Secondary Logo

Journal Logo


Reply to: Devil in the detail citation accuracy

Rama-Maceiras, Pablo; Parente, Suzana; Kranke, Peter

Author Information
European Journal of Anaesthesiology: March 2013 - Volume 30 - Issue 3 - p 129-131
doi: 10.1097/EJA.0b013e32835aa512
  • Free


‘I shall never be ashamed of citing a bad author if the line is good’. Seneca, Roman dramatist, philosopher and politician (5 BC to 65 AD).

We thank Zalcberg and Ben-Menachem1 for their interest in our review article covering job satisfaction, burnout and stress in anaesthesiology, recently published in the European Journal of Anaesthesiology,2 as well as their encouraging remarks regarding the importance of the topic addressed. We fully agree with the authors in view of the negative consequences of inadequate citation. Inaccuracy may lead to a skewed perception of the underlying evidence. This is nicely shown in the field of postoperative nausea and vomiting (PONV),3,4 in which the analysis of citations that supported the assumption that an increased BMI constitutes a risk factor for PONV,5 revealed that, first, most review articles were narrative in nature, and second, among the cited studies that were used to support an association between PONV and the BMI, the majority of reports were narrative reviews themselves or were inaccurately quoted, suggesting an overwhelming body of evidence not substantiated by original research data.

On the basis of recent analyses, there seems to be room for improvement with regard to inappropriate citation.6 The underlying reasons for the frequently observed inadequate and inaccurate citations in scientific journals are clearly multiple, and authors are not the only ones responsible. However, in view of our colleagues’ assumption that we ‘did not intentionally cite a creative writing piece as evidence’, we would like to make a few comments regarding their concerns.

First, the instructions for authors of the European Journal of Anaesthesiology [Guidance for Authors on the Preparation and Submission of Manuscripts to the European Journal of Anaesthesiology (; accessed 12 July 2012)] do not restrict citations to any types of articles, for instance, scientific original articles or systematic reviews. The citation of articles such as that by Cassella7 is neither forbidden nor discouraged. Authors may cite from late-breaking original articles in a journal with the highest impact factor, to a journalist note in a local newspaper, as long as the referenced paper is relevant to the topic and supports the statement made, is in any way supportive, leads to critical reflections, or allows readers to deepen their knowledge in the topic discussed.

We do not think the paper by Cassella is an inappropriate, inaccurate or inadequate citation in the context of the topic focused on in our review. On the contrary, we perceive that it is of great relevance. In fact, we think it is one of the most adequate, because the article summarises the author's own history of burnout and decreasing job activity, and thus – far from an intention to confuse the readership – it might be viewed and used as a mirror in which many of our colleagues may see themselves reflected every single day. Her real history (which we checked with Carol Cassella herself) is quite revealing and it would be certainly interesting to put some of her proposed solutions into practice. The reference was also chosen because it allows readers to dig deeper into the topics of burnout, job satisfaction and stress in our working environment. It might not include secondary references from the prestigious and high-ranked journals, but it is a clear, excellent and well written real life case.

As we stated in our review,2 evidence in terms of well conducted (prospective) trials dealing with burnout and satisfaction is weaker than for other topics. We also agree with Zalcberg and Ben-Menachem1 that in citing the study by Cassella, we are not referencing the highest level of evidence. Expert opinion is also accepted as evidence, and case reports may serve both scientific and educational purposes. This is especially true if other pieces of evidence are lacking. We consider Carol Cassella as an expert on burnout, given her personal experience telling us her own case report as a patient.

Furthermore, the first draft of our article included four more references to support our statement regarding intention to leave medical practice.8–11 As the peer reviewers suggested to reduce the number of references, we decided to remove them in the final version, but not Cassella's citation because we consider it a clear, useful and, as Zalcberg and Ben-Menachem state,1 well written article. As highlighted in the introduction, there are multiple reasons why reference lists appear as they do at the end of the article and not all reasons are under the authors’ control.

Finally, we would like to conclude, in accordance with Zalcberg and Ben-Menachem,1 that ‘all authors need to be mindful of accurately referencing literature in its correct context’ in order not to skew reality in a way that may mislead the readers.


Assistance with the letter: The authors would like to thank Dr Nieves Molíns and Rebecca Ramanathan for their assistance with the article.

Financial support and sponsorship: none declared.

Conflicts of interest: none declared.

Comment from the Editor: PK is an associate editor of the European Journal of Anaesthesiology.


1. Zalcberg D, Ben-Menachem E. Devil in the detail: citation accuracy. Eur J Anaesthesiol 2013; 30:130.
2. Rama-Maceiras P, Parente S, Kranke P. Job satisfaction, stress and burnout in anaesthesia: relevant topics for anaesthesiologists and healthcare managers? Eur J Anaesthesiol 2012; 29:311–319.
3. Kranke P, Eberhart LH. Possibilities and limitations in the pharmacological management of postoperative nausea and vomiting. Eur J Anaesthesiol 2011; 28:758–765.
4. Kranke P, Schnabel A, Eberhart LH, et al. Providing effective implementation of antiemetic strategies: the postoperative nausea and vomiting-free hospital is a laudable and realistic goal. Eur J Anaesthesiol 2011; 28:308–309.
5. Kranke P, Apefel CC, Papenfuss T, et al. An increased body mass index is no risk factor for postoperative nausea and vomiting. A systematic review and results of original data. Acta Anaesthesiol Scand 2001; 45:160–166.
6. Wager E, Middleton P. Technical editing of research reports in biomedical journals. Cochrane Database Syst Rev 2008:MR000002.
7. Cassella CW. Burnout and the relative value of dopamine. Anesthesiology 2011; 114:213–217.
8. Holt E. Czech doctors resign en masse. Lancet 2011; 377:111–112.
9. Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians’ intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. Healthcare Manage Rev 2010; 35:105–115.
10. Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction. Med Care 2006; 44:234–242.
11. Lee FJ, Stewart M, Brown JB. Stress, burnout, and strategies for reducing them: what's the situation among Canadian family physicians? Can Fam Physician 2008; 54:234–235.
© 2013 European Society of Anaesthesiology