Looking back, looking forward with CMAJ editors

On this special episode, Drs. Blair Bigham and Mojola Omole interview CMAJ editor-in-chief, Dr. Kirsten Patrick, and executive editor, Dr. James Maskalyk. They talk about the journal's accomplishments over the past year and some of the challenges related to its increased focus on social determinants of health and equity.

In the year ahead, Drs. Patrick and Maskalyk say the journal will focus on exploring topics related to access to care, and particularly encourage the submission of articles that discuss bold solutions that can bring about wide-reaching systemic change.

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole

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The CMAJ Podcast is produced by PodCraft Productions

Transcript

Dr. Mojola Omole:

Hi, I'm Mojola Omole.

Dr. Blair Bigham:

I'm Blair Bigham. This is the CMAJ Podcast.

Welcome to this special episode. We're not going to be talking about research papers or very much science. What we're going to do is go behind the scenes and look at the journal itself.

Dr. Mojola Omole:

So we're going to be speaking to both Kirsten Patrick, the Editor-in-Chief, and James Maskalyk, the Executive Editor.

Dr. Blair Bigham:

So Jola, we're going to interview our bosses today and take a look back and see how the year's gone, and also look forward to the year ahead and hear about what CMAJ has in store.

Jola, anything jump out at you from this year?

Dr. Mojola Omole:

This year has been a very eventful year in terms of moving the journal, under Kirsten's stewardship, towards focusing on health equity and also on anti-racism, anti-colonial practices. So I'm really looking forward to speaking to her about what the feedback has been from the CMAJ readership regarding these initiatives to move the CMAJ into the 21st century.

How about you, Blair?

Dr. Blair Bigham:

I think I've been surprised how, even when we pick super clinical topics, we always seem to wade into social determinants of health. And we talk a lot about the collapsing healthcare system and the under-resourced setting that we all work in, and I guess under-resourced is relative, but it does seem like we just don't have the tools to do what people need from us as healthcare providers. And I just love how every episode seems to just scratch away at the surface.

But I'm curious if James and Kirsten have some bright ideas about how CMAJ and how the healthcare system in general might be able to go beyond scratching the surface and actually start fixing what we seem to, every episode, describe as a crisis.

Dr. Mojola Omole:

For sure. And I would say that when you're talking to patients and you are asking them or you're giving them a diagnosis, the answers, like the questions they actually have is always about social determinants of health, is how now with this new diagnosis, am I going to be able to pay my mortgage? How am I going to be able to take care of my kids?

So it is something that is not just important for us as healthcare practitioners, but really for our patients, it's also top of their mind.

Dr. Blair Bigham:

So let's bring the bosses on the line and see what they think.

Kirsten Patrick is the Editor-in-Chief of CMAJ, and James Maskalyk is the newly appointed Executive Editor. Welcome to both of you.

Dr. Kirsten Patrick:

Thanks for having us on the podcast.

Dr. James Maskalyk:

Glad to be here.

Dr. Blair Bigham:

Kirsten, before we start talking about the future of the journal, let's look backwards over the past year. What stands out to you as a highlight of CMAJ's accomplishments?

Dr. Kirsten Patrick:

I think over the last year what stands out as something that you did cover on the podcast was the special issue on Black health and anti-Black racism in medicine in Canada, just because it was such a huge undertaking and it involved working with a committee, and a journey of learning, and it culminated in these two special issues, which seemed like such an achievement.

I also look at this podcast as one of the great achievements of this year. I mean, we started it a little over a year ago, maybe at the end of 2021, and it's going from strength to strength and I'm so happy to see our vision come to reality, and we've recently reached 100,000 downloads of the podcast and that's a huge achievement in less than a year. So yeah, congratulations to you both.

Dr. Blair Bigham:

It's been a lot of fun. But I want to go back to your highlight of the anti-Black racism in medicine special issue. That took an awful lot of work.

Jola, you were involved in that as well. What type of effort goes into that production?

Dr. Mojola Omole:

Kirsten, you can start.

Dr. Kirsten Patrick:

Well, I mean, Jola chaired the working group for a lot of the time and that was a big responsibility. ust because you have to be on the ball and have read all the manuscripts and kind of know which direction all the papers are going before we read them and before we discussed them. So Jola did a lot of the heavy lifting.

On the backend at CMAJ, we had three CMAJ editors who handled the manuscripts. We had such an overwhelming amount of really good stuff submitted for the special issue. And I think it was quite hard to make decisions about what could be in and what couldn't, and that's why it ended up being two special issues, just some quite groundbreaking stuff and interesting research along the lines that we've not had before. So it felt like it took things forward.

But you were asking about it being a huge undertaking. I mean, it was a lot of work. It was sort of at the forefront of my consciousness for the better part of the year, but it took a lot of work from a lot of people, like commitment from amazing folks on the working group, of which Jola was a part.

Dr. Blair Bigham:

Do you see that special issue being an example of something that would be replicated in the future as the journal evolves?

Dr. Kirsten Patrick:

So special issues are very difficult for a journal, especially a journal that's smallish like CMAJ. They're a huge undertaking. It's not like we're big like The Lancet and we can do special commissions every other year.

But I think it is something to focus on themes, and that is something that I've been talking about with James, going into 2023, is what theme are we going to focus on? Because what I did learn from the special issue is how you can take a conversation forward by really focusing on something. So if we focus on a theme and say, "This is something that we see as a huge problem in the healthcare system currently, we're going to focus on that for 2023," that helps us to attract the kind of groundbreaking articles that we would like to see.

Dr. Blair Bigham:

As we move into sort of our discussion of the future, what type of themes have been in discussion? What have you heard from CMAJ readers?

Dr. James Maskalyk:

I think the one in the forefront of our minds looking forward is access to care. And I know Canadians are interested in that and I know people around the world are as well too.

So the challenge with using it as a placeholder or an umbrella is that everything can almost be framed under access to care. Does racism stand in the way of Black Canadians accessing care in a safe way that's meaningful to them? Can Indigenous people access the care that they need by seeking traditional medicines if that's what their primary interest is? So I think that there are a lot of interesting opportunities to explore what that means to different people. And if you look at the ER overcrowding, that's the obvious one where our minds are at as people who are looking at a health system and we're thinking of the people who are boarded in those ERs for maybe a couple days before they get admitted to a hospital bed.

So that's just one place to start, but when you expand from it, kind of exploring what people actually need from the healthcare system, what they're actually looking for at the deepest level, and are they able to find it? I think it's just such an intriguing way to imagine a new version of a health system that works out for more and more people.

Dr. Kirsten Patrick:

The issue that keeps coming back to us is this overcrowding of EDs, closure of EDs, the crisis of nurses leaving, et cetera. And that's very much in the forefront of people's thinking like, "CMAJ really needs to highlight this."

But I would say we need to get to places where we're talking about solutions and not just tinkering around the edges solutions, but real solutions, real wholesale, break down the silos, rethink the system kind of solutions. And I think that's what we would be trying to go for when we are encouraging articles under the theme of access to care or fixing the health system crisis or whatever.

Dr. Mojola Omole:

Do you think that by being able to create that space to explore the solutions, when we talk about health equity and access to care, it can lead to meaningful change in the healthcare system?

Dr. Kirsten Patrick:

I like to think so, Jola, because I mean, if we think of the WHO's schema of health systems, it looks at these building blocks, some of which are resources, human resources, hospital infrastructure, the people that contribute to the healthcare system. But an important building block in healthcare systems is information. And journals provide this kind of rare place where you can put high-quality scholarly information that can lead and make a difference in the healthcare system.

So we are owned by the CMA, and CMA is interested in healthcare governance and healthcare change, but they also own us and we are a carrier of information and we need to strive for information that's really useful to making a difference. And then we go out there, as you know, like with the podcast and with Twitter and in other ways to spread that and see if we can get the word out there.

Dr. Blair Bigham:

I want to talk a little bit more about that, Kirsten. The information ecosystem has changed so much in the last decade. How have medical journals and how has CMAJ caught up to that to maintain their relevance? And are medical journals really the relevant institutions that they used to be when there's still sort of a process to peer review and what some would say is sort of a sluggishness to getting that information out to people?

Dr. Kirsten Patrick:

Absolutely. And we get this question. When I give talks about what journals do, I get this question all the time.

It is a rapidly changing ecosystem. So I would say over the last 20 years, what journals do has changed quite fundamentally. They used to have a monopoly on this information and I don't know that we were as good at producing reliable information as we should have been prior to the turn of the century, say. But now there are all these programs like the Committee on Publication Ethics, and the EQUATOR Network that comes up with checklists for reporting research and all that kind of stuff, and AllTrials that make sure that trial results are published, whether they get published in a journal or not, all those things that keep us to a higher standard.

So in the past, we used to be a repository for information. Now we know, because of the Internet, we're no longer the only repository for information, but what we do still have is this very clear vetting process. It's not a perfect process, but it's a process that aims to keep the standard of medical information really high.

And I think that came across well in the pandemic. Yes, there were frustrations because medical journals are slower, but we have medRxiv and people put up pre-prints. But then people still wanted to publish in journals, and journals did their best to be fast, and lots of studies changed a lot from pre-print stage to publication stage based on quality of peer review.

So I think journals are still very relevant in that quality of information space. And then we have to find out how to play our parts in this social media information ecosystem where loud voices and money and influence all play a part, right?

Dr. James Maskalyk:

And I'm just going to add, journals have never mattered more than they do now because you don't know what to believe when you go online. You don't even know if you can believe a video of a person online that appears to be legitimate.

And so that's where I think there's increasing relevance, to be honest, where you come to the CMAJ and you click on an article or you go to the podcast and you know that you're going to get relevant information that you can trust, and that, seems that threat no matter which way you're looking these days. So I think that's the position we're going to continue to hold.

Dr. Mojola Omole:

And James, Kirsten mentioned that there are the loud voices sometimes are the ones who are winning out, but how do we make sure that the journal is actually tapping into the questions and concerns of the broader community physicians?

Dr. James Maskalyk:

Yeah, I think it is. There's two ways that we continue to do it. And one is by being imaginative, imagining the questions that are going to excite a readership and the readership that turns to authorship is really what we're looking for. So that's our responsibility as a journal to be listening and reading and be truly curious about what the landscape of healthcare, not just in Canada is, but around the world.

And then the second is innovating with the times. So what that's going to look like in the coming years, we're going to do a series of journal literacy outreach throughout the country, and what I mean by that is we're going to have Kirsten, I hope, who's going to lead the charge on talking about what a journal looks like from the inside. I'll do a session on how to write persuasively, pitches, commentaries, how to form an argument. We'll get some of our research editors to talk about common mistakes in research they see, how to ask a valid question, what to do with research ethics boards, those types of things that we never really were taught in medical school as being important to our future.

But really, it is those people who write in our pages who change the medicine for future generations. There's no other place it happens. It doesn't happen in newspapers, it doesn't happen on Twitter, it happens on pages of medical journals. When the New England Journal publishes a medical journal about propafenone and atrial fibrillation being less or more superior to procainamide, that changes everyone's practice. And you have to believe in this iterative process of the clinical act getting more and more pure.  

But we really want to make the journal feel like it's owned by the readership. Fundamentally, perhaps, our budget comes from the CMA, but it's owned by the people who write to us and write for us and write within it. And if they knew how much time we spent really wishing them the best and talking about how to take their idea and make it ever more clearer and push it forward, I think that's also part of something we can do is really open the doors a little bit and let people into some of these conversations that are happening because we really want people to succeed. We really want that case report to get published. We really want that study to say what it really does, say what its results really are.

Dr. Mojola Omole:

As the journal is doing more papers highlighting social aspects of medicine, social determinants of medicine, like the anti-racism special issue we did, or just even talking about equity within medicine, how much pushback have you received from people who think we're moving away from the clinical context and concrete, as they say, evidence in medicine?

Dr. Kirsten Patrick:

A fair bit, Jola, I have to say, because I've been talking about this since I became interim Editor-in-Chief and I've been receiving comments and emails that I'm focusing on the wrong thing, that this journal has become too “woke”, that it's moving away from discussing medicine and healthcare, and things like anti-racism and patient involvement are not necessary to that conversation. Some people have canceled their memberships as a result or their subscriptions to the journal.

However, I do think that this is super important stuff. I mean, coming back to the issue of access, what we are hearing now is privileged people talking about how they're not getting access. And when privileged people, when doctors are talking about how worried they are that they can't get access in the healthcare system, then we know that folks who are historically marginalized are having an unbelievably hard time. And that's just the way it is. Social determinants, in the broadest sense, are extremely important to healthcare outcomes and it's therefore our responsibility to continue to shine a light on them, not just once but over and over again until people get it.

Dr. Blair Bigham:

Along those lines, Kirsten, I'm finding that a lot of my colleagues are, I'm as well, very burnt out over the current state of medicine. And I found a few years ago, it was the social stuff that would burn me out. It was social circumstances and trying my best to help people when I didn't have the toolbox to help them. But now it feels like even a new trial is just more than I can handle. I don't want more medical information. I'm drowning at work. I can't handle the social circumstances that are amped up on steroids right now that I just can't help. As you were saying, you don't even need to have social circumstances that make it difficult to access care. Nobody can access care right now. It's so difficult.

What is the role of the journal to feed our souls and inspire us as physicians beyond sort of delivering us new scientific content?

Dr. James Maskalyk:

I do some work in this space, the burnout space, having touched it myself here and there, and also being curious about its origins and how to mitigate it in myself and in other people. And I think one of the reasons why we are hurting so much as a group of people is you can't help but wonder, well, what do I believe in? Is this actually an enunciation of my deepest held beliefs of dignifying patients and giving them the best medicine that my country has to offer?

And so I think that what the journal can do is be a place for that deeper “why”. And what that might look like is, I hope, to have people use our pages to talk about their bold ideas about what the future would look like. 

Dr. Kirsten Patrick:

What I'd like to say is that CMAJ editors get that. We're not up in some ivory tower just rejecting manuscripts, right? We've got an ER doc on staff who's currently on sabbatical, and she's in the ER helping out because of overcrowding and understaffing. And we have a family doc on staff who's struggling in the way that family docs struggle.

So you talked about that in your last podcast with Tara Kiran a bit, about how important it is to work in collaborative teams and to feel a sense of community in medicine. And I think the journal can help a little bit with that. We have the Humanities section that allows a little bit of an outlet for folks to talk about their creative side. We've got commentaries and the blog where people can talk about ideas that they have and their opinions, and what they're feeling and what they're experiencing.

But I think what we would like to be able to do is be a vehicle for creating that change. And I'll come back to that thing, like be a vehicle for putting forward real solutions, not solutions that tinker around the edges, not a little incentive here or an incentive there, but what would wholesale change look like, that could make everybody feel like they weren't juggling 75 balls in the air all the time and never getting any sleep?

So that's what I hope the journal can be, a place for that, a conduit for that kind of thinking.

Dr. Blair Bigham:

So you both have an awful lot on your plate right now. We're talking about the journal's humanistic side, we're talking about bringing scientific rigor, both to the medical community and to the public at large in this rapidly evolving information ecosystem.

What does success look like to you both given all the challenges that you're facing? How will you know, next holiday season when we get to interview you again, that you've had a win in 2023?

Dr. Kirsten Patrick:

I'd like to be able to look back on the year and say, “we've had these articles that have hit it out of the park and changed something.”

I've got a couple that I look back on where I remember the hard work that I put in them, and I can see how many citations they get, and how they're still read really widely three years on, and all that kind of stuff. And one of them that we published during the pandemic that wasn't even about COVID was the Canadian Adult Obesity Guidelines, which were just so forward-thinking and they brought in a patient perspective, and they talked about weight stigma, and they were so groundbreaking that they just have had so much attention and citations. Other countries are looking to that guideline.

So, just to be able to, in a year, look back at what we've published and say, "Yeah, that made a difference," and hopefully there will be a lot of those things.

And I mean, I look back on the podcasts that you've done over this year, and I think some of them, phrases from within them, still resonate in my head. And I think, "Gosh, if I was listening to that and hearing it, I would feel heartened. I would feel like I'd learned something. I would feel motivated to move forward in my practice." So I hope we can look back at the end of 2023 and say the same thing.

Dr. James Maskalyk:

Yeah, that's inspiring. And I share much of the same vision.

What I would most love to see and what I will work most fastidiously on creating is trying to make the journal feel like a home for more people. Meaning, there's a relaunch of the blog soon to CMAJ Opinion, and I've got some people in mind who are going to write some provocative and solution-oriented shorter pieces, kind of more in keeping, perhaps, with our modern attention spans.

And I want the comments sections to be lively. I want it to be lightly moderated, if at all. I want it to be accountable and I want it to be a place where people can return to just because they love the idea that medicine is never perfect. It's only better. It gets only better as we talk about it.

That's it. And that's the spirit that lives in the journal, that's the spirit that is there with you when you walk into the doctor's offices of the hospital in which you work that's preceded us by hundreds and thousands of years. It's of really wanting the best for someone you don't even know. And I just believe in that so much, despite all evidence to the contrary in our modern time. I’ve just devoted my life to it.

Dr. Blair Bigham:

I want to thank both of you for chatting with us today. It's been a lot of fun. Thank you so much for making time.

Dr. Mojola Omole:

Thank you so much for joining us.

Dr. Blair Bigham:

Thank you, Blair, and thank you, Jola.

Dr. James Maskalyk:

Thanks, Jola. Thank you, Blair.

Dr. Blair Bigham:

Kirsten Patrick is the Editor-in-Chief of CMAJ. James Maskalyk is the newly appointed Executive Editor.

Jola, it's been a year.

Dr. Mojola Omole:

It's been a bit more than a year, and it's been a very wonderful year, I would say.

Dr. Blair Bigham:

It's been awesome. What do you think of Kirsten's vision for the future?

Dr. Mojola Omole:

I feel that she has been the perfect editor for CMAJ as society and medicine itself is changing and she's really met the moment of let's take a step back and actually start viewing medicine and health as not just disease processes, but also just the social implications of what's happening.

I know for some people, having that change is difficult. And the question, well, why do we have to examine whether it's racism or homophobia in medicine? Why isn't it just about your high blood pressure? And personally for me, I feel like that comes from a place of privilege because for those who are marginalized and who are racialized, our blood pressure has never just been about the number. It's also been about the systemic factors that lead us to have high blood pressure.

So I feel like Kirsten's vision for CMAJ really does meet the moment of what's happening in the greater social conversation about what medicine and health is.

Dr. Blair Bigham:

Absolutely. We had always said over the last year that we would try to bounce back and forth between a social episode and a clinical episode. And what we found, it seemed like every time we tried to focus on a clinical topic, we would get all of these social contributors to that, all these systemic flaws that were leading those clinical problems to be difficult to solve.

And so I feel like as we go into the next year, we should keep in mind that although the clinical essence of what we do is front of mind, there's so many other things that we've learned this year doing this podcast by speaking to patients, by speaking to experts, that have really advanced how I clinically practice, in addition to some of the science and medicine that we more traditionally think about.

Dr. Mojola Omole:

Yes, and I think when I was in med school, this is another Toronto comment, I was at UofT and we had a course called the Arts and Science of Clinical Medicine. And I think oftentimes, people consider the art to be soft skill, but really it is what is at the heart of what practicing medicine is. And what I've learned this year, same as you, is that, really, the talking about social determinants of health and the art of practicing medicine is what makes a difference in our patients' lives.

Dr. Blair Bigham:

Absolutely, if we don't have that true, trusting relationship, we're not going to be able to influence their behavior so that they make healthy choices.

Dr. Mojola Omole:

A hundred percent. And also, not just our patients making healthy choices, but our politicians and policymakers to make healthy choices for our system to actually function well.

Dr. Blair Bigham:

Well Jola, let's go into the new year with some New Year's resolutions. Let's aim to keep this podcast real, keep it current, and get a little bit more political and bring about some of those highlights about how we can actually change the system. Kirsten had said we need massive change and the only way we're going to do that is if we're political and if we continue to chirp at the norm and try to make things better for the people out there.

Dr. Mojola Omole:

A hundred percent. And it's having those uncomfortable conversations, and it's learning to be okay with being uncomfortable and that you might hear something, you might read something in the CMAJ that might make you uncomfortable, and that might make you even angry at the beginning, but maybe if you take a second, take a beat, and you go back to it, there might be some truth behind what's making you feel uncomfortable and explore what that is.

So I want to go into the new year, in terms of the podcast with increased curiosity about topics, even those that make me uncomfortable.

Dr. Blair Bigham:

Before we wrap up, we just want to thank our producer, Neil. Neil spends countless hours making sure that all of our guests and us are scheduled and on the air sounding good so that you can enjoy listening to this podcast and hopefully take something away in your own practice and your own lives.

Dr. Mojola Omole:

And I just want to say a special thank you for Neil for having patience with us, even though we act like it's our first time ever doing a podcast every single day.

Dr. Blair Bigham:

We have technical difficulties every single episode, Jola.

Dr. Mojola Omole:

We do.

Dr. Blair Bigham:

We're not quite professionals yet.

Dr. Mojola Omole:

And mostly, we want to thank you guys. Thank you so much for listening. Thank you for sharing because of your dedication to supporting the podcast, we've seen this podcast audience grow, and that's because of all your hard work.

And as Blair always says, please feel free to comment and share and tell us what you want to listen to hear more from us. So, thank you very much.

Dr. Blair Bigham:

And we're looking forward to deepening the conversation. Get in touch with us by email, get in touch with us on Twitter or social media. We're happy to always chat about the really cool topics that end up on the air.

Dr. Mojola Omole:

I'm currently on Post and Mastodon. I'm just joking.

Dr. Blair Bigham:

I'm Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole. Until next year, be well.

Neil Morrison:

No, this is the new year though. It's January 2nd.

Dr. Blair Bigham:

Oh.

Dr. Mojola Omole:

Oh, this is January 2nd?

Neil Morrison:

Yeah.

Dr. Mojola Omole:

Oh, okay. So just be well, I don't know.

Neil Morrison:

I feel like leaving this entire exchange in.

Dr. Mojola Omole:

That's all we got for you.

I'm Mojola Omole. Until next time, be well.