Fairness in medical publishing: Reforming the peer review process

In the middle of a busy week of balancing clinical, research, educational, administrative, and parental responsibilities, I receive an email request from a prominent journal to review a manuscript. If I agree, I will spend a couple of hours reading the manuscript, offering comments, and registering my opinion. Several weeks later, I’ll probably be asked to review an edited version all over again. And in exchange for this effort? Nothing. This journal is not going to compensate me for my time. My motivation to do this is supposed to be altruistic.

Historically, medical journals have not compensated their reviewers. In a traditional model, authors supply their work to a for-profit publisher which then sells access to the article. In an open-access journal, authors pay to have their work published. Either way, the reviewers performing the necessary component of peer-review receive nothing for providing their expertise. This certainly is not due to a lack of funding. Medical publishers record massive profits by charging fees that are so exorbitant that major academic medical centers can no longer provide their faculty access to them. Why do physicians and scientists continue to go along with this scheme?

The failure to compensate reviewers is just one of many ways medical publishing is screaming out for reform. The susceptibility to bias in the review process is another major problem. While reviewers and their qualifications often remain anonymous, authors’ identities are known to the reviewers. This can have huge implications in the research that gets published as we know that reviewers can display bias against people with names that sound like they are derived from non-majority ethnic groups. Reviewers are also given information such as the country of origin and institutions to which the authors belong, contributing more opportunities for bias. Identifying information about authors should not be provided to reviewers.

In addition to being biased, the publication process is also incredibly slow. Regardless of how long a journal takes to provide a decision, authors are prohibited from submitting their work to other journals. As a result, if an article is rejected once or twice, it can take well over a year for it to eventually be published, and by that time, it might already be out of date. You would think that a system that is this slow would at least be diligent about publishing only quality research, but we know that’s not true.

Much has already been written about the ability to defraud journals into publishing fake research. We have websites dedicated to tracking retractions because journals retract articles so often. Prominent journals are not immune to this, either. The two or three-person review process used by many journals simply doesn’t detect fraud. Yet the peer-review process remains – despite the bias, the delays, the failure to identify fraud, and the reliance on free labor – the gold standard for academic publication. It doesn’t have to be this way.

In the past, journals played a crucial role in disseminating research. Although many journals still publish printed versions, there really is no need to do so. I suspect these journals’ environmental impact, often mailed in plastic wrap, is substantial, but ironically, no study on this could be identified. Nevertheless, the use of disposable paper and plastic is clearly unnecessary in the current era. I would venture that there is nobody left who does academic literature searches on paper. Therefore, the medical community would be no worse off without printed journals.

Furthermore, journals have historically retained prominence through a contrived metric known as the impact factor. The impact factor is a highly self-promoting number used to allow certain journals to enjoy the right of first refusal as authors strive to publish in the highest impact factor journal that will accept their manuscripts. In reality, the impact factor has become meaningless. When I do a search, the article with the highest impact is the one PubMed finds for me, not the one from the highest-rated journal. As noted above, high impact factor journals are prey to academic fraud. As a result, we should be just as skeptical of an article published in a high-impact journal as a low-impact journal. Publication in a high-impact journal does not make the research any better. When we accept that there is no need for a high impact factor imprimatur and no need to print on paper, we realize that the rest of the peer-review process can occur outside medical journals’ confines.

If publishers do not reform their processes, one option to bypass for-profit journals would be to utilize and grow existing infrastructure, such as pre-print servers and the National Library of Medicine, which are not-for-profit and already index and publish massive numbers of articles. Authors could upload their articles to be displayed anonymously, whereupon they will be tagged as “not peer-reviewed.” Authors who submit their work and credentials become registered as peer reviewers and receive alerts when new manuscripts related to their expertise are uploaded. Once a manuscript receives a predetermined number of positive reviews, the authors’ names become visible, and the manuscript’s tag is replaced with “peer-reviewed.” This system also allows manuscripts to be published immediately without authors having to move from journal to journal. While this system does not provide an obvious mechanism to compensate reviewers for their effort, it is still preferable because the articles are then freely available with no cost to the authors or readers. This is just one possible way to reform medical publishing, and others have discussed alternatives.

The peer-review process is fallible, slow, and biased, and it takes advantage of the scientific community’s altruism. We need to keep pushing the conversation forward about making publishing more equitable, timely, accessible, and fair. An obvious and easy way to begin is to pay the experts who perform the peer reviews. Either the journals need to reform their practices, or the medical community should establish an alternative.

Andrew Spector is a neurologist.

Image credit: Shutterstock.com

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