If You Want to Publish, Be Part of the Process

Stuart F. Quan, MD¹

Colin Shapiro, BSc (Hon) MBBCh PhD MRCP (Psych ) FRCP(C)²

¹Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital,

Boston, MA, USA

²Department of Psychiatry, University of Toronto, Toronto, ON, Canada

The edifice of academic journals is predicated on the process of peer review. Inevitably it is subject to the vagaries of the individual perspectives and biases of the reviewers. However, there has not been a useful, equitable or viable alternative that would secure a level of quality control in the research domain (1). Given the inevitable human components of range of knowledge, potential biases  and sometimes lazy thinking, it is certainly not a perfect system. Certainly, a worthy paper occasionally is rejected, or a badly flawed paper is accepted. However, in the absence of a better process, it is the gold standard.

Historically, peer review has been an altruistic endeavor. Researchers understood that their reviews contributed to the scientific process by improving the quality of reported information and providing an imprimatur to the reported findings (2); reviewing was an obligation to the scientific community (3). However, there are other benefits to reviewing a paper. These include discovering new insights or approaches to a particular topic, improvement in one’s own writing skills by reading the work of others, and use as a tool for teaching trainees to analyze strengths and weaknesses of a study (4).

Despite the importance of peer review, it is the bane of virtually all scientific journals, and its expeditious functioning is approaching crisis levels. Most journals request that reviews be returned within 2 weeks of acceptance. However, in many cases this is wishful thinking, and reviews often are received far in excess of 2 weeks. This results in long delays in a publication decision;  in our experience, it sometimes can exceed 6 months.  Most delays in review are related to searching for reviewers and constantly reminding them to submit their review on time (5). As current editors for a sleep journal as well as having served as editors for other journals, we have sent up to 50 review invitations for some papers. Other editors confirm that finding reviewers in increasingly difficult for all journals (6).

There are two major factors that have led to this crisis. First is the proliferation of scientific journals. For example, ten years ago there were at least 15 sleep journals which was an increase of 9 over the preceding decade (7). There are even more now, and this does not include journals that only publish some sleep content such as the Southwest Journal of Pulmonary, Critical Care and Sleep, American Journal of Respiratory and Critical Care Medicine, or Neurology. Each of these journals needs reviewers for the papers submitted to them. Second is researchers and academic clinicians over the past several decades have been placed under increasing pressure to generate external funding whether it be grants or clinical income. A few decades ago, being invited to review an important article would have been viewed as a recognition of a degree of competence. Today, it is considered a burden in that there is no time to perform non-remunerative work (3).

Are there any means to alleviate this crisis? We offer the following possibilities:

• An expectation that anyone who publishes in a journal must agree to review a predetermined number of papers in order to submit subsequent manuscripts. This number would likely vary among journals, but we propose that it be a minimum of 3 reviews.
• For journals that charge an article publishing fee, discounts for publishing or other monetary incentive are provided to reviewers who provide expeditious and high-quality reviews. Some journals currently do this, but it is unclear whether these incentives are effective.
•  In addition to a requirement by academic bodies to list publications on one’s vita, there should be a list of reviews submitted including the journal’s name and impact factor and the review date.  
• Academic institutions require a minimum number of manuscript reviews as an essential criterion for promotion or retention. 
• Academic institutions should be encouraged to provide training in the process of writing a scientific article AND the approach to reviewing and evaluating a manuscript.
• Explore the possibility of using generative artificial intelligence to assist in conducting some aspects of peer review (8).

No doubt that there are other novel concepts and journals should adopt policies that will be effective for their own stakeholders. In the meantime, we strongly urge readers of this editorial to be generous with their time and regularly accept requests to review papers. Your efforts will be greatly appreciated by journal editors, and you will be assisting in the dissemination of science as well as fostering your own personal growth as a researcher or academic clinician.

References

1. Smith R. Peer review: a flawed process at the heart of science and journals. J R Soc Med. 2006 Apr;99(4):178-82. [CrossRef] [PubMed]
2. Carrell DT, Rajpert-De Meyts E. Meaningful peer review is integral to quality science and should provide benefits to the authors and reviewers alike. Andrology. 2013 Jul;1(4):531-2. [CrossRef] [PubMed]
3. Fiedorowicz JG, Kleinstäuber M, Lemogne C, Löwe B, Ola B, Sutin A, Wong S, Fabiano N, Tilburg MV, Mikocka-Walus A. Peer review as a measurable responsibility of those who publish: The peer review debt index. J Psychosom Res. 2022 Oct;161:110997. [CrossRef] [PubMed]
4. Quan SF. Expediting peer review: why say yes. J Clin Sleep Med. 2014 Nov 15;10(11):1167. [CrossRef] [PubMed]
5. Quan SF. Expediting peer review: just say no. J Clin Sleep Med. 2014 Sep 15;10(9):941. [CrossRef] [PubMed]
6. Gozal D, Adamantidis A, Stone KL, Pack AI. The current status of the journal SLEEP. Sleep. 2024 Sep 9;47(9):zsae154. [CrossRef] [PubMed]
7. Quan SF. Another Sleep Journal? A Reprise in 2014. J Clin Sleep Med. 2014; 10(7):717. [CrossRef]
8. Chauhan C, Currie G. The Impact of Generative Artificial Intelligence on Research Integrity in Scholarly Publishing. Am J Pathol. 2024 Dec;194(12):2234–8. [CrossRef] [PubMed]

Cite as: Quan SF, Shapiro C. If You Want to Publish, Be Part of the Process. Southwest J Pulm Crit Care Sleep. 2024;29(6):67-68. doi: https://doi.org/10.13175/swjpccs052-24 PDF

Equitable Peer Review and the National Practitioner Data Bank

The General Accounting Office (GAO) recently reported that Department of Veterans Affairs (VA) did not report most physicians whose clinical care was found to be, or suspected of being, substandard to the National Practitioner Data Bank (NPDB) or to state licensing boards (1). The GAO examined 5 VAMCs and found required reviews of 148 providers’ clinical care after concerns were raised from October 2013 through March 2017. Of the 148, 5 were subjected to adverse privileging actions and 4 resigned or retired while under review but before adverse actions were taken. Only 1 of these 9 was reported to the NPDB and none was reported to his or her state medical board.

In response to GAO's report and in testimony to the Subcommittee on Oversight and Investigations, VA officials said the agency was taking three steps to improve reporting of providers who don't meet required standards:

1. Reporting more clinical occupations to the NPDB;
2. Improving the timeliness of reporting;
3. Enhancing oversight to ensure that no settlement agreements waive the VA's ability to report to NPDB and state licensing boards (2).

What is lacking in the report is determination if substandard actually occurred and how it was determined. The VA has 3 ways of identifying substandard care (1).

1. Tort claims (the VA equivalent of a medical malpractice lawsuit);
2. Complaints or incident reports;
3. Peer review.

Each has major problems of accuracy and fairness at the VA.

The majority of US physicians have been sued (3). The minority of suits are associated with malpractice and malpractice has no apparent association with the outcome of the litigation (4). Over 90% of medical malpractice cases are settled out of court (5). A common misconception is that settling a case before trial means a large financial settlement. However, 90% of the 90% or 82% of all claims, close with no payment (5). However, the VA uses US District Attorney to defend malpractice claims (6). In many instances, the US District Attorney’s office settles the case without determining if there is malpractice. The VA then submits the offending physician(s) name to the NPDB or state boards whether malpractice has been shown or not.

Complaints or incident reports are common in many hospitals, and many, if not most, have little merit (7). However, the weight given to a complaint should be viewed differently depending on the source. When colleagues raise concern about a physician’s care this is more credible than a patient complaining about not receiving their narcotics to a patient advocate. In the GAO report it is unclear if this was a source the of possible substandard care.

Lastly, there is peer review. There are several problems with this process in the VA. The VA selects the “peers”. In many instances the reviewers are un- or under-qualified to review the case (6). Furthermore, the selected reviewers may be conflicted clouding a balanced and fair determination if the physician’s care met the standard of care. There are multiple instances of this at the VA, of which a couple have been cited in the SWJPCC (6).

No surprisingly, a bureaucracy in the federal government has suggested a bureaucratic solution to a nonexistent problem. The goal should not be for more bureaucratic reporting, but a system for determining if a physician’s care has met the standard of care. The VA has shown it is incapable of making this determination fairly and accurately. What is needed is an outside review separated from VA influence and politics. If malpractice is still questioned after an initial VA review, the medical schools or private practioners could provide a source of physician peer review. The case could be presented to a panel of non-VA physician peers chosen in an equitable ratio by the VA and the accused practitioner. In the absence of a more equitable review process, the VA will only succeed in driving away the quality practitioners the veterans need.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. General Accounting Office. VA health care: improved policies and oversight needed for reviewing and reporting providers for quality and safety concerns. Report to the chairman, committee on veterans’ affairs, House of Representatives. GAO-18-63 (Washington, D.C.: November, 2017). Available at: http://www.gao.gov/assets/690/688378.pdf (accessed 12/6/17).
2. Terry K. VA medical centers fail to report substandard doctors, GAO says. Medscape. December 5, 2017. Available at: https://www.medscape.com/viewarticle/889600?nlid=119420_4502&src=wnl_dne_171206_mscpedit&uac=9273DT&impID=1501593&faf=1 (accessed 12/6/17).
3. Matray M. Medscape malpractice report 2017 finds the majority of physicians sued. Medical Liability Monitor. November 15, 2017. Available at: http://medicalliabilitymonitor.com/news/2017/11/medscape-malpractice-report-2017-finds-the-majority-of-physicians-sued/ (accessed 12/6/17).
4. Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996 Dec 26;335(26):1963-7. [CrossRef] [PubMed]
5. Chesanow N. Malpractice: when to settle a suit and when to fight. Medscape. September 25, 2013. Available at: https://www.medscape.com/viewarticle/811323_3 (accessed 12/6/17).
6. Pham JC, Girard T, Pronovost PJ. What to do with healthcare incident reporting systems. J Public Health Res. 2013 Dec 1;2(3):e27. [CrossRef] [PubMed]
7. Robbins RA. Profiles in medical courage: Thomas Kummet and the courage to fight bureaucracy. Southwest J Pulm Crit Care. 2013;6(1):29-35.

Cite as: Robbins RA. Equitable peer review and the national practitioner data bank. Southwest J Pulm Crit Care. 2017;15(6):271-3. doi: https://doi.org/10.13175/swjpcc152-17 PDF