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

Who Should be Leading Healthcare for the COVID-19 Pandemic?

The recent COVID-19 pandemic brought to mind the Oscar Wilde quote, “An expert is an ordinary man away from home giving advice” (1). COVID-19 advice has flooded my inbox and dominated news coverage on television, in print and electronically. Everyone from the President to the hospital secretary seems to think they are qualified to offer advice on COVID-19 prevention and care. I admit to not being an expert on COVID-19 because I am not a virologist. However, despite retiring from the ICU in 2011, I think I know quite a bit about caring for sick patients with pneumonia having done it for over 30 years. For my part, and for many of my colleagues, the non-solicited, non-expert advice offered from these sources should be returned and the sender instructed to place it in that recess of the body most protected from sunlight.

The US government has not provided outstanding leadership during this pandemic. The President and CDC were both initially slow to respond and sometimes issued confusing or contradictory statements (2,3). Occasionally they were just wrong. The news media contributed to the confusion by reporting what was at times nonsense. All would be better off if we followed the guidance of someone like the NIH’s Dr. Tony Fauci who has said the right things while walking a political tightrope of gently contradicting the President.

Most hospitals have not done much better than the White House. I am overwhelmed with advice and sometimes pronouncements that claim to be evidence- or CDC-based. Sometimes they are-sometimes not. These are usually from a non- or minimally qualified administrator lacking medical expertise. We now hear reports that administrators are trying to direct health care providers not to wear personal protective equipment (PPE, masks, goggles, booties, etc.) in hallways or forbidding physicians and nurses from bringing their own PPE from home (4,5).

The hospitals give a variety of reasons for their actions, from conservation of PPE to the belief that it scares patients. Conservation of PPE is good idea. However, having someone change their mask every time they see a potential or a confirmed COVID-19 means using lots of masks while wearing one mask all day would help to conserve. Scaring patients is not good but unnecessarily exposing healthcare providers is worse. In Italy and Spain healthcare workers make up a disproportionately high number of cases (6-7). It is now thought that the hospital may be a primary source of infection and that the lack of doctors and nurses is impairing healthcare (6-8). Patients should be frightened and even more so when someone enters their room without a mask.

Although dealing with this crisis is the first priority, we need to ask ourselves at some point how could the US be so unprepared. We saw what a surge in ICU patients could do with the H1N1 influenza pandemic of 2009 leaving ICU beds and ventilators in short supply (9). In the 11 years since that time, the country did little to nothing. Where are the ventilators, the PPE and the medical personnel we now need?

Healthcare planning and emergency preparation have been done by non-medical people who now must take responsibility for our lack of preparedness. Those same people are now trying to direct care. They should back away and let those best able to deal with the present catastrophe provide the care. In the future we should ask what role they should play in planning for a National healthcare emergency. Will those planning be more concerned about allocating monies for future healthcare emergencies or another purpose? Perhaps we should have the planning done by those more knowledgeable and more concerned for the American people.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Guernsey L. Suddenly, everybody's an expert. NY Times. February 3, 2020. Available at: https://www.nytimes.com/2000/02/03/technology/suddenly-everybody-s-an-expert.html (accessed 3/27/20).
2. Edwards HS.  The Trump administration fumbled its initial response to coronavirus. Is there enough time to fix it? Time. March 19,2020. Available at: https://time.com/5805683/trump-administration-coronavirus/ (accessed 3/27/20).
3. Chen C, Allen M, Churchill L. Internal emails show how chaos at the CDC slowed the early response to coronavirus. ProPublica. March 26, 2020. Available at: https://www.propublica.org/article/internal-emails-show-how-chaos-at-the-cdc-slowed-the-early-response-to-coronavirus (accessed 3/27/20).
4. Ault A. Amid PPE shortage, clinicians face harassment, firing for self-care. Medscape. March 26, 2020. Available at: https://www.medscape.com/viewarticle/927590?nlid=134683_5461&src=wnl_dne_200327_mscpedit&uac=9273DT&impID=2325986&faf=1#vp_3 (accessed 3/27/20).
5. Whitman E. 'Taking masks off our faces': how Arizona hospitals are rationing protective gear. Available at: https://www.phoenixnewtimes.com/news/arizona-hospitals-rationing-masks-protective-gear-banner-11459400 (accessed 3/27/20).
6. Van Beusekom M. Doctors: COVID-19 pushing Italian ICUs toward collapse. Center for Infectious Disease Research and Policy, March 16, 2020. Available at: http://www.cidrap.umn.edu/news-perspective/2020/03/doctors-covid-19-pushing-italian-icus-toward-collapse (accessed 3/27/20).
7. Jones S. Spain: doctors struggle to cope as 514 die from coronavirus in a day. The Guardian. Available at: https://www.theguardian.com/world/2020/mar/24/spain-doctors-lack-protection-coronavirus-covid-19 (accessed 3/27/20).
8. Begley S. A plea from doctors in Italy: To avoid Covid-19 disaster, treat more patients at home. Stat. March 22, 2020. Available at: https://www.statnews.com/2020/03/21/coronavirus-plea-from-italy-treat-patients-at-home/ (accessed 3/27/20).
9. Levey NN, Christensen K, Phillips AM. A disaster foretold: Shortages of ventilators and other medical supplies have long been warned about. LA Times. March 20, 2020. Available at: https://www.latimes.com/politics/story/2020-03-20/disaster-foretold-shortages-ventilators-medical-supplies-warned-about (accessed 3/27/20).

Cite as: Robbins RA. Who should be leading healthcare for the COVID-19 pandemic? Southwest J Pulm Crit Care. 2020;20(3):103-4. doi: https://doi.org/10.13175/swjpcc021-20 PDF 

Maintaining Medical Competence

“I am free, no matter what rules surround me…because I know that I alone am morally responsible for everything I do.”― Robert A. Heinlein

I recently renewed my Arizona medical license and meet all the requirements. I far exceed the required CME hours and have no Medical Board actions, removal of hospital privileges, lawsuits, or felonies. None of the bad things are likely since I have not seen patients since July 1, 2011 and I no longer have hospital privileges. However, this caused me to pause when I came to the question of “Actively practicing”? A quick check of the status of several who do not see patients but are administrators, retired or full time editors of other medical journals revealed they were all listed as “active”. I guess that “medical journalism” is probably as much a medical activity as “administrative medicine” which is recognized by the Arizona Medical Board. This got me to thinking about competence and the Medical Board’s obligation to ensure competent physicians.

Medical boards focused on preventing the unlicensed practice of medicine by “quacks” and “charlatans” in the first half of the Twentieth Century. The Boards evolved over time to promote higher standards for undergraduate medical education; require assessment of knowledge and skills to qualify for initial licensure; and develop and enforce standards for professional practice. Beginning with New Mexico in 1971, nearly all state medical boards require a prescribed number of continued medical education (CME) hours with Colorado being a notable exception. Colorado’s lack of CME requirements goes against the recent trends. In 2010 the Federation of State Medical Boards (FSMB) House of Delegates voted to adopt a framework for maintenance of licensure to address concerns among policymakers and regulators (1). The FSMB’s framework contains three components: 1. reflective self assessment; 2. assessment of knowledge and skills; and 3. performance in practice.

Self-reflection has long been a mainstay of good medical practice. However, the requirement is vague and most evidence suggests that physicians are not very good at it (2). Assessment and reassessment of knowledge and skills has been present in most medical specialty and subspecialty boards for some time. Furthermore, actively practicing physicians are required to undergo periodic peer review and reapplication for hospital privileges. Further testing and assessment seems costly and largely unneeded. However, medical licensure is above all about seeing and treating patients. What is new is FSMB’s recognition of the importance of active medical practice in determining medical competence. In many instances, policymakers such as chiefs of staff, hospital board members, administrators or members of guideline writing committees have been non- or very limited practicing physicians. Their decisions have often been fundamentally flawed. Quality has been frequently politically defined rather than patient centered and evidence based. In too many cases, hastily adopted guidelines are proven wrong and even potentially dangerous to patients (3).

A physician who directs care should be subject to the “Continued Competency Rule” which is used in Colorado (4). This rule requires that a physician, “if not having engaged in active practice for two or more years…be able to demonstrate continued competency”. It needs to be recognized that those who meet this standard are only competent in their own area of practice. For example, a pulmonary and critical care physician has no business directing neurosurgical care or formulating orthopedic guidelines. Administrative medicine, and for that matter, medical journalism, would do not meet this standard of competency since neither involves taking responsibility for the care of patients. The requirement for physician administrators to be really active in the practice of medicine may be one key to improved medical care and competence. At least it should make them think about directing care or mandating a guideline that they, themselves have to follow.

Richard A. Robbins, MD*

References

1. Chaudhry HJ, Talmage LA, Alguire PC, Cain FE, Waters S, Rhyne JA. Maintenance of licensure: supporting a physician's commitment to lifelong learning. Ann Intern Med 2012;157:287-9.
2. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 2006;296:1094-102.
3. Robbins RA, Thomas AR, Raschke RA. Guidelines, recommendations and improvement in healthcare. Southwest J Pulm Crit Care 2011;2:34-37.
4. http://www.dora.state.co.us/medical/ (accessed 11/5/12).

* The views expressed are those of the author and do not necessarily represent the views of the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA. Maintaining medical competence. Southwest J Pulm Crit Care 2012;5:266-7. PDF