Distinguished Conversations

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Richard Lafayette, MD

Citation: Kidney News 9, 5


Gary Curhan, MD, FASN

Citation: Kidney News 9, 5

Dr. Lafayette: Congratulations on completing your six years as Editor-in-Chief of CJASN. It is a tremendous accomplishment to have served in this role. You have been able to create terrific new features and maintain the journal as the home of clinical nephrology.

What are your plans now?

Dr. Curhan: Thank you very much. It’s definitely been an exciting six years. My plans now are to use my “free” time to return to my research activities and mentoring. I’ve continued to do research but as you know, CJASN took a fair amount of my attention. But fortunately, I work with a large number of really talented investigators in a number of areas related to nephrology such as nephrolithiasis and some other areas such as primary hyperparathyroidism and hearing loss.

Dr. Lafayette: Do you have a new grand venture in store, or are you sort of reordering your life back to how you left it before CJASN?

Dr. Curhan: I am looking at what the next steps are. I have been reading some different books, such as “Designing your Life: How to Build a Well-Lived, Joyful Life,” written by a group at Stanford. I am trying to make sure my compass is still pointing me in the right direction.

Dr. Lafayette: That sounds great. Coming back to CJASN, were there any early learning points when you were first starting out that may have suggested being Editor-in-Chief would be different from what you had first expected? What do you think could have helped you better prepare for the role, perhaps by way of advice for the incoming editor?

Dr. Curhan: I was very fortunate to have been involved with CJASN from the very beginning, as I had worked as an associate editor under the founding Editor-in-Chief, Bill Bennett, MD, FASN. I learned a lot from his leadership style as well as from the two deputy editors at that time, Mohammed Sayegh, MD, and Harold Feldman, MD, FASN. That interaction gave me an appreciation for the involvement and effort required to be an associate editor. But I clearly underestimated the time and energy it takes to be a dedicated Editor-in-Chief. I also initially underestimated the importance of the editorial team, but quickly learned how fortunate and very lucky I was to have been able to work with a talented group of individuals.

The deputy editors during my term, Kirsten Johansen, MD, and Paul Palevsky, MD, FASN, had a tremendous, positive impact on the topics and quality of the journal. The 11 associate editors were also outstanding, and we relied on them heavily for decisions about original manuscripts. And I cannot overstate the importance of having our own managing editor, Shari Leventhal. When I started, the managing editor was handling both CJASN and JASN and doing a great job, but the leadership at ASN realized the rapid growth of each journal would require individual managing editors. Shari made a huge positive difference.

So what else do I wish I had known earlier? How to juggle the constant deadlines and huge number of manuscripts, while at the same time trying to focus on making the process as easy as possible for authors, keeping the quality high, and selecting the best original and invited manuscripts. So I wish I’d known and understood more about these issues earlier on, but I learned quickly.

We launched a number of important series that Paul Palevsky developed, including Renal Physiology and Renal Immunology. The time and effort it took for what I thought was going to be just a series of review articles was really much more extensive, and that was because of the high standards Paul set. We also standardized the images because we envisioned—and I think it’s happening—that these would be used for a long time, not just by our readers, but also by fellows, residents, and medical students.

Dr. Lafayette: I think the community very much appreciates the continuity of the outstanding quality of the content and images. That’s probably why you get so many submissions, and why special sections have been so greatly appreciated. Looking back at your time as Editor-in-Chief, what do you consider your main accomplishments during those six years? Of which accomplishments are you most proud?

Dr. Curhan: There were several obvious, and some less obvious, accomplishments that I will talk about in no particular order.

From the beginning, my priority was to improve the quality of the journal. Bill Bennett had done a great job launching CJASN, which was extremely challenging, but under his leadership it rapidly became a source for submission of high quality articles. This strong foundation allowed us to continue to raise the bar to improve the quality of manuscripts accepted, both original and invited.

We also devoted a lot of time to presentation to make sure the information was presented in a way readers could easily understand. We aimed for clear, high-quality figures.

We paid a lot of attention to the review process to ensure we had high quality reviews by experienced reviewers.

Another aim was to improve the author’s experience. As an author myself, I know what it’s like to be on the other end and how frustrating and aggravating it can sometimes be to try to submit a manuscript and deal with a website that isn’t completely understandable or sometimes gives contradictory instructions. So we made the submission process as easy as possible. Shari often provided personal support to authors along the way.

I wanted to make sure the journal was educational. The first thing I did as Editor-in-Chief was to redesign the cover. My goal was to select a new image every month that didn’t necessary relate to what was inside, but just to remind people of the importance of images and to use them to educate. Along with the cover image, we included a short case vignette and discussion of the diagnosis—this was something that made the journal more appealing.

We received outstanding invited material and launched a number of innovative series, such as Renal Physiology, Renal Immunology, Ethics, Public Policy, Attending Rounds, and the Medical Director series. Our expectation was that these series would not necessarily be cited, but we knew they would be of interest to our audience and widely read. Downloads of these series far exceeded our expectations. In fact, for the Medical Director series, one of the large dialysis organizations requested and received permission to require that all of their medical directors read the series.

We also launched eJournal Club, an idea of David Goldfarb’s. The goal was to have ongoing interactions between authors and readers—not just a one-time letter to the editor—but a back-and-forth discussion among a group.

Ming Chawla, MD, did an unbelievable job designing the original CJASN app, and JASN followed suit. We added biostatistical editors to emphasize the importance of careful analysis. And we had a really diverse editorial team and editorial board. From the beginning, I wanted to have transparency so everyone involved with the journal—myself, deputy editors, associate editors, and the editorial board—completed detailed disclosure forms, and these were posted online for anyone to see.

I am particularly proud of the survey that found that CJASN was the most read nephrology journal. That was always a priority—not just to publish articles, but to have a journal that people would want to read.

Dr. Lafayette: What were the things that didn’t go as smoothly? What could have been done differently that you can now reflect back on with either a chuckle or as something for the new group to take on?

Dr. Curhan: There is always room for improvement, and I think change is often for the better. I think it was wise to implement term limits for the Editor-in-Chief’s role for the ASN journals, and I am sure that the new team will continue to improve on what was done before.

The main challenges are time and resources. All of us involved with the journal have other full time jobs, so time is very precious, as well as the limited resources. What I would have liked to have done was have a larger editorial team so we could have done more things and done them faster.

As far as what I would have done differently . . . there are all sorts of different metrics by which you can judge success, and I think we could have used more frequent internal assessments. I am not talking about impact factor, as I personally don’t think it is really the best measure of quality. The example I always give is that if you publish a really bad article that gets cited a lot as being a bad article, that makes your impact factor go up—that doesn’t seem like the ideal system.

If we had more time, we would have had more broad discussions and would have ideally have had even more series, but the time and resources really limited what we could do.

Dr. Lafayette: To extend on that and look more globally, where do you think we are today in terms of medical publishing, especially in nephrology?

Dr. Curhan: I think it is an exciting time. Since I was a fellow a long time ago, the number of high quality manuscripts has continued to increase both nationally and internationally. There are also more journals, but perhaps now there are too many. It is unclear to me right now about quality control for some of the for-profit journals. This increase in the number of journals can lead to a substantial burden on the pool of reviewers. There is a limited number of high-quality reviewers, but with an increasing number of manuscripts and journals, the competition for these reviewers becomes greater.

There are innovative approaches to using electronic or online versions of the journal. Up-to-Date uses embedded links and other approaches; in my mind there’s no reason those couldn’t and shouldn’t be used in online versions of journal articles.

Another aspect is ongoing discussions, such as what we tried with the eJournal Club. Despite being an innovative approach, it unfortunately didn’t take off the way David and I had hoped it would. There is so much competition for peoples’ eyes, and it’s very challenging to engage people in ongoing thoughtful conversations about articles. Although a large number of people enrolled in eJournal club, the number of those who actively contributed was less than we had hoped.

This is an area where perhaps a different model will foster ongoing engagement between authors and readers.

Dr. Lafayette: There has always been a desire to learn how we can keep nephrologists interested and provide them with an opportunity to further their own knowledge while constantly improving kidney practice. With board recertification as it is now, what is your opinion about the best way to share new knowledge and update community standards available for nephrologists? How do you give nephrologists a sort of carrot-and-stick to keep them up to date?

Dr. Curhan: As a clinician, I want to have information that is readily available, interesting, and presented in a way that will help me and my patients. Are journals the only way to do that? I don’t think so. Journals play many different roles, and I think each journal needs to decide what roles it will fill. Doing too much with a journal may cause it to lose its way. At CJASN, we had criteria about what it was that we wanted to do. We hoped that at least some of the items we published would be of interest to everyone, and that others would be of interest to various subgroups. For example, some investigators were more interested in the original articles and some clinicians or medical students were more interested in the invited material. It varied by month and topic, but having a clear overall strategy about who the audiences are and what it is you are trying to provide for them helps keep a journal on track.

As consumers, I think nephrologists are going to have to look at the different resources available to them. I hope CJASN serves a lot of their needs, but it cannot and should not serve up everything everyone wants. We primarily targeted the journal to clinical nephrologists and clinical investigators.

As far as the status of renal research, I think it is an exciting time. There are a lot of young fellows and junior faculty who want to pursue academic careers, and new drugs are being developed. Hopefully, there will continue to be an increasing number of private companies developing new treatments, and not just medications, but devices as well. I hope NIH funding will increase—that will be very important to help maintain interest and continuity in renal research.

Dr. Lafayette: I agree, and we’ll certainly continue to advocate our government to continue to support research.

You mentioned medical students. We are at a particular time when there is some concern about a lack of interest in nephrology as a career, and trying to get medical students and residents interested in our field has become more of a challenge. What are your general thoughts about that challenge and what do you think journals like CJASN can do to help?

Dr. Curhan: Yes, the challenge is clear, as we see each year with the Match, particularly with the number of graduates in the US and elsewhere who show an interest in the field. I think there is still much work that needs to be devoted to expanding the level of interest. There is a lot of misunderstanding about how exciting and vibrant nephrology is, and I know a lot of people are trying to work on that.

We hope our efforts to make CJASN content understandable to a broad range of readers made the journal attractive and interesting to students, residents, and senior practitioners. Selecting exciting, cutting edge topics such as new drugs and devices can help expand interest in nephrology. And inserting links (such as an original article that links to the Renal Physiology series) can make it easier for a reader to not have to go to a completely different book but to rather use published peer-reviewed material, allowing them to go back and forth between the original article and the more general article that might help improve their understanding of renal physiology. These approaches take time and effort, but the opportunities are certainly there.

And, of course, we need to find other creative ways to engage young people, including using social media. Getting the message out there in this manner and making sure content is readily accessible can help a lot.

Dr. Lafayette: You were there as an associate editor when CJASN was started, at a time when ASN already had a very successful journal, JASN. It was always going to be interesting how the two journals either acted separately or found common ground. What was your experience of working together at ASN to keep the two journals successful? Was there a partnership or competition for scientific and review articles?

Dr. Curhan: The ASN Council made a very wise decision to launch a second journal because clearly there was a need. The high quality material that CJASN was receiving and publishing confirmed that JASN alone could not publish everything, particularly a large number of clinical investigation manuscripts.

I also believe that competition is good, even among friends. So having the journals separate, and they were indeed completely independent publications, was the wise thing to do. But at the same time, working with Karl Nath, who was Editor-in-Chief of JASN, was a particularly special aspect of my term. Karl is just a wonderful individual, and we’ve had a very collegial relationship. We worked together on several items such as the apps and had several interactions with the publisher. I hope that relationship will continue for the new editors of CJASN and JASN. Healthy competition, as well as collaboration, would help both journals.

Dr. Lafayette: The CJASN Editor-in-Chief does have sort of broad power to influence the journal—the type of science it covers and the articles it attracts. During your stay as an epidemiologist, some may say there was a lot more epidemiology in CJASN than before. How does one strike that balance of moving toward the information you are passionate about vs. perhaps wanting to stay broad and cover the whole field? Is that ever a challenge, or is it an opportunity as well?

Dr. Curhan: That was something I was concerned about when I was preparing to take over as Editor-in-Chief. I wanted to make the journal as broad as possible so it would be of interest to our readers. Epidemiology is just one way to do that. At the same time, there has been huge growth in the number of epidemiologic studies compared with physiologic studies, so if anything, we were trying harder to get other types of studies—not just epidemiology, but, for example, health services research studies, clinical trials, and physiologic studies. But as we know, there is just not the same number of submissions from these other areas.

We also wanted more studies about transplantation, pediatric nephrology, and other areas, but CJASN is dependent on the types of articles that are submitted. I like to think we reviewed the articles based on their quality and not just the type of article. We worked very hard to find associate editors with a broad range of backgrounds, and they played a very critical role in the decision-making process. While there were some epidemiologists, the vast majority were not. I insisted that all associate editors be clinical investigators and practicing clinical nephrologists because I knew that would bring a unique perspective to the journal.

There are probably more epidemiology-type studies in CJASN than other types, but I doubt the relative number is any different from that in the nephrology journals focused on clinical investigation.

Dr. Lafayette: Is there anything else you would like to comment on concerning your viewpoints about nephrology in general, medicine in general, or your tenure at CJASN?

Dr. Curhan: One area we did not talk about was print vs. electronic publication. From the beginning, when I was first asked whether or not by the end of my tenure we would still have print publications, I wasn’t sure. If you asked me now about whether we will still have print publications at the end of the next six years, I would say the transition is going to happen at some point. I don’t know exactly when, but there are many reasons why it’s appropriate to have paper versions, yet these are becoming less and less so. Electronic versions of journals don’t solve everything, and there are plenty of electronic journals that I can’t say I am impressed with. Just the fact that they’re electronic does not mean that the quality is better. I would hope when this journal does eventually switch over to being all electronic, that the same standards are met, including limits on word count.

Electronic publication does open up some other possibilities: figures and tables and the ways they can be manipulated, results that may allow a reader to say, “What happens if I remove this aspect or that aspect?” These facets of electronic publication may be for the future, but I can easily imagine how as investigators we could have multiple versions of the same table or figure.

Other possibilities are creative figures or videos, with embedded links. Already, abstracts show up when you hover the mouse over the references, but I can imagine that one day related articles might pop up, not just to what’s on PubMed, but also to related books and educational materials. I think there are opportunities, but bringing them to pass will take a lot of time and effort.

And as long as there are people who prefer the paper version, I think there is every reason to keep publishing a paper version.

It was my pleasure to interview Gary Curhan, MD, ScD, for our Distinguished Conversation series. At the time of this interview, he was completing his 6-year term as Editor-in-Chief of the Clinical Journal of the American Society of Nephrology. Gary has already enjoyed a highly distinguished career as professor of medicine at Harvard Medical School and Harvard School of Public Health. He will be continuing to pursue his major research interests including the epidemiology of nephrolithiasis, risk factors for renal function decline, epidemiology of hearing loss, novel risk factors for cardiovascular disease, health effects of analgesic use, novel risk factors for hypertension, and the epidemiology of gout. These interests have led to more than 350 and counting peer-reviewed publications. He has served on the Advisory Council for the NIH National Center for Complementary and Alternative Medicine and has served on numerous NIH Study Sections. He has been continuously funded by NIH for over two decades, and is an active mentor, with his own training grant, and was a founder and Co-Director of Harvard’s PASTEUR program for student research mentoring.

–Richard Lafayette, MD, Kidney News Editor-in-Chief