaining scholarly standards, attention to ethical principles (Tolsgaard et al. 2019). In this we think the two of us are of a mind and see the handover as an evolutionary rather than a revolutionary step in the development of the journal. Gleefully mixing our metaphors, Geoff is off the hook and Rachel is rolling on the sleeve garters.

We would like to take the opportunity to thank all of our Deputy Editors, Associate Editors, our colleagues at Springer for their tireless work in making AHSE the journal it is today, as well as our many peer reviewers and authors. The continuing success of the journal is largely due to your selfless efforts.