Twenty years ago, I sat in this chair as an editorial fellow, writing for the CMAJ. The view from inside a medical journal is fascinating at any time, but was particularly so in 2003. A coronavirus had swept in from Asia, sickening people in Canada.1 Another newly arrived zoonosis, monkeypox, caused a concerning cluster of infections.2 Emergency departments, my future clinical home, were overcrowded and understaffed, and some even shuttered.3
If Heraclitus was right and a person cannot step into the same river again, it still holds familiar turns. Then, as now, many Indigenous communities in Canada lacked clean water and good food, and endured more disease, incarcerations and suicides than any other.4 Ebola’s death rate is the same, its victims too poor and too Black to excite the medical–industrial complex.5 Grapefruit juice still has drug interactions.6
There is movement too. Although SARS caught us unaware in Toronto in 2003, we waited for COVID-19 grimly, our phones filling first with pictures of overrun health systems and names of health care workers who got infected and died. The world published the SARS-CoV-2 virus genome within days, and vaccines followed so fast that some people still do not believe they are legitimate. Monkeypox changed its virulence, infecting thousands in North America.
My emergency department got bigger and fuller. Patient volumes are almost double what they were in 2003. Machines dispense drugs. Radiographs, like our clinical notes, flash onto computer screens moments after they are done.
Everyone is looking at a screen. Everyone.
Clinical practice, too, has shifted. I hardly see bleeds from warfarin anymore. In the trauma room, permissive hypotension avoids over-resuscitation, and tranexamic acid lets people clot. Ultrasonography is used at the bedside every day, and noninvasive ventilation steers breathless people from endotracheal tubes.
The journal has also seen movement. Its official record is now online, like everything, and it is published fewer times in print. Since January 2021, all CMAJ articles have been free to view, and the journal’s impact factor has quadrupled since 2003. I see other editors mostly on computer screens. The weekly stack of papers to read arrives with a “ping” instead of a “thud.”
In fits and starts of imagination and recantations, medicine flows freer, includes more people, hurts fewer. Heraclitus was not just talking about the river; he was talking about the person who steps into it. It is you who changes most, not the river.
The view of the self is too myopic to say exactly how I have changed, so I will leave it to other people. I became involved with Médecins Sans Frontières, suffered griefs and sicknesses in my own life, and am a better doctor for all of it. A better editor too, I hope.
In a commentary 20 years ago,7 I imagined a CMAJ reader, a family doctor from Wawa, Ontario, who had a busy practice and life, and who cared about her patients and the world in which her children were growing. Her attention was the journal’s most valuable, unmeasured resource, and whatever was spent on CMAJ, editors wanted it to count. Has she changed? Demographically, almost certainly. She may even be reading from Ethiopia. She is busier than ever, trying to keep up with the accrual of new medical information, which is 3 times the rate of 20 years ago. I wonder if she is as idealistic as I imagined her then. I hope so. I am.
Even more, I am curious about what changes she will see in the next 20 years. A cure for some cancers, HIV? Hospital care moving into patient homes, no matter where they are?8
Whatever comes, and when, will never seem sufficient or soon enough. That is the view from where we stand, as editors, clinicians and humans; not of the work done, but of what remains. It is a hard position to hold. I think it is why I like the editing life. It is another place, besides the bedside, to savour what passes through our hearts, minds and hands.
I started this editorial on my return from a 3-day retreat at Turtle Lodge, an Anishinaabe centre of wisdom, in Sagkeeng, Manitoba.9 The theme for this gathering was “Back to the Land,” a testimony to the deeply held belief that we are not nature’s master nor even her steward, but a facet of a whole, each dependent on the other. Attendees spent the mornings of each day in ceremony, and the afternoons showing youth from First Nations communities how to prepare a deer or singe feathers from a plucked goose. In her parting words, Katherine Whitecloud reminded attendees to make every action a prayer toward a better world, that each bead on a moccasin should be placed with a wish for a better life for the person who might wear it. Every video consultation, every auscultation, every word, is part of a story bigger than any single person and is 7 generations long, rushing through us, into the future.
The health care workforce, which is said to be growing 3 times faster than the global population, will be a big part in telling it.10
If you, the CMAJ readers, are keen, I would love to hear your imagining of what changes we might see in the next 20 years as a response to this editorial.
In the meantime, we at CMAJ will make your moments with the journal matter. Adapting what I say to my team in the trauma room: glad to be here with all of you, in the middle of the river, doing our best.
Footnotes
Competing interests: www.cmaj.ca/staff
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