Observing Objective, Structure, Clinical Examinations (OSCE)
IRB Reform In North America: Challenges And Opportunities
Emerging Patterns In The Resistance To The Medicalization Of Birth In
Suffer The Little Children
A More Objective Approach For Selecting The Journal To Which One Submits
Observing Objective, Structure, Clinical Examinations (OSCE)
Objective, structure, clinical examinations (OSCE) are increasingly
used to examine clinical skills in both undergraduate and
postgraduate students in the UK (1). As suggested by their name, the OSCEs
are intended to reduce subjectivity amongst examiners by having
This objectivity of marking as well as the structure of the
examination, where all students are asked to answer the same
questions and perform
the same procedures, is intended to make OSCEs 'fairer' than
other types of clinical examinations, such as short and long
I have now taken part in six OSCEs - four as a clinical medical student
and two as a 'sim', or simulated patient. My first experience on the other
side of the couch was as a young woman who wanted to start taking the
contraceptive pill. Fourth year medical students had to determine whether
or not I was an appropriate candidate for the pill and explain to me how
to take it and what to do if I missed one. More recently, third year dental
students were asked to perform an extra- and intra oral examination on
me. As a postgraduate student trying to get by on something similar to
the minimum wage, the incentive of £9 an hour to do almost nothing
is irresistible. Although it makes for a rather mind, or mouth, numbing
morning, being a sim patient can have its interesting aspects.
In terms of advice for students, I learned two key things. Firstly, remembering
to introduce yourself can make the difference between passing and failing
(3). In both exams, specific marks were allotted for introducing yourself
and confirming the patient's identity. Secondly, communication skills
(3). In the medical exam, there were three marks assigned to 'overall
impression'. These weren't awarded for knowledge but for confidence, demeanor
and ability to put the patient at ease and treat with respect.
In addition, I also have a number of reflections on the whole process
of OSCEs. To begin with, I feel a small sense of injustice that I never
had the chance to take part in an OSCE as a sim patient before, rather
than after, taking part as a student. Having the opportunity to observe
a number of individuals perform exactly the same task gives you a very
good sense of what works and what doesn't. Everyone has to develop a clinical
style that they feel comfortable with. Being on the receiving end of a
number of different approaches to the same problem is a great way of identifying
just what aspects you might want to incorporate into your own style.
OSCEs could, therefore, be used as a learning experience for one group
of students at the same time as an examination procedure for another.
Undergraduate, like postgraduate students, are a willing and constant
source of labor. Disclosure of exam contents from student sim patients
should be of no concern since (4) it is easy enough to find out what appeared
in last year's OSCE by simply asking someone who took it.
Next, there were one or two dental students who managed to hurt me. Not
hurting the patient is a golden rule of exams, and clinical medicine in
general. However, the OSCEs that I have taken part in had no way of assessing
distress caused to patients. It would have taken minimal training and
time to ask me to mark each student on their gentleness and include this
at the bottom of the examiner's mark sheet. In fact, there are numerous
examples in the literature, particularly from the USA, where sim patients
are trained to do some or all of the marking at OSCE stations (5-7). This
not only allows the patients to comment on 'how it was for them', but
can also remove the need for a separate examiner altogether if sim patients
are trained to perform all the marking. In turn, this can make OSCEs cheaper
and easier to run, as fewer clinical staff are required.
Lastly, the OSCEs that I have taken part in as a medical student have
provided no real opportunity for feedback on my performance. Whilst one
of the main aims of exams, particularly in the later stages of the course,
is to confirm that students will make safe practitioners (8,9), failing
to provide feedback beyond an overall mark is a wasted opportunity. The
General Medical Council has recently emphasized the need for formative
(where students are given feedback on their performance), as well as summative
(where students are graded on their performance) assessments in medical
education (10). One of the identified benefits of OSCEs are the opportunities
they give for formative assessment and feedback (2).
OSCEs are an opportunity for each individual student to be observed by
experts in a number of different clinical encounters. It makes sense to
make use of this unique opportunity to provide all students with an assessment
of their performance that goes beyond pass or fail. Again, there are examples
of this in the literature, particularly from the USA, where students are
given feedback either after the exam or as part of each OSCE station (2,5).
One possible way of providing individualized feedback would be to ask
examiners to write, or dictate, a few sentences on each student between
stations. These notes could then be transcribed, collated and returned
to students with their marks. Such a procedure would not be particularly
onerous and would allow students to learn from the experience of the OSCE,
as well as the preparation beforehand.
OSCEs were first trialed in 1975 (11) and despite varied responses from
both staff and students (12-16), they look set to stay with us.
Although they are undoubtedly an improvement on the old 'long cases' in
fairness (1), the current use of OSCEs in the UK seems to present
a number of missed opportunities in terms of both education and efficiency.
Jean Adams, BMedSci, MBBS
School of Population and Health Sciences
University of Newcastle upon Tyne
Many thanks to Prof. John Spencer and Dr. Martin White (both
of Newcastle University) for engaging in discussions that
help shape the arguments presented in this article.
1. Wass V, Jones R, Van der Vleuten C. Standarised or
real patients to test clinical competence? The long case
revisited. Medical Education 2001;35:321-325.
2. Carraccio C, Englander R. The objective structured
clinical examination: a step in the direction of competancy-based
Archives of Pediatrics and Adolescent Medicine 2000;154(7):736-741.
Wass V. Getting through OSCEs. Student BMJ 2000;8(9):361-362.
4. Varma S. Should candidates be given their marked up
papers back after examinations - the case for. Student BMJ
5. Duerson M, Romrell L, Stevens C. Impacting faculty
teaching and student performance: nine years' experience
with the objective structured
clinical examination. Teaching and Learning in Medicine 2000;12(4):176-182.
6. Merrick H, Nowacek G, Boyer J, Robertson J. Comparison
of the objective structured clinical examination with the performance
of third-year medical students in surgery. American Journal
of Surgery 2000;179:286-288.
7. Mavis B. Does studying for an objective structured clinical
examination make a difference. Medical Education 2000;34:808-812.
8. Weetman A. Should candidates be given their marked up
papers back after examinations - the case against. Student
9. Kaufman D. Assessing medical students: hit or miss. Student
10. Tomorrow's Doctors: Recommendations on Undergraduate
Medical Education. July 2002. http://www.gmc-uk.org/global_sections/sitemap_frameset.htm
11. Harden R, Stevenson M, Wilson Downie W, Wilson G. Assessment
of clinical competence using objective structured examination.
British Medical Journal 1975;1:447-451.
12. Kearney P. OSCEs don't work. Student BMJ 2000;8(3):123.
13. Green T. OSCEs are useful to assess particular skills.
Student BMJ 2000;8(4).
14. Morris C. Objective structured clinical examination.
Student BMJ 2001;9(7):303.
15. Mottram V. Objective structured clinical examination.
Student BMJ 2000;8(2):82.
16. Phillips S. OSCE oscars. Student BMJ 2000;8(4):168.
IRB Reform In North America:
Challenges And Opportunities
Clinical research is necessary to advance medical knowledge and
to test new drugs or devices. It is therefore vital to society,
and ethically imperative, that clinical studies be performed
if patients are to have access to safe and effective treatments. However,
research by its very nature involves risk. Subjects who volunteer
in clinical studies may receive no benefit; in fact, they may
harmed or even die as a result of their participation. Indeed,
injuries and deaths, though relatively few in number (1), have
become the subject of much controversy in recent years (2). Thus,
protection of human research subjects must be given the highest priority
their institutions, and the government and regulatory bodies
charged with overseeing the clinical research process. Central
is the institutional review board (IRB) in the United States
(U.S.), or research ethics board as it is known in Canada. (For
the purpose of this paper, the term "IRB" will be used to refer to both
American and Canadian boards.) The IRB has frequently been referred
to as the "first line of defense" in research subject protection
(3), yet the specific roles and responsibilities of this board
and its members are not clear (4). Defining these roles and responsibilities
is more important now than ever before, for several reasons.
IRBs in crisis
First, biomedical science is advancing at an unprecedented rate, and
the number of clinical studies is increasing exponentially (5). This situation
can only add to the strain on already over-burdened IRBs (6). Numerous
articles in recent literature have made reference to the "crisis" in
American IRBs (7,8), being unable to cope with the sheer volume of protocols
they are asked to review, and the "pressure-cooker atmosphere" (9)
IRB members must contend with as they struggle to balance the interests
of subjects with those of the researchers. A report commissioned by the
Law Commission of Canada indicates that Canadian IRBs are not faring any
better (10). The U.S. Office of Human Research Protection (OHRP; the agency
responsible for oversight of IRBs in the U.S.) concluded in a 1998 report
that IRBs review "too much, too quickly, with too little expertise" (6),
and that the entire system was "in jeopardy" (6). Though there
is no equivalent to the OHRP in Canada, Canadian IRBs have not
escaped criticism (11,12) or calls for reform (10,13). Clearly, IRBs in
America are overwhelmed under the current system. It is not reasonable
to expect these same IRBs to handle double or triple their current
workload without a significant reduction in the quality of their reviews.
are to continue to be relied upon as the primary safeguard of
clinical trial volunteers, a clear mandate for their roles and responsibilities
must be established. In defining these roles and responsibilities,
may be possible to lessen the current burden on IRBs by delegating
certain responsibilities to other committees or regulatory bodies. Alternatively,
recognition of the many obligations of the board and its members
result in provisions for increased support to give the members
the resources they need to do their job properly.
Liability and the IRB member
The second reason for the impetus to define the IRB's specific roles
and responsibilities is the alarming, albeit not new, threat
of personal legal liability of IRB members. The U.S. National Commission
for the Protection
of Human Subjects Report and Recommendations: Institutional Review
Boards, published in 1978, clearly states that IRB members may
liable "for malpractice or negligence in discharging their IRB functions" (14).
Angela Holder, a legal expert on human subject research, was
quick to respond in her 1979 article "Liability and the IRB Member:
The Legal Aspects", that such a thing would never actually happen
(15). Times have changed. In 2001, a lawsuit filed on behalf
of subjects who had participated
in a study of a melanoma vaccine at the University of Oklahoma
named twelve IRB members as defendants (16). The 130-page complaint
allegations, including inadequate procedures for the manufacturing
and safety testing of the vaccine, failure to adhere to the protocol
inclusion/exclusion criteria, incomplete informed consent documents, and
IRB to meet its federal regulatory obligations (16). The individual
IRB members were accused of negligence in their duties (16).
This precedent-setting case sent shockwaves through IRBs across North
IRB members are, for the most part, volunteers who commit a tremendous
amount of time and energy to the onerous task of reviewing the hundreds
of protocols that pour into their institutions each year. Their work is
often not respected by researchers, who tend to view the ethics review
process as "a bureaucratic pain in the neck" (3). IRB members
face a great deal of pressure from researchers, sponsors, institutions,
and even the public to push through protocols at a rate that cannot possibly
be consistent with a meticulous and thoughtful consideration of all the
ethical issues at stake. Though the IRB has the power to require revisions
to protocols, "exercise of this power does not enhance a committee's
popularity within its institution" (17). In addition, IRB members
must make difficult decisions about increasingly complex protocols that
do not fall neatly under any guidelines currently in use (17). These decisions,
which often come down to judgment calls, require "a fair exercise
of intelligence and discretion on the part of IRB members" (18).
As one article describes it, "the quality of an IRB's work depends
to an inordinate degree on the conscience and commitment of its volunteer
members" (19). The idea that individual IRB members could be held
legally liable for these decisions is disturbing. This threat of legal
action may result in IRBs rejecting more protocols than they approve,
or reviews so painstakingly thorough that the review process effectively
grinds to a halt (20). It will undoubtedly serve as a deterrent to future
IRB members, at a time when it is already difficult to fill these positions
(20,21). However, no one would suggest that IRB members be exempt from
accountability. Certainly, even without a proper set of guidelines, one
would expect IRB members to carry out their duties in a conscientious
manner. But knowing precisely what they will be held accountable for,
and what protections are in place for them, will be essential if these
individuals are to be expected to continue this important work without
fear of litigation.
The IRB in the public eye
Finally, for clinical trials to proceed and potentially life-saving treatments
to reach patients who need them, researchers need the public's trust.
Donors, funding agencies, government, and most importantly, clinical study
volunteers and their families, all want assurance that a solid system
of checks and balances is in place to protect research subjects. Without
the public's trust, the system cannot function. Unfortunately, this trust
has been eroded in recent years by high-profile incidents involving the
tragic deaths of research subjects, and the allegations of misconduct
that followed. As Dennis De Rosia, chairman of the Association of Clinical
Research Professionals, said in an interview, "Each time you have
one of these incidents, there's a rash of publicity, and it gets harder
to recruit volunteers" (22). Most notable among these are the cases
of 18 year-old Jesse Gelsinger, who died while participating in a gene
therapy trial at the University of Pennsylvania (23), and 24 year-old
Ellen Roche, a healthy volunteer who died after inhaling hexamethonium
as part of an asthma study at Johns Hopkins (24). Both of these cases
drew international attention when failures of the research subject protection
system were uncovered. Since 1998, the OHRP has suspended or restricted
research at over a dozen institutions due to IRB inadequacies, including
such prestigious institutions as Duke (25) and Johns Hopkins (26). In
both Canada and the U.S., research related deaths and injuries have landed
IRBs or their sponsoring institutions in court (27,28). Subsequent investigations
have often directed much of their criticism at the IRB involved (20).
The reports themselves often reflect expectations of the IRB that are
simply unwarranted. As an example, the report of the external review committee
for the Johns Hopkins incident faults the IRB for not having a pharmacologist
on their board (29). Yet none of the current guidelines for IRB membership
contain any reference to a requirement for the presence of pharmacologist
(30), nor is it obvious that "rigorous pharmacological review" (29)
is the responsibility of the IRB (31). Discrepanciessuch as these serve
as excellent examples to illustrate why the IRB
and its members must be given a specific framework within which
to act. The public's
faith in the system is flagging (2,22); a clear set of responsibilities
for the IRB would put an end to finger-pointing that further
damages that faith.
Coping Strategies And Solutions
Several mechanisms have arisen over the past few years as means to cope
with the over-burdening of local IRBs. As a result of the significant
increase in industry funded research, commercial or "for-hire" IRBs
were established. Commercial IRBs now exist in both Canada and the U.S.,
though official information on the number of these boards operating in
either country is lacking (18). These IRBs primarily review research to
take place at research centers affiliated with pharmaceutical companies,
at contract research organizations, or in private clinics by medical professionals
not associated with academic research institutions (32).
Review through these IRBs is faster and arguably better and more consistent
than that obtained through traditional IRBs, given the stipulations these
boards may hold regarding the education and expertise of their members
and the fact that there is less turnover in their membership. Using a
commercial IRB for a multicenter trial may also save time and money by
allowing researchers to forgo multiple, redundant reviews of the same
protocol at each individual site (32). However, serious concerns have
arisen regarding the inherent conflicts of interest that exist within
commercial IRBs (18,32). Whether the commercial IRB is one set up by a
pharmaceutical company to review research on its own products, or an independent
review board on contract to review research taking place elsewhere, in
both cases the IRB is a for-profit enterprise. Academic IRBs have also
been criticized for conflicts of interest, as IRB members may be motivated
by their desire for career advancement, future opportunities for collaboration,
or even maintaining friendships with colleagues when reviewing protocols
(33). However, because academic IRBs are non-profit institutions, these
concerns - at least in terms of financial conflicts of interest - are
less obvious. Further problems with commercial IRBs arise when a researcher
who has a protocol rejected by one IRB simply takes it to another. The
researcher has no obligation to inform an IRB of previous submissions
of the same protocol, nor does an IRB have access to any other IRB's review.
The problem of "IRB shopping" is a serious one, and one that
did not exist when the traditional IRB was the only channel through
which a researcher could have their protocols reviewed. Similarly, independent
IRBs are not required to monitor the research they have approved,
the case for traditional IRBs. Independent IRBs may also lack
the familiarity with local research conditions and culture that traditional
Thus, while the commercial IRB fills an important niche in the
context of the current ethics review system, it is not without problems,
it a replacement for the traditional IRB. In fact, because there
are no clear rules and regulations for IRB review, oversight and accountability,
commercial IRBs are no better equipped than traditional IRBs
to meet the
challenges posed by the present system.
A second development in recent years is the creation of the central IRB
(CIRB) for multi-center trials. This CIRB could perform a detailed review
of the science and experimental design of a protocol for multi-center
trials, eliminating the need for the IRB at each individual site to repeat
this process (34). The local IRBs could then expedite their review of
a protocol approved by the CIRB, focusing their attention on local issues
the protocol may present (such as institutional policies, or language
differences that may require changes to the consent form), rather than
needlessly duplicating the review of the scientific aspects of the protocol
(35). An added advantage of the CIRB would be in managing the ongoing
monitoring of these trials. Safety reports and annual study reports from
multicenter trials comprise a significant proportion of the workload of
local IRBs (7). A centralized approach to monitoring these trials would
not only free up more of the local IRBs time and resources to put toward
other responsibilities (such as review of local studies), but may in fact
result in more effective review of adverse events. The CIRB would be reviewing
reports of adverse events from all individual sites in the context of
the trial as a whole, a comprehensive view that most local IRBs do not
have. Furthermore, the CIRB would have access to reports by data and safety
monitoring boards (DSMBs) and information from the sponsor that is not
available to local IRBs, but which could be crucial in making decisions
with respect to monitoring. The CIRB approach is currently in the pilot
phase at the National Cancer Institute in the U.S. (34). This pilot model
was established in order to increase patient access to National Cancer
Institute-supported trials. With sixteen members, all cancer experts,
from both academic and community organizations across the U.S., the CIRB
initially served 22 local institutions (34). Results so far have been
promising, and plans are presently underway to expand to serve 100 (34).
However, challenges still remain in terms of the division of responsibilities,
both between the local and CIRB and between the CIRB and other bodies
(such as the DSMB). Another potential complication is that local IRBs
may also want to continue to conduct complete reviews of protocols even
after CIRB approval if they are concerned about being held accountable
for the decision to approve. This is another instance where defining responsibilities
for IRBs would facilitate quicker reviews and more effective collaboration
between partners in the review process.
A third way in which the research ethics review system is attempting
to deal with its ever-increasing workload is by rethinking how the IRB
manages its many obligations. By most accounts, monitoring is the function
that IRBs perform most poorly. Canadian (11) and American (36) reports
indicate that few IRBs conduct any monitoring beyond reviewing annual
study reports, the bare minimum requirement in both countries (14,37).
Papers in recent literature have proposed that monitoring should be delegated
to a separate body, particularly for multi-center trials (7,34). Both
the Office of Human Research Protection and the Food and Drug Administration
in the U.S. are encouraging greater use of DSMBs, and the National Institutes
of Health now require an independent DSMB for all Phase III trials (1).
Others suggest that certain aspects of monitoring, such as consent monitoring
(determining whether research subjects understand the risks and benefits
of the research they are being asked to participate in) be delegated to
a subcommittee of the IRB, or an intermediary (38). While at present these
proposals are just that - proposals - the idea of delegating some of the
IRB's responsibilities is attractive. Many IRBs already assign some aspects
of the review process, such as the review of contracts between clinical
investigators and sponsors, or the assessment of statistical power of
clinical trials, to individuals who are not members of the IRB. While
the danger exists that adding several subcommittees or consulting bodies
will increase the time and red tape involved in reviewing protocols, the
reassurance that all the functions of the IRB are being fulfilled by persons
with the expertise to perform them properly makes the additional layer
of bureaucracy worthwhile. The IRB can then concentrate its time and efforts
on thorough primary reviews and oversight of local studies.
In considering any changes to the current system, it must be kept in
mind that the IRB's primary purpose is the protection of research subjects.
This mandate cannot be achieved without a formal regulatory framework
within which the IRB can operate. Such a system would need to establish
standards harmonizing national and international laws and policies. A
single set of clear guidelines is required with respect to conflicts of
interest, division of duties, and accountability. The IRBs need greater
support from government and their institutions, both in terms of funding
and staff, as well as training and ongoing education for IRB members and
How close is this major overhaul to becoming a reality? It may be closer
than it seems. Last fall, an Institute of Medicine committee
delivered its recommendations for improving research subject protection
in the U.S.
(39). A central theme throughout the report is easing the strain
on IRBs by reducing their workload and increasing their resources. Among
are calls for a national registry to track research participants,
as well as the creation of a CIRB. The report also contains a plan to
the IRB's functions into three committees: one to evaluate the
scientific merit of a protocol, one to assess potential conflicts of interest,
a third to integrate all the
information, consider other issues and make a decision.
The Institute of Medicine plan also proposes a no-fault compensation
system for subjects who are harmed as a result of their participation
in research, thereby avoiding litigation. It remains to be seen
whether these changes will be implemented, and whether Canada will adopt
strategies. If our governments, granting agencies and institutions
recognize the value of clinical research and the independent ethics review
accompany it to our society, then they must also recognize that
this important issue needs to be addressed, and deserves our
Marjorie Ellen Zettler, B.Sc.
Division of Stroke and Vascular Disease
St. Boniface Research Centre and
Department of Physiology, University of Manitoba
1. Office of Inspector General. Protecting Human Research
Subjects: Status of Recommendations. Washington, D.C. Department
of Health and Human Services, 2000.
2. Drennan KB. Have the ultimate benefits of clinical trials
been maligned beyond repair? DDT 6(12): 597-599; 2001.
3. Lemonick MD, Goldstein A. At your own risk. Time 159(16):
4. Hirtle M, Lemmons T, Sprumont D. A comparative analysis
of research ethics review mechanisms and the ICH Good Clinical
Practice guideline. Eur J Health Law 7: 265-292; 2000.
5. No author listed. Anticipating a clinical investigator
shortfall. Centerwatch 8(April): 1,5-13; 2001.
6. Office of Inspector General. Institutional Review Boards:
A Time for Reform. Washington, D.C. U.S. Department of Health
and Human Services, 1998.
7. Burman WJ, Reves RR, Cohn DL et al. Breaking the camel's
back: multicenter clinical trials and local institutional review
boards. Ann Intern Med 134: 152-157; 2001.
8. Levine RJ. The crisis in institutional review boards. Ann
Intern Med 134: 161-163; 2001.
9. Phillips DF. Institutional review boards under stress:
will they explode or will they change? JAMA 276: 1623-1625; 1996.
10. McDonald M. The governance of health research involving
human subjects. Law Commission of Canada. Ottawa, Ontario, 2000.
11. Weijer C, Shapiro S, Fuks A et al. Monitoring clinical
research: an obligation unfulfilled. CMAJ 152(12): 1973-80; 1995.
12. Thorne, D. Researchers put patients at risk. Edmonton
Journal. September 28: B3; 2002.
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Protection of Human
Subjects of Biomedical and Behavioral Research. Federal Register
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IRB member: the legal aspects. IRB 1(3): 7-8; 1979.
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January 29, 2001.)
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18. Lemmens T, Freedman B. Ethics review for sale? Conflicts
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78(4): 547-84; 2000.
19. Edgar H and Rothman DJ. The institutional review board
and beyond: future challenges to the ethics of human experimentation.
Milbank Q. 73(4): 489-506; 1995.
20. Anderlik MR, Elster N. Lawsuits against IRBs: accountability
or incongruity? J Law Med Ethics 29(2): 220-228; 2001.
21. Foubister V. Clinical trial patients sue IRB members.
Amednews.com. February 26; 2001.
22. Abate T. Special report: experiments on humans. San Francisco
Chronicle. August 5; 2002.
23. Stolberg SG. The biotech death of Jesse Gelsinger. N Y
Times Mag Nov 28: 136-140, 149-150; 1999.
24. Smaglik P. Asthma study death spurs inquiry. Nature 138(5):
25. Shamp J. Agency halts federally funded Duke research
on new patients. Herald-Sun (Durham NC). May 12: A1; 1999.
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after death. New York Times. July 20: A1, A18; 2001.
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28. Kus v. Sherman Hospital. (1995). 268 Ill App 3d 771,644
29. Cassel C, Stock MC, Wood A, Zapol W, Hellman S. Report
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Emerging Patterns In The Resistance To The Medicalization Of Birth In
Childbirth is one of the most ubiquitous experiences of human
life. It is an integral ritual of the life cycle. Nevertheless,
different cultures have evolved strikingly varied practices
As such, one might argue that in any society, "the way a woman gives
birth and the kind of care given to her point as sharply as an arrowhead
to the key values in the culture” (1).
Within the last century, the process of childbirth has increasingly taken
place within the realm of medicine: in a hospital, attended by a physician.
This medicalization of childbirth is especially evident in Western societies
with an established technomedical infrastructure such as in "non-Indigenous" North
America and societies where the medicalization of birth has been imposed
such as in Inuit communities. This paper will explore women's concerns
regarding the medicalization of childbirth, as illustrated by the example
of the Inuit women in Canada.
In North America, the ritual of birth was once the dominion of women,
but has since been incorporated into the practice of medicine, causing
a shift of "authoritative knowledge" from older women and midwives
to trained physicians. The increasing reliance of medicine on technology
within North American society has permeated the realm of childbirth. In
so doing, the framework of empirical science has been introduced into
the birthing process, perpetuating the values of a technologically-oriented
society. One might argue that "[b]y making the naturally transformative
process of birth into a cultural rite of passage, a society can ensure
that its basic values will be transmitted" (2). Many feel as though
the process of childbirth is being "sterilized" and its cultural
and emotional content diminished.
Many "non-Indigenous" North American women feel as though they
are being alienated from the birthing process and have lost control of
their own bodies. As such, women are increasingly seeking alternatives
to hospital deliveries (3). There has been a recent and marked resurgence
of homebirths and reliance on midwives. Midwifery allows women to play
a larger role in their deliveries, and returns the process of childbirth
to the home: roughly half of all midwife-attended births are performed
in the home (4). Until 1992, midwifery was illegal in Canada when Ontario
became the first province to legalize midwifery. Since then, four other
provinces including Quebec have followed suit and midwifery is becoming
an increasingly accepted alternative to hospital childbirths (3). In 2000,
4% of Ontario births were attended by midwifes and by the year 2004, the
percentage is estimated to rise to 10% (4).
The experience of Inuit women in the last few decades provides an even
more salient example of the institutionalization of childbirth and its
separation from community life. In traditional Inuit culture, an expectant
woman was followed throughout her pregnancy and assisted in childbirth
by a midwife and several women helpers (5). Traditional midwives received
no official training, but were taught how to deliver by older women. Hence,
the skills associated with midwifery were passed on from generation to
generation. The knowledge of midwives was considered indispensable and
midwives were accorded much respect within the community. In fact, the
ability to assist in childbirth endowed women with a sense of pride and
empowerment in a predominantly patriarchal society (6). In addition to
an honoured position within society, a special relationship existed between
the children and the midwives who delivered them. An Inuit boy gave the
midwife who delivered him his first catch, and a girl, the first item
she sowed (5). For the Nuu-chah-nulth people of British Columbia, the
term midwife translates as "she who can do everything." Hence,
depriving these women of assisting in childbirth is tantamount to removing
them from their influential and honoured position in society (7).
In addition to the reliance on midwives and women helpers, several other
aspects of traditional Inuit childbirth are worth mentioning. Unlike current
Western practices, such as those outlined in the 2002 National Guidelines
for the Childbearing Years (8), an expectant woman was to remain highly
active throughout her pregnancy, performing all her daily chores until
the advent of labour. It was thought that such activity would give the
woman the strength needed to deliver (5). Women would give birth in rapidly
constructed snow houses in either a squatting or kneeling position with
the midwife behind them (6). The midwife would often enlist the help of
the pregnant woman's husband and female relatives, thus involving the
whole family in the process of childbirth (5).
The traditional Inuit process of childbirth, as described above, was
practiced without scrutiny until the 1960s. During the 1960s, so-called
Nursing Stations were set up throughout the Canadian North and deliveries
were relegated to officially-trained, licensed midwives within these stations.
Although traditional Inuit midwives were legally excluded from these deliveries,
these Nursing Stations nevertheless permitted women to deliver within
their communities, surrounded by their families. Since the 1980s, however,
due mostly to a shortage of professionally trained midwives, deliveries
must be performed within hospitals in cities far removed from the Northern
communities. Today, Inuit women are "evacuated" three weeks
before their due date and sent to hospitals in cities, such as Winnipeg,
where obstetricians perform their deliveries. Hence, within three generations,
Inuit women have experienced a transition from birth performed by a traditional
midwife in the context of the home and family, to birth performed by a
professional midwife in a Nursing Station within their community and presently,
to birth performed by a physician in a hospital far removed from their
Since the practice of sending women to distant hospitals began, Inuit
women have repeatedly expressed their dissatisfaction with the current
system. In fact, since its inception in 1984, a primary concern of the
Inuit Women's Association has been the issue of childbirth (5,9). The
concerns about the system in place centre around five main issues: (1)
the women sent to distant hospitals experience loneliness and alienation,
(2) the family is removed from the process of childbirth, (3) the separation
of the expectant woman from herhusband and children causes undue strain
on their relationship, (4) the skills and knowledge of traditional Inuit
midwives are being eradicated, and (5) Inuit children are receiving out-of-territory
birth certificates. Inuit women feel as though their control over childbirth
has been usurped by the government and that they have now become dependent
on health care services. The status previously endowed by the knowledge
of childbirth on midwives and women in general has been perturbed by the
forced reliance on the expertise of faraway physicians.
According to John O'Neil and Patricia A. Kaufert (6), the practice of
sending Inuit women to distant hospitals is a manifestation of "internal
colonialism." Although a discussion of Inuit childbirth as an extension
of colonialism is beyond the scope of this paper, this idea serves to
illustrate the clash of cultures at hand. The imposition of the Western
culture's birthing practices on the Inuit community has left many Inuit
feeling robbed of yet another aspect of their culture and heritage. The
Western culture which tends to dissociate childbirth and illness, in general,
from community life is in sharp contrast to the Inuit culture which views
childbirth and illness as being integral and continuous aspects of community
As the current situation remains unfavourable to the majority of Inuit
women, a compromise of some sort must be reached. Such a compromise was
articulated at a workshop held in the Inuit community of Keewatin in 1988
and relies on a cooperation between traditional midwives and obstetricians
such that high-risk deliveries would be performed by obstetricians and
low-risk deliveries by traditional midwives. Although the death of a newborn
was traditionally viewed as "meant to be," Inuit women overwhelmingly
approve of seeking the expertise of an obstetrician for high-risk deliveries,
but wish to be given the choice to have their births performed by traditional
midwives in the case of low-risk deliveries. A spokeswoman for the Inuit
Women's Association spoke of a system that will "look into the past
to find the elements that can be adapted to contemporary conditions to
ensure that the knowledge and experience of the elder midwives is retained
as part of Inuit heritage” (5). Others, however, are proponents
of a more confrontational approach. Women in the community of Puvirnituq
have returned to performing traditional-style births and have reclaimed
their dominion over the childbirth process (10). These women are doing
so illegally. When Quebec legalized midwifery in 1999, Quebec law failed
to recognize training programmes other than the one offered at the Université du
Québec in Trois-Rivières. The women training at the Innuulitsivik
Health Centre in Puvirnituq are unable to apply for a midwifery license.
Negotiations are under way between the provincial Ministry of Health and
the Inuit community, and offer promise that the traditional apprenticeship
model of training midwives will be officially recognized (7).
It is likely that in the years to come, the trend towards the deinstitutionalization
of childbirth will be amplified, though technology's value in reducing
infant and maternal mortality will undoubtedly ensure that it remains
an integral component of childbirth. However, "[t]he issue is not
whether technology is good or bad in and of itself, but under what circumstances
should it be used, when does it augment the quality of life of those who
use it, when does it detract from that quality, and, perhaps, most importantly,
who has the power to decide what is appropriate use” (11). A better
understanding of these issues and a discussion of the needs and
concerns of those involved will likely enhance the quality, safety and
of tomorrow's childbirth practices.
Gillian Morantz-Ornstein, B. Sc.
Louis-Patrick Haraoui, B. Sc.
1. Kitzinger S. Women as Mothers: How They See Themselves
in Different Cultures. New York, NY: Vintage Books, 1980.
2. Davis-Floyd RE. Birth as an American Rite of Passage
in Childbirth in America: Anthropological Perspectives.
In: Michaelson KL,
editor. South Hadley, MA: Bergin and Garvey Publishers,
3. Davis-Floyd RE, Sargent C. Introduction: The Anthropology
of Birth Childbirth in Childbirth and Authoritative Knowledge:
Cross-Cultural Perspectives. In: Davis-Floyd, RE, Sargent
CF, editors. Berkeley, CA:
University of California Press, 1997.
4. Holliday T. The re-emergence
of Canadian midwifery: A profession dedicated to normal birth.
2001 9. Inuit Women's Association. 1984-1985 Resolutions. www.birthinternational.com
5. O'Neil JD, Gilbert P. Childbirth in the Canadian North:
Epidemiological, Clinical and Cultural Perspectives. Winnipeg,
MB: University of Manitoba, 1990.
6. O'Neil JD, Kaufert P. The Politics of Obstetric Care: The Inuit
Experience in Births and Power: Social Change and the Politics
of Reproduction. In: Handwerker W. Boulder, CO: Westview
7. Carrol D, Benoit C. Aboriginal midwifery in Canada:
Blendingtraditional and modern forms. CWHN Network 4:5-10;
8. Nutrition for a Healthy Pregnancy- National Guidelines for the Childbearing
Years, Health Canada, 2002.
9. Inuit Women's Association. 1984-1985 Resolutions.
10. Daviss BA. Heeding Warnings from the Canary, the Whale, and
the Inuit. A Framework for Analyzing Competing Types of
Knowledge about Childbirth in Childbirth and Authoritative
Knowledge: Cross-Cultural Perspectives. In: Davis-Floyd, RE,
Sargent CF, editors. Berkeley, CA: University of California Press, 1997.
11. Michaelson KL. Birth Place/Birth Style in Childbirth in
America: Anthropological Perspectives. In: Michaelson KL.
South Hadley, MA: Bergin and Garvey Publishers, 1988.
Suffer The Little Children
Doctors and patients have come to expect a cure for most every
illness and condition. Unfortunately for both groups, this
is not always possible. When faced with the prospect of the imminent
death of a patient,
doctors may exhibit curative attitudes and perform interventions
which may not be in the best interest of the patient. Referral to
care may become the only appropriate avenue of treatment, yet
it may never be offered. Nowhere is this seen more clearly than in
the treatment of
a dying child. The lack of healing services provided to terminally
ill children is alarming. This dearth of pediatric palliative care
the history of palliative care, societal attitudes about dying
children, the current standard of medical education, the limited experience
with death, and the issues of required parental consent. These
factors cumulatively affect the interactions between doctors, parents
faced with a terminal illness.
The World Health Organization has defined pediatric palliative care as "the
active total care of patients whose disease is not responsive to curative
treatment. Control of pain, of other symptoms and of psychological, social
and spiritual problems is paramount. The goal of palliative care is achievement
of the best quality of life for patients and families (1)." Contemporary
society is obsessed with curative treatment. The last one hundred years
have seen a dramatic increase in medical technology. Many once-fatal diseases
are now mere inconveniences and science has given doctors incredible tools
to eradicate illness and death. With respect to children, world mortality
rates have been declining steadily. The chance of a newborn dying before
its fifth birthday is seven percent, down from 25 percent in 1950 (2).
This decrease is due largely to advances like pre-natal care, antibiotics,
immunizations, and surgical repair of anomalies.
Before the many scientific advances, a physician's role was fundamentally
different. Without the many curative measures that we have today, death
was much more common and different skills were in demand. Because of their
inability to cure, doctors used a palliative approach to comfort and ease
the burden of death on patients and their families. Today the curing role
has superceded this healing role because science has given us the opportunity
to do so.
The ability to cure has changed the focus of medicine. With all the life-saving
measures that exist, it is difficult for many to believe that nothing
curative can be done. While the ability to prolong life may be possible,
it is questionable whether or not it is advisable. In medicine, curing
has been associated with life while palliative care has been linked with
death. One reason why these associations exist: it seems to be easier
for physicians and family to accept that a person died because heroic
This direct association of palliative care with death makes its implementation
an uncomfortable decision when children are concerned. Dying children
defy the natural order (3). While elderly individuals and their families
may be more open to palliative care, parents and doctors of children seem
to be reluctant to implement it. Those who have lived a long life are
more apt to accept its final, inevitable, conclusion. Since they hold
out no hope for a permanent cure, palliative care can be a desirable option
for terminally ill adults. The Institute of Medicine states that a "decent
or good death is: free from avoidable distress and suffering for patients,
families, and caregivers; in general accord with patients' and families'
wishes; and is reasonably consistent with clinical, cultural, and ethical
standards (4)." Achieving this is the main goal of palliative care.
However, this goal of palliative care is not envisioned in pediatric
situations. One reason is lack of pediatric palliative care training and
education. Training programs in the United States, like those offered
by the American Academy for Hospice and Palliative Care, focus primarily
on adults. There are no established national standards for pediatric palliative
care curriculum (5). As a result, only 10 percent of pediatric oncologists
have had formal courses and only 2.2 percent have undergone a clinical
rotation in palliative care (6). In addition, undergraduate medical education
in the United States has focused predominantly on palliative care for
adult and geriatric patients (7). Therefore, the established adult model
of seeking a cure, then palliating until death, is being applied to children.
This model does not necessarily fit the situation experienced by caregivers
of children. In what has been called the Persephone syndrome, a course
of disease that is fraught with rebound-relapse episodes may lead family
and other care providers to be more persistent in pursuing aggressive
therapy for prolonged periods of time in hope of yet another astonishing
recovery (8). Because the adult model is cure or palliate, these children
never receive palliative treatment. They are perceived as being perpetually
in the cure stage, despite terminal illness. The logical conclusion would
indicate to use both curative and palliative treatments, but, because
of current educational practices, the combination of potentially curative
and palliative medicine currently escapes us (9). Even the World Health
Organization's definition of pediatric palliative care as quoted earlier
in this paper seems to artificially separate curative and palliative efforts.
Further complicating the issue, pediatricians are relatively inexperienced
with death. On average, a general pediatrician will come into contact
with 3 children per year who will die (10). This limited exposure has
two major effects: first, pediatricians lack experience dealing with the
complex emotions related to death; and second, they report feeling a sense
of guilt about their inability to cure. As a result, a common reaction
is to separate themselves emotionally and physically from the dying children
and their families (11).
Although adults involved in the medical care of family members want dying
parents not to suffer, they expect their children to outlive them. When
families are faced with the terminal illness of a child, they are presented
with many challenges, some of which the medical system imposes upon them.
They receive an overwhelming amount of technically complicated information
from which they must make difficult decisions about the fate of their
child. They may feel that an incorrect choice will cause undue suffering
or death. As a result, families in these situations prefer to be guided
by their practitioners (12).
Unfortunately, this creates a situation where pediatricians may influence
parental attitudes and behavior. The feeling that the inability to cure
a child is a personal failure, combined with a lack of education in pediatric
palliative care, makes pediatricians reluctant to provide palliative care
as an option. Even those pediatricians that do receive adult palliative
care training are reluctant to turn care over to another clinician because
of their strong relationship with the patient and his or her family (13).
This makes the family see only one course: cure or nothing. This is unfortunate,
because the decision of when to provide end-of-life care is paramount.
Delay causes difficulties in tailoring treatment and exacerbates feelings
of vulnerability and helplessness in the family and patient (14). Because
of the paradoxical issues previously discussed, doctors are waiting for
the family to decide to stop the curing process while the family is expecting
the doctor to inform them when curative treatments should be abandoned.
As a result, neither party actively initiates the discussion of terminal
care. This can lead to prolonged suffering. "The need to do everything
is a powerful force. This is relevant when interventions focused on cure
are no longer reasonable and may well be harmful” (15).
In a Wisconsin study of dying children whose parents had received a palliative
care consultation, they found a significant decrease in the administration
of blood tests, central lines, feeding tubes, gastrostomy tubes, endotracheal
tubes, x-rays, and paralytic medications compared to children whose parents
had not (16). This study suggests that once palliative care is introduced
as an option, invasive medical procedures with limited benefit are refused.
Misconceptions about children needing protection from pain, assumptions
about their ability to understand, or the thought that they are too young
to be affected continue today (17). In one study of dying hospitalized
children in Edmonton between January 1996 and June 1998, only one child
among 77 was documented as being specifically told that they were dying
(18). Though legally unable to give informed consent, the "assent" of
sick children may be weighed heavily by parents and doctors in deciding
a course of treatment. When children are not informed that they are dying,
they cannot make any direct contributions to their care. Because the parents
and the child are not both directly included, they have no opportunity
to work together in deciding the best course of action (19). Therefore
the patient's best interests may not be met.
The combination of these factors contribute to the lack of palliative
care options offered for pediatric cases. Parents are dependent on the
pediatrician to help make choices about end of life care. The pediatrician
is not trained in offering such options, and the child is essentially
uninvolved in the process. Since parents are not presented with the option
to provide palliative care, they see stopping curative treatment as stopping
all treatment for their child.
There is some academic work being done in the area. Some schools, like
The Johns Hopkins Children's center, offer a one-day seminar
to residents (20). Several articles have been written recently (21,22,23)
that awareness of the problem is growing. The issues at hand
are: does medical intervention really lead to an improved quality of life
Are the necessary facilities and training available to residents
and students to assist them in this aspect? Can doctors make better use
and training that already exist? These are issues that must remain
in the spotlight. Only by focusing on them will palliative services for
become more utilized in the future.
Garrett Reed Bird, B.Sc.
Faculty of Medicine, McGill University
John Hilton, M.Sc.
Faculty of Medicine, McGill University
1. World Health Organization. Cancer Pain Relief and Palliative
care in Children. World Health Organization, Geneva 1998.
2. WHO/67 press release 12 October 2000. http://www.who.int/inf_pr_2000/en/pr2000_67.html.
3. Hilden JM, Himelstein BP, Freyer DR, Friebert S, Kane JR:
End-of-Life Care: Special Issues in Pediatric Oncology. In Foley KM, Gelbrand
H eds. Improving Palliative Care for Cancer. National Academy Press, Washington,
2001. pp 161-198.
4. Institute of Medicine. Approaching Death: Improving Care at
the End of Life. Washington, DC: National Academy Press; 1997.
5. Hilden, Himelstein et al., 2001.
6. Hilden JM, Emmanuel EJ, Fairclough DL, Link MP, Foley KL,
Clarridge BC, Schnipper LE, Mayer RJ: Attitudes and practices among paediatric
oncologist regarding end of life care: results of a 1998 American Society
of Pediatric Oncology survey. Journal Clinical Oncology 2001;19:205-212.
7. Billings JA, Block S. Palliative care in undergraduate medical
education. JAMA 1997; 278:733-738.
8. Feudtner C, Christakis DA, Zimmerman FJ, Muldoon JH, Neff
JM, Koepsell TD: Characteristics of deaths occurring in children's hospitals:
implications for supportive care services. Pediatrics 2002; 109:887-893.
9. Hilden, Himmelstein et al., 2001.
10. Sahler OJE, Frager G, Levetown M, Cohn FG, Lipson MA: Medical
education about end-of-life care in the pediatric setting: principles,
challenges and opportunities. Pediatrics 2000;105:575-584.
11. Sahler et al., 2000.
12. Frager G: Paediatric palliative care: building the model
bridging the gaps. Journal of Palliative Care 1996;12:9-12.
13. Hynson, JL and Sawyer, SM. Annotation: Paediatric palliative
care; Distinctive needs and emerging issues. Journal Paediatrics Child
14. Frager 1996.
15. Penny NP, Frager G: Refractory symptoms and terminal sedation:
ethical issues and practical management. Journal of Palliative Care 1996;12:40-45.
16. Pierucci RL, Kirby RS, Leuthner SR: End-of-life care for
neonates and infants: the experience and effects of a palliative care
consultation service. Pediatrics 2001;108:653-660.
17. Pettle SA, Britten CM: Talking with children about death
and dying. Child: Care, Health and Development 1995;21:395-404.
18. McCallum DE, Byrne P, Bruera E: How children die in hospital.
Journal of Pain and Symptom Management 2000;20:417-423.
19. Liben S: Pediatric palliative care: obstacles to overcome.
Journal of Palliative Care 1996;12:24-28.
20. Serwint JR, Rutherford LE, Hutton N, Rowe PC, Barker S, Adamo
G: "I learned that no death is routine": description of a death
and bereavement seminar for pediatrics residents. Academic Medicine. 77(4):278-84,
21. Dangel T: The status of pediatric palliative care in Europe.
Journal of Pain & Symptom Management. 24(2):160-5, Aug 2002.
22. Beardsmore S, Fitzmaurice N: Palliative care in paediatric
oncology. European Journal of Cancer. 38(14):1900-7; 1908-10, Sep 2002.
23. Shah R, Ting T, Taylor P, Glover J: The increasing need for
pediatric palliative care. West Virginia Medical Journal. 98(3):104-7,
A More Objective Approach For Selecting The Journal
To Which One Submits A Manuscript
There is considerable variability in the methods authors use
to identify journals for manuscript submission, and this
process may be difficult for some junior (and even some more senior)
investigators. Given the wide range of potential journal-candidates
for any article being submitted, we believed that a grid-instrument
might help authors explicitly set journal selection priorities
that reflect realities, hopes, and expectations. Our model
is based on five main steps for authors. Step one: authors
individualized criteria for submission. We produced a research-
and pragmatically-based model list of criteria and subcriteria,
and subjected it to a modified Delphi process with participants
that ranged from junior investigators to seasoned editors.
Our proposed list for authors' initial consideration includes:
prestige, likelihood of manuscript acceptance, quality of
review, rapidity of turnaround, and intangibles. Step two: authors
weight criteria by importance/priority for that particular
that particular manuscript. Step three: select potential
candidate journals. Step four: score each criterion on a grid for each
candidate journal. Step five: calculate scores, and rank
All five steps are explained in greater detail in our full
model description, and examples of model grid implementation
This method is rapid and can be engaging, and could make
the submission process more efficient and effective. It
should be particularly useful for those authors with little
experience or external guidance, and for more senior authors who wish
make their journal selection process more explicit.
A five-step analytic model
|1. Identify the priority setting criteria
|2. Weight the criteria
|3. Select the candidate journals
|4. Rate each criterion
|5. Calculate priorities
|Figure 1. Overview of the journal
selection priority-setting process
Authors' motives and methods for choosing a goal journal for manuscript
submission vary.(1) Such decisions are probably typically made
implicitly and informally, with a view to achieving the highest
commensurate to the quality of the proposed manuscript.(1) Manuscript
submission is accompanied by much uncertainty on how the material
will be judged (2). Considering the vast array of existing journals,
the wide range of potential journals (and editorial reactions)
for any article being submitted, it might be beneficial to identify
instrument that helps authors explicitly and parsimoniously set
journal selection priorities, in keeping with their own expectations.
priority setting would enable authors to both structure and refine
their thinking about this often subjective topic. The model is
based on five main steps (Figure 1) that are outlined below.
Step 1: Identifying the main priority-setting criteria
The first step is to select which criteria to consider in deciding where
to submit an article. Our model is outlined below, but authors should
modify this model with their own procedures and considerations. To create
our list, we produced a provisional list of criteria and subcriteria taken
from prior work (1) and guided pragmatically. The list was submitted to
16 colleagues from various nationalities (Italy, Australia, USA, Russia,
UK) and healthcare domains, who had in common experience as authors in
national and international peer-reviewed journals. Many of these individuals
had also served as reviewers and editors, and some were the junior faculty
who are potential users of this method. Using the received observations,
we constructed a final list, and propose including the following five
criteria (Table 1): "Prestige", "Likelihood of acceptance", "Quality
of review", "Rapidity of turnaround" and "Intangibles".
||The importance attributed to a particular journal.
|Likelihood of acceptance
||Perception of the probability of a certain article
being published in a certain journal.
|Quality of review
||Perception of the fairness of the reviewer process
and that, whatever the outcome, there will be a benefit
|Rapidity of turnaround
||Speed with which the editor of a journal passes judgement
on an article.
||Perception of other mainly
subjective advantages, such as
preference for a certain journal,
the need to diversify one's
production, acquaintance with an editor, etc.
|Table 1. Overview of the journal
selection priority-setting process
Step 2: Weighting the criteria
In addition to selecting criteria, weighting the value of each assigned
criterion also drives the outcome. In using our proposed method,
authors would need to attentively assess the quality of their work, the
with which they desire publication versus their need for prestigious
publications, etc., in accordance with the criteria and subcriteria listed
in step 1. The author should weight each criterion on a scale of 0 to
10, conforming with the above considerations. The criterion deemed most
important by the author is assigned a value of 10 and the other criteria
are rated accordingly. The scale is a rational scale, and the importance
of the various criteria are represented proportionally, i.e. a value of
4 corresponds to an importance rating half the value of 8 and twice the
value of 2. Decimal fractions of the points on the scale can also be used.
A weight of 0 signifies that zero importance is attributed to that particular
criterion for that particular manuscript. If there is more than one author,
scoring could be conducted via a simplified two-round delphi method in
which authors iteratively discuss (either electronically or through other
media) and achieve consensus on their reasons for assigning particular
weights. Scoring likely should be independent in the first round, but
each author may revise his/her ratings on being informed (perhaps in aggregate,
anonymous form) of the other authors' scores. A final determination could
be made in a second round, with a decision created using consensus, a
mean of authors' ratings, or other criteria.
Step 3: Selecting the candidate journals
The choice of candidate journals chiefly depends on an assessment of
the manuscript and its prospects, the authors' personal objectives,
and the objectives of the institutions for which the researchers work.
task is to reduce the extensive array of journals published throughout
the world to a list of desirable candidates for subsequent ranking.
A list may be generated from the authors' familiarity (keeping files on
experiences with journals may help), colleagues' knowledge, a
search in a local library, or via the Internet. One easily accessible
source, for instance, is that of the journals listed by the main
databases (3) or leading Impact Factor (IF) calculating companies (4),
provide a service online and/or the option of receiving a free
Step 4: Rating each criterion
Most criteria proposed in this article require substantial subjective
assessment, with only rapidity of turnaround and prestige (through using
a journal's IF or Immediacy Index or readership composition) being more
heavily based on objective elements. Each criterion's score should be
represented on a scale of 0 to 10, identifying for each criterion the
highest-ranking journal and giving it a rating of 10. Other journals will
then be given a score directly or inversely proportional to that of the
best journal. For example, if three journals (a,b,c) typically present
a turnaround of 2 (a), 4 (b) and 10 weeks (c), the score given to the "Turnaround
rapidity" criterion will be 10 for journal (a), which has the greatest
rapidity. The score for journal b will be calculated by solving
for x: a score of x is to a score of 10 as the inverse of 4 weeks
is to the inverse
of 2 weeks
(i.e. x:10=1/4:1/2; or x=5) and the score for journal c bythe
formula x:10=1/10:1/2 (i.e. 2). Some readers may find it easier
to consider score calculation in the following way, solving for
x: for journal b,
a score of x (for journal b) is to a score of 10 (for journal
a) as (using the inverse proportion, since a higher number of
weeks is a worse outcome)
2 weeks is to 4 weeks (i.e. x/10=2/4; or x=5) and the score for
journal c by the formula x/10=2/10 (i.e. 2). Where there is more
than one author,
the delphi methodology described in step 2 may be used.
CRITERION 1: PRESTIGE
Definition: The importance attributed to a particular journal.
Specific considerations: A journal's prestige generally depends on reputation,
reliability, circulation size, availability, and news coverage. There
are somewhat objective methods for the measurement of prestige that rely
mainly on citations in scientific journals; while these have been challenged
and require critical, cautious adoption, they form a useful guide. The
main methods of this kind are the Impact Factor (IF), measuring the frequency
with which the "average article" in a journal has been cited
in a particular year after publication, and the Immediacy Index, which
considers citations made during the publication year of the quoted items.
Another objective subcriterion is journal circulation, which can be measured
by number of copies and readership estimates. The author may also be interested
in impact via mass media and hence the level of attention paid to journals
by the main press agencies. And prestige must be set in the context of
specialty, particular objectives, and geography. For example, a laboratorian
may prefer to publish a certain work in a journal from his/her own field
rather than in a general medicine journal, even if the latter has a higher
IF. Similarly, a European author might prefer to publish a work in a good
national peer-reviewed journal than in a more renowned international one,
bearing in mind the English-language barriers experienced in some countries
and the author's desire for use/recognition of the work in their home
country. In sum, the "prestige" criteria consider the relationship
between perceived journal quality and appeal, and the ensuing personal
and/or institutional benefits.
Instructions: A subjective assessment must be made for each journal on
a scale of 0 to 10 that considers such factors as reputation, reliability,
circulation, availability, media coverage, and IF. The journal considered
to be most prestigious should be assigned a score of 10, and the other
journals proportionally lower scores. Where consideration is limited to
just the IF, we are faced with an objective criterion. In this case, the
journal with the highest IF will be given a score of 10 and the other
journals a proportionally lower score in relation to their respective
IFs. Let's suppose, for example, that there are three candidate journals:
BMJ, Annals of Internal Medicine and New England Journal of Medicine,
for which the IFs in 2000 were 5.331, 9.833 and 29.512, respectively.
In this case, the New England Journal of Medicine will be assigned a criterion
score of 10, BMJ a score of 2 (by approximation), derived by calculating
the proportion 29.512:10=5.331:x, and the Annals of Internal Medicine
a score of 3 (by approximation), derived by calculating the proportion
Data sources: IF values are published annually by the Journal of Citation
Reports (JCR) of the Institute for Scientific Information (ISI). The report
may be purchased from the ISI, or may be consulted at many medical libraries.
As for subjective assessment, subcriteria might include prestige assigned
to a journal by (a) colleagues at one's institution, (b) colleagues outsideone's
institution in one's field, (c) other colleagues outside one's discipline,
(d) one's Chair, (e) the promotions committee at one's institution, or
(f) lay people to whom one will talk about one's work.
CRITERION 2: LIKELIHOOD OF ACCEPTANCE
Definition: Perception of the probability of a certain article being
published in a certain journal
Specific considerations: This crucial point requires both an impartial
view of one's paper (a skilled task) and a very good and current knowledge
of the rejection rate, how the target journal is managed, its mission,
and the sequence of publications on the same topic. Considerations should
include appropriateness of style/manuscript type and content, ability
to apply results to the journal's audience, a past record with the target
journal, and personal acquaintance with the Editor. Generally speaking,
the difficulty in being accepted increases as a journal's prestige increases.
Achievement of personal objectives thus demands careful weighting of all
Instructions: A subjective assessment must be made for each journal
on a scale of 0 to 10 that takes account of factors such as those above
described. The journal considered to be most advantageous must be assigned
a score of 10 and the other journals proportionally lower scores.
Data sources: This is a criterion with many subjective and even unknowable
aspects, but it is helpful to know the aims, target and rejection
rate of potential journals; these can often be gleaned from the instructions
for authors, which are usually available on the Web.
CRITERION 3: QUALITY OF REVIEW
Definition: Perception of the quality of the review process and that,
Specific considerations: The helpfulness of the suggestions contained
in the reviewed manuscript is linked to the ability of the editorial staff
and pool of referees used by the journal, and concerns both the text and
statistics/tables. Quality revisions make for good working relations,
opportunities for professional growth, and improved articles. This criterion
may warrant higher esteem than some authors might accord it, particularly
for first submissions.
Instructions: As with the prior criteria, a subjective assessment must
be made for each journal on a scale of 0 to 10 that takes account of factors
such as those described above, and the journal considered to be most advantageous
should be assigned a score of 10 and the other journals proportionally
Data sources: This is a subjective criterion chiefly based on one's own,
or one's colleagues' experiences, perceptions, and expectations.
CRITERION 4: RAPIDITY OF TURNAROUND
Definition: Speed with which the editor of a journal passes judgement
on an article.
||10 (2 weeks)
||50 (10 weeks)
||5 (4 weeks)
|Table 2. Example of Priority Scores
calculated for three journals (a,b,c) before submitting an
Specific considerations: Another critical parameter is the speed with
which the journal reviews manuscripts and gives authors decisions. Many
journals seem to give increasing attention to this factor, thereby shortening
response times, in some cases taking advantage of communication by fax
or entirely electronic communications. Some hard copy and on-line journals
offer the interesting opportunity of following the revision process via
Internet. Waiting times of 6 months and over, which still unfortunately
occur, are becoming even less acceptable, with the result that many authors
are becoming more able to act on a preference for journals that provide
rapid reviews and decisions.
Instructions: Whenever possible, an objective assessment must be made
for each journal on a scale of 0 to 10. The journal considered to be most
rapid must be assigned a score of 10 and the other journals proportionally
lower scores. If data are not available, this criterion cannot be applied.
Data sources: The rapidity of turnaround is sometimes indicated by the
journal in the section of the Information for Authors that outlines their
peer review process. In other cases, this information is based on one's
own experience or that of colleagues, and can occasionally be inferred
from acknowledgement letters.
CRITERION 5: INTANGIBLES
Definition: Perception of other mainly subjective advantages, such as
an aesthetic preference for a certain journal, acquaintance with an editor,
Specific considerations: Lastly, there are less concrete factors that
explicitly consider personal taste. These elements include personal preference
for a certain journal, its editorial and graphical style, a liking for
the editor or a member of the editorial board, or the desire to diversify
the journals in which one publishes.
Instructions: A subjective assessment must be made for each journal on
a scale of 0 to 10 that takes account of factors such as those above described.
The journal considered to be most advantageous must be assigned a score
of 10, and the other journals proportionally lower scores.
Data sources: It is a subjective criterion.
Step 5: Calculating priorities
The final choice of journal is made at the end of the process, using
a simple mathematical priority-calculating formula. After weighting and
rating the criteria, the total score can be calculated for each journal
included in the author's list of candidates. Practically speaking, each
criterion score is adjusted by the weight given to each criterion.
Let us consider a finite number of candidate journals (a, b, c, ...)
based on a finite number of criteria (1,2,3,4,5) which are given criterion
weights (W1, W2, W3, W4, W5); these criteria and their weights are the
same for all the candidate journals. Each journal also receives criterion
scores (S1, S2, S3, S4, S5) which are calculated for each criterion for
each alternative journal.
The formula to calculate the priority score for journal (a) would therefore
be as follows: Priority score forjournal (a) = [(criterion weight of criterion
1) x (criterion score attributed to journal a for criterion 1)] + [(criterion
weight of criterion 2) x (criterion score attributed to journal a for
criterion 2)] + [(criterion weight of criterion 3) x (criterion score
attributed to journal a for criterion 3)] + [(criterion weight of criterion
4) x (criterion score attributed to journal a for criterion 4)] + [(criterion
weight of criterion 5) x (criterion score attributed to journal a for
criterion 5)] = [W1 x S(1a)] + [W2 x S(2a)] + [W3 x S(3a)] + [W4 x S(4a)]
+ [W5 x S(5a)].
Each of the 5 criteria receives a score based on its merits vs. those
of the other candidate journals (see Table 2). Let's suppose for journal
(a) that the maximum criterion score is given to "Prestige" (i.e.
a score of 10), a score of 5 to "Likelihood of acceptance",
a score of 5 to "Intangibles", a score of 9 to "Quality
of review", and a score of 10 to "Rapidity of turnaround".
Each of these scores is multiplied by the weight previously attributed
to each criterion (for this example, let's assign: "Prestige"=10; "Likelihood
of acceptance"=7, "Intangibles"=2; "Quality of review"=4; "Rapidity
of turnaround"=5). Hence, the total score for journal (a) becomes:
WS=(10x10) + (7x5) + (2x5) + (4x9) + (5x10) = 100+35+10+36+50 = 231. Priority
scores are then calculated for the other candidate journals in the list
(b, c, d, and e), which are then ranked, and the journal with the highest
score gets priority of submission.
Given this high score, an author may choose to first submit the paper
to journal (a). If the paper is rejected by journal (a), the author, preferably
after revision based on reviews, may submit the article to journal (b),
which presents the score immediately below. In the event of rejection
by (b), the author may behave in two ways. S/he may decide to submit the
manuscript to journal (c) or, since journal (c)'s ranking is well below
that of journal (a) (231) and (b) (206), may opt to repeat the assessment
process with additional candidate journals. These candidate journals for
reassessment (c, d, e) must be considered according to the first-time
assessment procedure, as described above.
Comment on the model
The proposed method is drawn in part from the Donaldson & Sox model
for priority setting for the Office of Health Technology Assessment of
the Agency for Healthcare Research and Quality, designed to determine
which of the countless available health care technologies should be subject
to systematic yearly assessment (5). Our model considerably simplifies
theirs, particularly mathematically, and is (to the best of our knowledge)
the only published method for objective determination of journal selection
This novel approach to journal selection is a quantitative model. It
is suggested because of its explicitness, and its ability to bring together
different concepts and units of measurement in the same scale. It clarifies
selection criteria, acknowledging their definitions, main characteristics,
importance, and subjectivity. Subjective criteria may still prevail; while
this method does not provide objective standards, it begins to pragmatically
and explicitly outline the subjective and objective criteria for choosing
the journal to which one submits a manuscript for publication. While some
might find it rigid, time consuming, or overly quantitative, the method
could be useful both for experienced authors who wish to make more explicit
the criteria they use for deciding manuscript destinations, and for more
junior authors whose lack of experience might benefit from a rational
Mariotto, Aldo, M.D.
Medicine Service, Head, Health Authority No. 2,
" Isontina", Italy
Frank, Erica, M.D., M.P.H.
Associate Professor and Vice Chair, Department of
Family and Preventive Medicine, Emory University
School of Medicine
1. Frank E. Authors' Criteria for Selecting Journals. JAMA 1994 ;272:163-164.
2. Hojat M, Gonnella JS, Caelleigh AS. Impartial Judgment by the "Gatekeepers" of
Science: Fallibility and Accountability in the Peer Review Process. Adv Health
Sci Educ Theory Pract 2003;8:75-96.
5. Donaldson MS, Sox HC. Setting Priorities for Health Technology Assessment:
A Model Process. Washington, DC: National Academy Press, 1992.