Three Was Just A Start
By Dr. Rick Rader
On the occasion of World Down Syndrome Day (March 21st), I had the privilege of addressing the United Nations. This year’s theme was Health Equity and, for the first time in the history of the United Nations, the subject of medical education and disabilities was mentioned.
Of course, I was preaching to the choir, so there was an abundance of high fives, thumbs up and back pats from members of the world’s disability community. Representatives from around the world made it abundantly clear that the lack of competent healthcare for people with complex disabilities was a global experience. I was encouraged to disseminate my address so that it might ignite a much needed and much overdue conversation that might lead to corrective action.
While there are over 30,000 medical journals published around the world, only a handful of titles have what is known as “high impact.” These are the journals that have the most influence, have the most articles cited by other journals, and are known to promote follow-up research.
It was obvious that my far-reaching aspirations would not be reached if I published them in the Journal of Irreproducible Results or the Annals of Improbable Research or the Journal of Controversial Ideas. I immediately opted out of submitting to the Journal of Universal Rejection, a journal that rejects all submissions, as a commentary on the difficulty of getting papers published.
“I was encouraged to disseminate my (U.N.) address so that it might ignite a much needed and much overdue conversation that might lead to corrective action.”
According to Quora, “These journals often publish tongue-in-cheek, absurdist, or unconventional, academic work to poke fun at the more serious side of scholarly publishing. The goal is usually to highlight the quirky, humorous, or questionable aspects of certain fields of study.”
I didn’t think that a paper proposing that all medical students should be required to learn how to communicate with, relate to, and treat individuals with disabilities was “tongue-in-cheek, or absurdist.” And with that belief I created my “short list” of journals; the “big ones,” “the majors,” the “big enchiladas,” and one by one, I submitted my United Nations address.
The first one out of the box was the New England Journal of Medicine (NEJM) and why not? They have more than one million readers; enough to cause a fire storm. Their rejection was formal and polite.
Second was the Journal of the American Medical Association (JAMA). I thought this would do nicely since it is the most widely circulated medical journal in the world. The JAMA Network has over 34 million contacts. Their rejection was formal and polite.
I thought perhaps the American-based journals were perhaps too academic and not particularly interested in starting a revolution in medical education. So next was the Lancet, the famed British medical journal that was founded in 1823 and enjoys a high-impact factor. Surely, they would be receptive to an article that was global-centric and not American-centric. Their rejection was formal and polite.
So that was what is called a “hat trick.” Three submissions and three rejections. A “hat trick” in ice hockey or soccer is the scoring of three goals in a game by one player. While I didn’t score, I was not benched (at least not by my own doing).
I was still under the impression that my best bet might be with the Brits. After all, they did elevate medical care with antiseptic surgery, the discovery of penicillin and the smallpox vaccine. Surely they would embrace the concept that people with disabilities deserve to receive comprehensive medical care. So, the next submission was to the British Medical Journal (BMJ). They boast 2,700,000 views per month. Their rejection was formal and polite.
I was reminded of the thousands of high school graduates who were soon to enter colleges and universities. Many of them were also rejected by their first-tier schools and were headed off to their “safe schools.” That is the term for those schools that the students were confident would accept them. I thought that might be a good model for my four rounds of rejections.
While I conceded that academic journals might not be interested in teaching medical students on how to treat patients with Down syndrome or autism, it dawned on me who would be interested. Surely the family physician was the group that, by self-identity, would raise their right hands in committing to insist that the next generation of physicians needed to have the skills, confidence and experience to treat people with disabilities. The family physician, after all, takes pride in treating every member of a family, in every community and in every society. As a matter of fact, the journal of the American family physician is named The American Family Physician (the official journal of the American Academy of Family Physicians, or AAFP). They have 200,000 readers and it is the number one journal for primary care physicians. Their rejection was formal and polite.
It was late one evening when I came to the realization that I wanted to change medical education, and perhaps I was knocking on the wrong door. I was reminded of the response offered by the famous American bank robber (in the 1920s) Willie Sutton when he was asked why he robbed banks. He said, “That’s where the money was.”
So, using that logical model, I asked which is the journal of medical education?. The American Association of Medical Colleges (AAMC) publishes a journal called Academic Medicine. It is the voice of the almost 200 American medical schools. If there is a journal that is dedicated to medical education, it certainly is Academic Medicine. Providing me with the encouragement that I had come to the right place was the quote from David J. Skorton, President and CEO of the Association of American Medical Colleges (AAMC)— “Academic Medicine leads the nation forward by improving health for everyone living in America.” I did a mini victory dance around the word “everyone,” confident that people with disabilities qualified to being members of “everyone.” I submitted the UN address to Academic Medicine and received their rejection which was formal and polite.
So that was the double hat trick. Six submissions and six rejections.
In fairness to the journals, I understand and appreciate that being published by these high-impact journals is very competitive. While there is no single list or database of acceptance rates, most of the high-impact journals have an acceptance rate close to ten percent. In the case of JAMA, they receive more than 10,000 annual submissions and their acceptance rate is 13%, and out of the 5,000 research manuscripts received, they accept only 6%.
So, I am not alone in having an overflowing “in-box” of medical journal rejection slips. My despair is not because my submissions were rejected. I am not expressing “sour grapes.” Indeed, my position is not dependent on being published. My dismay is based on the following four “take home” messages about the present state of organized medicine not being more responsive to the health disparities experienced by people with disabilities.
1. Everyone agrees that people with disabilities deserve to receive optimal healthcare across their lifespan.
2. Everyone agrees that physicians should have the skills, experience and confidence to provide optimal healthcare to people with disabilities.
3. Organized medicine (medical educators) does not feel that “disability clinical competency” should be required in the curriculum of every medical student.
4. Governmental healthcare agencies do not feel that offering incentives to clinicians to treat people with disabilities is a sensible expenditure; nor do they think that people with intellectual and developmental disabilities should be designated as belonging to a Medically Underserved Population (MUP).
While I am not a particularly spiritual person, I appreciate that numbers have spiritual significance. In the case of having six rejections, the number seems to have relevance. “In numerology, the number 6 is associated with love, compassion, and service to others. It resonates with the vibrations of harmony and responsibility. This number offers a gentle reminder for us to prioritize our relationships both with ourselves and with others.” (Ref: Quora)
While I might be battle-scarred, I’m not alone. My like-minded colleagues provide me with the needed and welcomed support, encouragement and understanding nods. They consistently offer me and other trench-dwellers the lights, compass and stamina that we need to ensure that we are headed in the right direction.
We know we are.
