Fifty Years of Critical Care Medicine: The Editors' Perspective.

Abstract

The first article published in this journal was the transcript of Max Harry (“Hal”) Weil’s address as the first elected President of the Society of Critical Care Medicine (SCCM). Recounting the history of the formation of SCCM, Weil included this two-sentence paragraph: In February 1971, the Constitution and By-Laws of this Society were formally adopted by the 54 founders. It was also suggested at this time that the Society initiate publication of a journal (1). We have reprinted Peter Safar’s short article from the first issue of this journal to commemorate the 50th Anniversary celebration. Safar’s account differs slightly chronologically from that of Weil: Plans for a scientific journal on CCM were first discussed in 1969, by some of SCCM’s founding members. Finally, in 1972, the SCCM Council and membership overwhelmingly voted in favor of a journal, which would cross-fertilize ideas between physicians of various disciplines and between physicians and non-physicians interested in CCM (an objective apparently not met by existing journals) (2). Historians reading these source documents might infer that the desire for a specialty journal catalyzed the formation of the SCCM; or they might infer that the multiprofessional foundation of SCCM demanded the creation of this new periodical. Three things are nevertheless unquestioned: 1) a deal was struck with the first publisher on November 7, 1972; 2) the first issue was scheduled for publication early the following year; and 3) the journal needed an editor. The purpose of this report is to collect the thoughts, recollections, and reflections of the editors of Critical Care Medicine. It is a history only in the sense that Thucydides’ commentary on The Peloponnesian War is a history: a recounting by the general(s) of events as they were experienced. Our intent is to record and detail the decisions, actions, and consequences of our individual and collective tenure in that role. Our commentary is thus transparently subjective and offered in the first person. It is narrative, neither systematic nor complete; our intent is to illuminate the “why” of the journals’ evolutions. Acknowledgments usually appear at the end of such articles. Here, they belong at the beginning. Every issue of this periodical reflects the essential contributions of dozens of committed professionals—from managing editors and supporting personnel in the Society offices, to each Editors’ personal assistants, to our journals’ publishers and their copy editors and production staff. Our Associate, Scientific, Specialty, Deputy, and Book Editors have engaged legions of reviewers to bring authors, their science, and readers together for the last half century. We are grateful to each and to all. The foundation of the official journals of the SCCM is the staff at the SCCM offices—initially in California and subsequently in Illinois. They have been exemplary and critical to the quality and efficiency of journal management and production. The Editors—individually and collectively—acknowledge their essential contributions and thank them for all their hard work and expertise over the decades. Our success is truly theirs. THE FIRST EDITOR (1973−1990): WILLIAM C. SHOEMAKER, MD (3) When Hal Weil and Peter Safar asked me to become the editor of the new journal, I was unprepared for the complexities and the challenges that would come in the years ahead. Call it naivete, call it “rose-colored glasses,” my experience as an author and as a reviewer of manuscripts only dimly illuminated the publication world that I was about to enter. As I alluded in my farewell note in the last issue that I edited in my many years in the role, the SCCM and the journal co-evolved (4). As with most things in the natural world, such evolution is never a smooth process. Rather, there were successes and also some bumps in the road. We were a young Society and an even younger journal. New members and readers might not realize that my wife, Norma, ran the SCCM as Executive Director during those early years out of our home. Her membership rolls were kept (literally) in a shoebox, and the entirety of the journal existed (for the first few years at least) in a file cabinet. It was our “mom-and-pop” operation—the Society and the journal—and the additional role of the Society presidency fell to me in 1973−1974, the year that journal was first published. Two early decisions created the character of the journal during my tenure. First, the multidisciplinary nature of the SCCM extended to the journal. I had two Associate Editors appointed with me, so that the specialties of surgery, anesthesiology, and internal medicine would all be represented at the level of the executive editorial leadership. I knew a lot about shock and fluids and hemodynamics and cancer, but others knew more than I did about anesthetics and the electrocardiogram. Second, I made it a point to use my connections and my attendance at surgical meetings (I am a surgeon, after all) to listen to and attend as many presentations as I could and, if the content was at all related to critical care, to solicit contributions to the journal. As a young society and younger journal, we were fairly desperate for content. A glance at those first few issues and volumes tells a story: we reprinted synopses from other journals’ content in order to fill pages. Even though we originally published bimonthly, we still had to repurpose content for a couple of years to make minimum publishable size. Each issue had 55−65 pages—barely enough to bind. By the end of volume 6, we had enough original content to fill 400 pages a year, and in 1979, we became a monthly publication and published around 500 pages that year—back again to barely enough to bind. Over the next decade, we gradually expanded to publish about 1,500 pages annually. There was some judgement required in formulating an acceptance policy. We needed to keep the journal growing, we were only receiving a few hundred submissions each year, and therefore we accepted “selectively”—by that I mean we didn’t publish everything that was submitted, but we published almost everything. I thought it important to use the review process to make submissions as good as they could be, not to restrict communication. As a consequence, we had a very high acceptance rate but the articles were of variable quality. Starting a journal “from scratch” was a learning experience—for me, for Norma, and for the Society. During the last years of my tenure as editor, we started publishing rosters of those graduating from accredited critical care training programs—pediatric and adult—and one of the things I am proudest of from my time as editor is that those new graduates had a well-recognized and widely read journal that they could read, for which they could write, and that they could use in the care of critically ill patients (5). So many in those lists became not only authors on manuscripts but ultimately leaders in our discipline. Editing a journal is a labor of love. It is also a unique privilege and great responsibility. After all, it is the editor who bears ultimate responsibility in ensuring there is reliable content to engage, to educate, and to inspire our subscribers and other readers. I was proud to serve, and prouder still to hand over what I had built to my Associate Editor, Bart Chernow. THE SECOND EDITOR (1990−1996): BART CHERNOW, MD Will Shoemaker launched the journal and served as its steward for nearly two decades. When he asked to be replaced, a search committee was convened. After a rigorous process of evaluation, I was honored to be selected as the next editor. I had served with Will as his Associate Editor, so I knew the strengths and opportunities of the journal. I had recently moved to Baltimore from the Massachusetts General Hospital in Boston to become a member of the faculty at Johns Hopkins and Physician-in-Chief at the Sinai Hospital in Baltimore. Despite my busy academic schedule, I was delighted to assume the editor role. There were some strengths to be leveraged. Our publisher was Williams and Wilkins, headquartered in Baltimore. As a consequence, I was able to become involved in timely production of the journal. SCCM provided a stipend for an assistant to help me expedite correspondence with authors, editorial board members, and reviewers and to communicate with the publisher more efficiently and the SCCM leadership and staff. There were also many challenges. The journal had been seen largely as a member service. In order to be successful in the fast-moving world of medical publishing, it needed to be re-envisioned as a time-sensitive and high-quality product. Perhaps more importantly, it needed to be regarded as competitive with major scientific and medical journals. For those reasons, I introduced several changes that persist in the fabric of the journal to this day. These changes include 1) structured abstracts; 2) Medline (Index Medicus) citations; 3) generic names for drugs; 4) requirement for citation of IRB (human) and IACUC (animal) study approvals; 5) required disclosure of conflicts of interest; 6) standard usage of scientific units of measurement; and 7) selection of feature articles (6). These changes allowed us to adopt best practices from leading journals. Just prior to my tenure, in 1989, the first International Congress on Peer Review in Biomedical Publications was convened and established high standards for manuscript evaluation (7). We found this material to be extremely useful. The journal was focusing on high-quality randomized control trials as well as leading animal and basic science studies. Although case reports and reviews were welcomed, they needed to provide new insight in order to gain acceptance for publication. Citations needed to be current. With this came much higher expectations of reviewers: critiques needed to be specific and objective, organized in a way that my editorial board could evaluate each concern and response (8). What triggered this push for quality and for rigor in peer review? Appropriate or not, bibliometrics were rapidly being adopted as objective criteria of scientific importance by appointment, promotion, and tenure committees. Authors were becoming increasingly sensitive to the impact factor of the journal accepting their paper, never mind whether it was presented in “their” specialty journal. This shift in author attitude was partially driven by two key technological advances: 1) the appearance of the personal computer, and 2) the ascent of PubMedTM. (PubMed was initially released in 1996 as an experimental database; access became both free and web-based in 1997.) This made it easy to “troll” abstracts and find reports of interest regardless of whether the venue was on a personal bookshelf: all that was required was a walk to the library. A more prosaic—yet perhaps more impactful—consequence of the rise of the personal computer as a professional tool was the shift to electronic submission and redistribution of manuscripts for review by electronic mail. This accelerated turn-around time while reducing reliance on mail and courier services. The consequence of these changes was a steady increase in manuscript submissions toward a thousand manuscripts each year, with varying acceptance rates of 25% to 30%. The journal’s visibility increased as well, with circulation rising by half during my editorship. There was a reciprocal relationship with the SCCM: the journal attracted interest in the Society, and one of the benefits of Society membership was a subscription to the journal (9). There were three other initiatives that we pursued during my tenure. First, with advice and support from the Society leadership, and from colleagues around the world, I began to recruit more international submissions. Second, we focused more on pediatric critical care. Third, SCCM supported the evolution of a quarterly supplement, New Horizons. This supplement deserves further comment. New Horizons had been launched as an SCCM series within Critical Care Medicine during the 1980s. The aim of the series was the integration of scientific advances with clinical practice. These publications were the product of consensus conferences and issued as monographs, however they proved to be too costly to sustain and therefore the SCCM Council eventually contracted with Williams and Wilkins (the publisher of Critical Care Medicine) to produce quarterly issues in journal format, each with a different faculty, series editor, and annotated bibliography. The first issue, published in February 1993, was on the topic of sepsis. The first article in that first issue, a review article titled “Endotoxin, Tumor Necrosis Factor, and Related Mediators: New Approaches to Shock” was penned by a 35-year-old early career investigator, Bruce Beutler (10). Two decades later, in 2011, Beutler was awarded The Nobel Prize in Physiology or Medicine (11). To my knowledge, no other journal has had such an auspicious first article. By the second year, this new quarterly was turning a profit for SCCM, and by the end of the third year, the journal was fully indexed. Quality remained the highest priority for all the journals. The imperative to read every manuscript, every revision, every correction prior to release for publication was consuming and ultimately became incompatible with burgeoning responsibilities in my primary academic roles. Over the years that I edited the journal, my academic responsibilities increased dramatically; I reluctantly asked that my successor be identified and appointed to the editor role. A multiprofessional search committee was appointed. The committee selected an enormously talented physician-scientist, Joe Parrillo, who had just served as SCCM’s President. I hold Joe in the highest regard and believe that he was a wonderful selection. It was a great honor to serve SCCM in the role of Editor-in-Chief of the journal (12). THE THIRD EDITOR (1997−2014): JOSEPH E. PARRILLO, MD Will Shoemaker and Bart Chernow had started and greatly improved a journal devoted to the new discipline. I applied to become Editor-in-Chief in 1996 because I hoped to contribute to the academic stature of the journal and to our young specialty of critical care medicine (CCM). Formal certification of special or added qualifications (and training programs) in CCM was not offered until 1987; thus, several other disciplines had a head start on critical care. My goal was to advance the science and clinical care of the CCM patient by continuing the journal tradition of providing a repository for new, carefully conducted investigations, both clinical and laboratory. I believed that another dimension was needed: our journal needed to add perspective to important subjects using reviews, editorials, letters, and special articles. My reasoning was that medical and scientific fields move forward in an iterative fashion, necessitating questioning and further evaluation of new data and ideas arising from original investigations. We invited many editorials to accompany the clinical and laboratory investigations. We quickly achieved our goal of having 70% to 80% of our original articles accompanied by editorials, a percentage similar to other major medical journals. My purpose in soliciting and publishing those editorials was to provide an objective overview of a topic, particularly since CCM was—and remains—a vast, growing field with many new avenues. Editorials sometimes provided a contrary opinion, so the reader could reflect on an alternative viewpoint. Editorial commentary commonly identified subtle issues that were not apparent in the original article. In summary, editorials enhanced the iterative process of developing sophisticated information and reasoning in our field. As internet-connected desktop computing became an international standard, we joined other major journals, transitioning the journal from paper to a fully electronic submission and peer review process. Many problems and roadblocks occurred with the change to electronic format, problems that were resolved by the persistence of the excellent SCCM staff. The result was a substantial acceleration in journal processes, with marked shortening of the time from submission to first decision (a decline from 112 to 30 days) and from acceptance to publication (shortening from more than a year to 4 months). The evolution of pediatric critical care as a complement to adult critical care created an opportunity for SCCM to advocate for a new journal, Pediatric Critical Care Medicine, which appeared in 2000. Sponsored jointly by SCCM and the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS), this new journal represented the first scientific peer-reviewed publication to focus exclusively on pediatric critical care medicine and critical care neonatology. Pediatric Critical Care Medicine remained closely coordinated with Critical Care Medicine with initially combined Editorial Boards. Patrick Kochanek, MD was chosen to be the Editor of Pediatric Critical Care Medicine in 2001. I remarked above on the importance of perspective provided by authoritative topical reviews. New Horizons filled the role in 1980s, evolving into a separate supplement in 1993. These topic-themed supplements ranged from signal transduction and molecular biology to acute lung injury and echocardiography in the ICU, each emphasizing the interface and integration of new science with the practice of critical care. Unfortunately, the high cost of publishing New Horizons led to a difficult decision by SCCM’s Council in 2010 to discontinue the series. Reviews were nevertheless important to the discipline: in 2003, we launched Concise Definitive Reviews as a recurring section within Critical Care Medicine, featuring invited reviews of core critical care clinical areas. The reviews were definitive (using most recent literature, authored by an acknowledged expert in the field), concise (offering a digest of useful information), and clinically directed. These reviews remain one of the most popular and often cited components of the journal. One of the most rewarding responsibilities of the job of Editor-in-Chief was the identification and solicitation of excellent studies to be published in our journal. I would frequently hear of important studies, and I would approach the authors and urge them to submit to our journal for the reasons enumerated above. Two among many deserve special mention. First, a multicenter clinical trial of N-Methylarginine (NMA) in septic shock had been performed with unexpected results—the NMA group had a higher mortality than the control group (13). The investigators were somewhat reluctant to submit the controversial study for peer review. I argued that the findings were of immense importance and must be vetted through the peer-review process and subsequent publication. The author submitted the manuscript to Critical Care Medicine, and I guided it through a contentious peer review. The publication remains one of the most important in the sepsis literature. Second, we recruited the publication of another article that demonstrated in a large, multicenter, retrospectively collected database, that the duration of hypotension prior to antimicrobial administration was the critical determinant of survival in human septic shock (14). The study found that mortality increased by 8% per hour when antimicrobial agents were delayed. This article remains widely cited and ushered in the emphasis on administering antimicrobial agents as early as possible during septic shock—which has led to a substantial decrease in associated mortality. Recruitment of good studies to publish in our journal was a major method to advance both our journal and the field of critical care. In 2009, the Special Library Association’s Biomedical and Life Sciences Division, an international organization of professional librarians, in honor of their centennial meeting, performed a study of identify the most influential journals in biology and medicine. Critical Care Medicine was chosen as one of the 100 most influential journals in the past 100 years based on the quality and importance of its published scientific articles. Other journals honored at this ceremony were Nature, Science, Proceedings of the National Academy of Sciences, New England Journal of Medicine, JAMA, and The Lancet. With our hope and goal to attract the highest quality science and clinical investigations, the journal experienced an extraordinary increase in submitted manuscripts and a substantial upward trajectory in journal quality metrics during 1997−2014. Our submitted volume went from an estimated 700 manuscripts in 1998 to 1,960 submissions in 2014. Our acceptance rate decreased from an estimated 50% in 1996 to 15% in 2014. Our impact factor in 1991 was 1.573 and in 2015 (based on 2014 citations) was 7.422. The field of critical care had become a recognized, high-quality multidisciplinary specialty, and its stature was reflected in the high quality of the science and clinical studies published in our journal. I consider it a distinct honor to have served as Editor-in-Chief of Critical Care Medicine for 18 years. The job was very challenging and highly rewarding. I extend my sincerest thanks to SCCM, to SCCM Council and staff, and to the readers and supporters of our Journal (15). THE FOURTH EDITOR (2015−PRESENT): TIMOTHY G. BUCHMAN, PHD, MD When I became the journal’s steward following 18 years of leadership by Joe Parrillo, Critical Care Medicine was a powerhouse, and yet externalities had begun to appear that would demand new evolution. The journal not only had to affirm its identity but also had to adapt to several rapidly changing landscapes. In February, 2015, I published a foreword titled “Practical Science and the Science of Practice,” clarifying the reciprocal relationship between SCCM members and the journal and telegraphing to authors and reviewers what we would deliver to readers: clear communication, public debate, high standards for quality and scientific ethics, concern with illness and health (not just syndromes and diseases), and the airing of ethical tensions (16). Three months later, I directly addressed our authors. In the May, 2015 Foreword titled “The Review Process,” I described the three core review criteria of novelty, generalizability, and the probability that the submission would change thinking or practice (17). The approach would prove successful: the journal achieved its highest-ever impact factor, 9.296, in the most recent available year (2021). Managing reader and author expectations was foundational to a response to three immediate externalities. First, medical information started flowing through multiple new channels. Some of those channels were collectively known as social media and ranged from brief, 140-character “sound bites” (Twitter had launched in 2006 and had emerged as a force in critical care a few years later) to article publication announcements on vehicles such as Facebook to extensive commentaries on private (ListServs) and public (blogs) sites. Second, the journal no longer controlled publication either ahead of print or following print. The birth and expansion of pre-print servers in which authors routinely communicated new findings prior to peer review meant that whatever was (finally) published in the journal would increasingly appear as “old news.” The rise of podcasts, online journal clubs, and derivative collections (such as Free Open Access Medical Education [FOAMed]) meant that the journal had even less control over the message communicated in the article and any accompanying editorial. Third, consumer demand for communication beyond the traditional manuscript format continued to grow. Visual abstracts, responsive online access via any electronic platform, and interactive tools were no longer exotic; rather they were expected. In response, the journal appointed a Social Media Editor and Social Media Ambassadors. Another externality involved the accumulation of public and private datasets, the proliferation of statistical analysis software, and the simplification of primitive machine learning tools. The near universal adoption of electronic health records under the United States Federal Meaningful Use initiative led, as a byproduct, to an explosion in health services research: datasets could be explored for associations among variables and both linear and nonlinear predictive models could be easily created. There were sufficient growing pains that the Journal’s data scientists led coalitions of editors from many respiratory, sleep, and critical care journals toward standard guidance around propensity scoring, causal inference, and prediction modeling (18−21). The role of Associate Editor for Data Science was established. To improve the quality and clarity of diverse study types, the journal began to require certain article types to register and/or report standard design, data, and technical elements. These article types included human and animal trials, review articles, and development and reporting of predictive analytics. While there was initial resistance to such registration and reporting requirements, the importance of having such information quickly became apparent to authors, reviewers, and ultimately readers. Novelty could be claimed, there was confidence that essential elements would be found in the reports, and the review processes flowed more smoothly. Perhaps the strongest externalities during my tenure (thus far) were the pressures related to open access publishing. In contrast to the traditional subscription model (subscribers pay for restricted access to all articles within a journal title), open access places the burden of publication costs on the authors, with the (final published) article free for reading and distribution. The American effort toward open access began in 2000 with the launch of the Public Library of Science journal family, the first offering being PLoS One. Although open access catalyzed the growth of vanity journals and predatory practices (in which anything could be and would be published for a price), there were signs that hybrid models that blended subscription with open access would be required of traditional publishers. Both American and European funding agencies began to insist that work supported by grants be made available at no cost. Journal publishers pushed back and said that such a requirement would destroy their traditional subscription model. They nevertheless engineered immediate open access (for a fee) and delayed open access after an arbitrary period (typically, a year) had passed. This satisfied neither the consumer-reader, nor certain institutional subscribers, nor certain funding agencies. Some institutional subscribers simply dropped expensive/lucrative relationships with traditional publishers (Critical Care Medicine and its publisher were not affected). By 2018, a consortium of 12 European countries had advanced Plan S, requiring scientists and researchers who benefit from European state-funded research organizations and institutions to publish their work in open repositories or in journals available to all by 2021. SCCM, which had ignored the appearance of open access journals in the discipline (such as Critical Care and Annals of the American Thoracic Society), asked me to quickly stand up an open access companion to Critical Care Medicine. The new title, Critical Care Explorations, published its first issue fewer than four months after SCCM council authorized the venture (22). Submissions quickly followed, and in its third year of publication the new journal reported more original research than Critical Care Medicine. Critical Care Explorations met two other SCCM needs. First, as a new title, it enabled the appointment of editorial leadership with a view toward diversity, equity, and inclusion. Second, and even more important to the longevity of SCCM publications, it was designed to attract early career journalists (editors and editorial board members) who wanted the chance to show and improve their skills. The expectation—which has been realized—is that some would remain at Critical Care Explorations to grow and lead, some would rotate off to pursue other areas of interest, and a few would choose further assignment to leadership ranks at Critical Care Medicine. All three paths have been followed. Thus, in addition to having the largest published content among official SCCM journals, Critical Care Explorations, has a unique role as SCCM’s engine for the training and production of future generations interested in journal leadership. The serial mastheads of both journals continue to reflect that story. Both journals were strongly affected by the SARS-CoV-2 pandemic in 2020−2022. Severe coronavirus disease (COVID-19) led to a sudden global increase and shift in submitted content: in 2020, submissions to Critical Care Medicine increased 50% over the prior year, requiring the rapid development and dissemination of responsible policy around reporting of pandemic findings. Fortunately, the years prior to COVID had seen a shift in editorial leadership strategy, with frequent and increasing involvement of the Associate, Scientific, and Social Media Editors in journal policy and publication decisions. A special report, titled “Pandemic-Related Submissions: The Challenge of Discerning Signal Amidst Noise” was circulated within the first few months of the pandemic and officially published in the August 2020 issue, outlining a rational and consistently applicable approach (23). A decline to a more manageable submission level quickly followed. There have been various special projects. I commissioned and edited a series of 23 articles commemorating the 50th Anniversary of SCCM, published in 2021 during the height of the pandemic and subsequently collected in a volume celebrating th