The Myth of Sisyphus. The refounding of SECOT

Mediocracy encourages us in every possible way to doze rather than to think, to view as inevitable what is unacceptable and as necessary what is revolting.

Alain Deneault¹

“These are games, one must first answer […] if I ask myself how to judge that one question is more urgent than another, I reply that one judges by the action it entails”. Thus concludes Albert Camus in “The Myth of Sisyphus”² in its initial paragraph and this is the purpose of this article, which is a continuation of another published two years ago that analysed the need to refound the Spanish Society of Orthopaedic Surgery and Traumatology (SECOT for its initials in Spanish).³ The argument in favour of this need is based on the construction of a more inclusive and transparent yet sustainable society through a new financial model, to be undertaken silently because the Society cannot cease to function and above all because its organisational culture is what is most difficult to change.

In terms of market economy, a scientific society, like any other civil society, is highly acceptable if it possesses two essential characteristics: that what it produces is of high quality and that it operates transparently. These are indisputable premises because the market knows that prices are neither high nor low but are what the consumer is willing to pay, and they would never acquire a good (course or congress) if it were not high quality and much less so if being owner (associate) of the institution, they were not included in it and there was no transparency.

SECOT therefore understands that it must base its scientific and ethical value on its transformation into a more inclusive and transparent society. If it does not, a major opportunity in unidentified valuable people is lost, and this inclusion must be financially sustainable.

Transparency

During the last debt crisis years, Daron Acemoglou and James Robinson, prestigious researchers of the Massachusetts Institute of Technology (MIT) and of Harvard University, supported by six Nobel prizes for economy and by many other prestigious researchers, published “Why nations fail”.⁴ In the book the authors distinguish between societies led by inclusive elites, where the citizens form part of their projects, and extractive societies where the citizens are excluded, but where by diverse mechanisms, their income is extracted from them. Arkelof – Nobel prize-winner for economy in 2001 – attributed the same transcendent category⁵ as that of Adam Smith's⁶ “The wealth of nations” to the introduction by Acemoglu and Robinson of the concept of societies with inclusive institutions and societies with extractive institutions.

It is striking that this concept of inclusive or extractive societies which aims to explain a macro economy, such as that of a nation, has not been extended and studied in microeconomics, such as that of scientific societies. This is no doubt due to its so recent introduction. Would a scientific society be more prosperous if it were more inclusive? We should of course highlight that an extractive scientific society is not usually one where the leaders appropriate its funds but one with a narrow establishment. This, by its own definition, revolves around power essentially through subjective personal relationships of different types³ and people who believe that the regulations governing everyone else do not need to be applied to them. To a certain extent this encumbrance is even present in countries whose civil society may be the epitome of inclusion.

Given that the concept of inclusive society and transparency are complementary, during these two years four inclusive projects have been piloted, based on new technologies: extensive changes to the Society's journal, new web site uses, the development of the Spanish Orthopaedic Trauma Association (SOTA) and greater financial transparency.

The Spanish Journal of Orthopaedic Surgery and Traumatology (RECOT for its initials in Spanish) is more inclusive

Since the beginning of 2012 the indexing of RECOT has been one of SECOT's maximum acquired values. Up until then, the journal rarely received articles because Spanish authors who published usually did so in indexed journals. Universities and hospital strategists decided years ago to only rate articles which were published in this type of journal⁷ and this is how the authors operated, meeting the economic principle that people are motivated by incentives. After indexation, the journal has expanded and has continued having professionals who have collaborated altruistically in achieving its high quality. However, it is now time to take another leap forward to build up loyalty from Spanish authors seeking journals with a high impact factor (IF) beyond Spain. To do so it must become more inclusive, in its readers and in its committees.

The transformation of RECOT to an “open access” and exclusively “on-line” model involves more readers. However, it is a major challenge because changing the model is not yet always easily accepted due to its higher cost, to the risk of its list of authors being accessible to predatory journals,⁸ to “black open access” illegal sites,⁹ to the ease of falling prey to plagiarism – to “Questionable Research Practice: QRP”¹⁰ – and to the rejection by generations who remain faithful to printed editions. Still, progress will not be deterred.¹¹ Nowadays consideration is that the higher and easier the number of readers, the greater the importance of the journal.^12,13 It is not without reason that during the last decade the number of open access journals in the “Web of science”¹⁴ data base has tripled and it is expected to increase far more in upcoming years.¹⁵ Open access journals have a higher number of citations and therefore gain in IF and visibility.^15–18 It is true that mostly trivial values^{12,13,19–21} are presented by the IF but it is far from negligible for a language like Spanish, ranking among the most important in the world of science and for the community of Spanish orthopaedic surgeons who publish over 800 articles annually in international indexed journals. RECOT and its authors will effectively increase their IF and h-index with open access, and despite the biases of these indicators, they represent standardisation with the rest of the world and will lead to greater inclusion for SECOT in the international scientific community.

This does, however, mean a major increase in costs. An appropriate financial capitalisation plan was developed for this in 2019, with provision of funds in 2020 for the “open access” publication in 2021 and in its business plan it is predicted that the journal will be partially self-financing over the next five years since the financing of open access journals revolves around the payment of a tariff.^18,22 Notwithstanding, at least at the beginning, the members of SECOT should not have to make any payment to publish their articles in RECOT, and this is an added value for membership. By doing so, it is expected that both the number of articles submitted and the number of Society members will increase. This is no trivial matter when demographic expectations are those of stagnation, with mass retirements of tenure members who will become emeritus members and will possibly not be fully replaced by the next generation.³ Open access publication will have an added value: the inclusion of many Latin American colleague readers and authors,²³ whose fluency in the language is of immediate value.

Although the concept of an inclusive society for RECOT will be more gradual internationally, its inclusion has already been emphasised within SECOT. During these two years two tenders have been adopted, one to select the RECOT editor and the other the reviewer. However, the democratisation of science, which is inclusive by definition, should not decline into demagogy²⁴ and the regulations governing the tender were based on the objectivity of suitability to the post. Response was astounding, with over 50 applications from colleagues with excellent profile-matching curriculum vitae.

The Journal is undoubtedly of great value to the scientific society and equally, a journal affiliated with a society acquires greater acclaim.^{19–21,25,26}

A more inclusive web. Changes in knowledge transfer

The web page has been innovative in its technological aspects and has also contributed to the construction of a more inclusive Society. All members, whatever their field or experience, now have access to all courses which were previously exclusively available to a certain group. Why were some courses dedicated only to one type of member and therefore exclusive to all others? Most of them became MOOCs (Massive Open Online Courses), basically on the Moddle platform, and the speakers with their voices and their slides are now available 24 hours a day to every member in their home.

The result of this strategy had been excellent because where 100 students attended a course they now have over 1000 national and foreign followers, with tutoring continuing to be carried out to specific groups in person and this objective has been increased through alliances with other societies with similar results. The Society has included specialist members – tenure ownership members of SECOT – in all teaching activities, including the annual fully recorded Congress. This was a legitimate concern for everyone, and a right and need for the raison d’être of SECOT. In addition to this, major financial savings have been made that, along with other issues, are necessary for the financial capitalisation of the open access journal.

Development of SOTA. A society within SECOT for piloting changes

SOTA is an excellent pilot project because it falls within the group of already existing “scientific matters”, together with tumours and infections, and like these constitutes an association within SECOT which does not detract from the rights of its members. They may freely and voluntarily belong to SOTA simply by being members of SECOT, completing a web page questionnaire and without the need to be submitted to the decision of any committee: it is a fully-fledged right. The response to this offer has been splendid: almost 500 members of SECOT belong to SOTA and they benefit from their interest from the part of our speciality dedicated to traumatology. The creation of SOTA corresponds to an invitation from the IOTA (its international version) to be founder member and form part of it, after an initiative by OTA (its North American version).

The creation of SOTA within SECOT is an excellent opportunity to internationalise Spanish traumatology and its members in the world of “orthopaedic trauma”. SOTA has provided an idea of the level of specialisation, approach, and dedication of the SECOT members to traumatology in relation to orthopaedics, to view trends, provide more specialised treatment and offer members the opportunity to contact each other to conduct multicentre studies and other projects.

The creation of SOTA has also been an opportunity to pilot possible future changes within SECOT without altering the Society and to extend the inclusive model. SOTA-SECOT – its true name – has launched several tenders among its member for obtaining quality fellowships in North America, Europe and Asia, observership programmes and even for forming part of the panel of speakers in the annual SECOT Congress.

For the first time SECOT, through SOTA and RECOT has provided any member with the opportunity to publish articles in a supplement of the journal Injury – recently financed by SECOT – a journal with an IF currently in the second quartile. The response to the tender was again far higher than previous editions, where only certain people were directly invited to take part. Members have had a new opportunity to be included in a common project and this extraordinary experience should be equally extended to sub-specialisations in orthopaedics. The SOTA-SECOT is the 2021 guest society for OTA and we hope that many Spanish surgeons will become speakers at such a significant forum.

Greater transparency in financing

Financing must also be transparent. In a nation, for example, because the citizens are its owner, they understand that they have to maintain it with their taxes and in exchange they want to receive high quality services. Who does not understand that taxes have to be paid? The answer to this question falls exclusively on the benefits which are returned to the contributors and on the transparency with which this contribution is administered.

Lack of transparency in scientific societies is currently an issue of intense debate,^27–35 from which SECOT is not exempt. Why is there now less transparency than there was during the initial years of the Society's existence? Curiously, the answer does not lie in a desire to hide the truth but in the increase in financing.

Over the years there have been other agents interested in participating in the financing of scientific societies^27–30 and with them the societies have grown in the number of activities and supplementary consumables which, paradoxically have not always offered positive contributions to the value chain to improve the final product. Furthermore, even in the actual added product values, these external contributions have increased the cost of living which requires an increase in contributions from the owners (the members) to such an extent that they become unaware of the value of things, what they cost, and how they are financed. What used to be a complementary contribution has become paramount. No scientific society is exempt from this.^27–35

However, once the monster has been created, recent trends have dictated that external contributions to these grant funds will continue dropping because apart from strategic changes to the industry, much stricter governmental regulation will gradually increase. External funds will be depleted until they become irrelevant and the owners of the scientific societies – their members – will have to contribute to financing. They will not be willing to cover this at today's costs but will look closely at what they are contributing and the return it gives them in terms of receiving a quality product, feeling part of the project and having transparent access to how funds are administered. No doubt this poses more of an opportunity than a problem here.

To date SECOT has had a high degree of transparency. In the annual Assembly all of its activities are exposed. The accounts are presented and analysed by the president and treasurer. The members have the opportunity to ask questions and, if applicable, approve operations. However, interest in attending this Assembly is scant. No doubt this is because annual individual contribution is scant too, together with a sense of ownership and belonging, and because the format of on-site communication cannot compete with other restful or even leisure activities. The Assembly does not normally programme other activities at the same time. The lack of a feeling of inclusion is relevant here insofar as it affects the feeling of irrelevance at non-appearance.

Obviously, the argument for the lack of interest cannot be excused by the non-arrival of information but by the need for a change in format. SECOT has already included a transparency portal in its web page which, among other things, includes all the information to be presented in the Assembly prior to it taking place, in an attractive format of a Moodle recording. This is similar to the presentation which will be made live, together with other documents such as the minutes of all the Board of Directors’ meetings, the conflict of interests declaration and a proposal for modification of the statutes in this regard.

The move towards a more transparent society is the demand of any democratic regime. Stratification of knowledge within a scientific society does not mean that it is not democratic in its participation, although it is actions which provide better preparation of knowledge. The society also has to be more transparent through tenders like those proposed, and the establishment of conflicts of interest.

The Spanish Society of Epidemiology (SEE) was the first scientific society to make public its revenues, breaking them down by origin and the conflict of interest of its Board members.³⁶ This was probably because it received the lowest amount of external financing. The 2011 public health law also forecasts moving towards greater transparency when it states that financing must be compulsorily explained by scientific and professional organisations in a “clear, simple and comprehensible” fashion, demanding this transparency “from professionals and experts who collaborate with public health actions, including those of training and research, and the people and organisations that receive grants or with whom contracts, agreements, or accords of any type are made.³⁷ The pharmaceutical industry has also taken steps and in 2016 published in individual detail what each scientific society and each professional had received.^38–40

Financing

The financing model had to be changed in conjunction with the changes to transparency and with a view to future financial problems. SECOT has been financed twenty per cent by membership and mostly from funds coming from the industry, since many activities are sponsored by it. Even the majority of inscriptions to the Congress have the same origin.

The financial health of SECOT has always been measured by the net income from Congress revenue which covers structural costs (head office, staff, etc.) and the activities of the following year. It seems obvious that an annual balance with a large financial surplus to be added onto previous years’ surpluses (working capital) is and has up until now been the security upon which activities have rested.

Notwithstanding, although in theory maintaining working capital to cover contingencies seems a prudent and desirable measure, allying the future solvency of the Society to it may fail because the capital may suffer from major annual devaluation with the consumer price index (CPI) rising at a higher rate than that of the working capital. Furthermore, when it is deposited in safe investment funds – aptly it was never before invested in risk funds because neither the members nor the Tax Office would allow for SECOT to lose financial assets through speculation – the yield could reach such as point that, due to the CPI, the (devalued) working capital would not be able to offset the (revalued) expense.

The working capital also has an important peculiarity: over seventy per cent of this fund is equity and only thirty per cent liquid assets. Equity is represented by the head office and liquid assets are similar to the income from a congress, insolubly depreciated due to the increase in the cost of living. This is effectively financial fragility because if a need arises the head office cannot be sold, at least not with the required alacrity, nor can the personnel be dismissed without a considerable fall in production. As a consequence, the consideration of working capital as equity as a guarantee fund is a conceptual error.

Another major matter related to financing by the industry is the value of the brand SECOT. Many of the already diminishing contributions from industry to scientific societies, not just to SECOT, have been transferred to courses of their own making. Over the last few years industry has been subjected to a process of transparency never before experienced and the contributions it makes to scientific societies may no longer be of interest because the expected return and required transparency is not forthcoming.

However, as scientific society prestige remains, part of the industry has continued seeking to endorse its own courses or those given by professionals it sponsors who at the time are members of the society, with the society brand and thereby gaining the endorsement free of charge. As a result, practically all scientific societies have striven enormously to attach value to their brand with regulations that govern which courses may be endorsed by the society and what the conditions are. However, relaxation by SECOT has, in isolated cases, led to a perverse situation of obtaining a SECOT course which is nothing other than a course imparted by an individual member, but which contributes nothing to the society.

Two questions arise here: should this example be moved to the companies which do collaborate with SECOT and this free short-circuit be continued? Are the excellent courses imparted though individual, not company initiative, really any better these days because they carry the SECOT brand? Paradoxically, the brand – which in business economy is known as goodwill – is the most important issue any scientific or mercantile institution has. This issue was called to attention 12 years ago⁴¹ and we have worked on it during this two-year period but with discouraging results. Introducing changes to organisational culture takes many years but should still be a fundamental objective.

However, the growth of goodwill, at least initially, should lead to marginal income and consequently in view of that discussed above there is no doubt that the future financing of SECOT will be essentially based on member contributions. Industry will continue to reduce funding and the Society will be freer and more critical if it is not based on the contributions of these financiers – although in actual fact this equation is as yet unformed.

It is therefore important to have a large mass of members and their annual increase shows positive signs of development and financing. However, in the mid-term, there is a genuine risk of member numbers declining due to demographic implosion. Basically the negative growth rate can be explained by the retirement of the baby-boom generation and the non replacement by younger generations.⁴² In fewer than 10–15 years the pyramid of the SECOT members will move towards higher values, several standard deviations and many tenure members becoming emeritus members. The statues of SECOT will grant the latter “common rights and obligations with the tenure members” but they will be “exempt from membership contributions”.

Furthermore, if we look at a theoretical framework of how these emeritus members would behave towards the timeless discount rate (TDI), i.e. the amount necessary to hold in the working capital at any one time for possible future expenses, there would be a paradoxical tendency to increase this capital, seeing the disposal of assets as a disaster, even if it was a financial hindrance.

During this two-year period, seeing as how the foregoing required profound discussion and the matter of accountability was pressing, we therefore considered more pragmatic aspects. The only possible alternative path open was to drastically reduce expenses, with a progressive reduction in funds provided by industry and the simultaneous development of specific projects with scientific solidity.

How were these expenses reduced? In terms of analytical accounting a distinction is made between production cost and expense. A production cost is what is used to obtain a product. An expense is the outlay which is not involved in production but which mediates it and gives it a value, for example, logistics. We may state that production costs in the majority of scientific societies are zero because its members offer to freely produce (e.g. giving a conference in a course or writing a chapter of a book) but this is not so of expenses which are essentially focused on logistics (paying for the transport and accommodation at a Congress – because the industry usually pays for this – but not a course where there are speakers, as this cost is borne by the scientific society).

With these premises during these two years, we have used the MOOCs new technologies, combined with the development of a more inclusive Society. This has involved a profound re-assignation of resources which used to be dedicated to logistics, thus drastically lowering expenses and obtaining in 2019 a financial margin almost 1000% higher than in 2018 (sic): this combination has been the essential key to these two years of management. In addition to this, with courses outsourced a transfer of risk in the event of losses was renegotiated, but with income in the event of profits. Five more research projects than were usually conducted were also financed.

Since this was essentially, albeit not exclusively, carried out with on-site courses for resident doctors, this strategy brought other added values with it: that of promoting a strong work ethic and accountability from the young people. The resident doctors received the modules on the Moodle platform, as did the other members, and on-site lectures of only one day. These lectures were always in Madrid, due to equidistance and logistical ease, with written consent given to SECOT by the attendees for it to be able to inform their respective hospital tutors about how long they were in the classroom and on their performance. Information regarding this initiative was introduced into the SECOT course for tutors. All members were also given the opportunity to take the EBOT exam and this was financed exclusively for those resident doctors who passed. It should be stressed that the attitude of the young doctors to this new organisation has been exemplary.

These actions led to capitalisation to ensure the open access journal, increase the temporary guarantee fund and to raise the extremely low number of people in the secretariat, increasing their specialisation. Although the latter involved increasing structural costs, it was a necessary step in achieving greater specialisation to acquire a comparative advantage (a financial concept which means increasing the quality and quantity of production as a consequence of specialisation) that has led to an institutional growth in value with greater member communication and services. However, the next steps to be taken cannot involve new structural growth, but the opposite must occur: the reduction of assets and the increase in the outsourcing of services already begun to achieve a gradual reduction in the before-mentioned expenses. Outsourcing – congress management has been outsourced for some time – brings great advantages because the supplier may change, as was the case in 2019, following a public tender, thus entailing added values and a more expeditious management of revenue.

After the publication of a programmatic leader in this journal 2 years ago, analysing the challenges faced by SECOT³ and advocating a refoundation, a response to the proposed problem was needed, as was a display of the outcomes to the solutions proposed at the time. Only a society that had completed a genuine refoundation would be able to provide greater transparency and accountability.³ In upcoming years there will be major challenges which will sociologically alter the scientific societies, and be a reflection of the major changes which will take place in civil society. These will involve higher demands in product quality with easier and faster provision using new technologies,⁴³ greater transparency, an increase of women in positions of responsibility⁴⁴ and the advance of highly qualified immigrants who will contribute value to the national economy.^45–47 For it to enjoy success in that society, SECOT must expand its far-reaching changes in the immediate future and become an even more inclusive and transparent society.

Camus, when citing Pindar in the work from which the title of this leader is taken, states that one should not strive for the life of the immortals but exhaust the realm of the possible² and as members we should know that SECOT cannot change spontaneously if we do not daily demand further transparency. If not, as in “the myth of Sisyphus”,² any attempt at change may end up wiping itself out, only to begin again years later when it is probably too late.

Conflict of interests

The author has no conflict of interest to declare. No direct or indirect financing was received.