Peer review at medical journals, from a former JAMA editor

Picture this: A medical journal receives an unsolicited manuscript from an unknown author, and then … Type 1 medical journal.

The peer review process employed by Type 1 medical journals uses secret, anonymous peer reviewers working behind an opaque shield hiding clueless and spineless editors who may use either no reviewers, or a few cronies, or those reviewers known to be opposed or known to be in favor of some medical theory, hypothesis, study, test, product, or procedure.

As such, the results of the entire review process may be rigged by any of that cast of journal decisionmakers, known collectively as “editors.” They may promote whole fields of medicine into which vast sums of a nation’s resources may be channeled and harvested. One famous medical school dean once described an American academic medical center as “the most efficient resource-trapping device in the history of the world.” In sum, a vast medical cartel in conspiracy to assure the maintenance of its self-interest in perpetuity, cloaked in “peer review.”

Or, Type 2 medical journal.

The peer review process employed by Type 2 medical journals revolves around a sacred trust relationship between a skillful, competent, unbiased, and eminently moral chief editor, who, with a similarly pristine staff with no conflicts of interest, attracts and selects the most scientifically pure and clinically useful articles.

To do so, he or she uses the unpaid voluntary talents of a host of similarly unbiased, rapid-response peer reviewers to help accept all articles that justify publication in that stellar venue based purely upon merit. These are rapidly published in electronic form with no page or length limitations and free, open access to all, unhampered by advertising or subscription requirements. The entire process is transparent, including names, dates, opinions, revisions, and decisions.

My insider bias is that many elements of Type 2 are more prevalent than many elements of Type 1. But, in fact, variations and blends of editorial and publishing conduct between these 2 types are the dominant mode in 2011.

Of course, post-publication peer review has always been the most important peer review of medical journal articles.

That is when potentially large numbers of readers, in contrast to only a few pre-publication readers, can have at an article.

Most published medical journal articles are ignored, and deservedly so. Very few advance scientific knowledge and medical thinking a great deal. Some of the messes medical journals make are made right by that journal publishing “corrections” or even “retractions,” and by the “letters” column.

But, how about that more than 90% of submitted articles that “the best” journals reject and that more than 50% of submitted articles that the second-tier journals reject, many of which were never seen by eyes outside the editorial offices?

How many gems of observation, data, and thinking were simply lost by dogmatic suppression, narrowness of thinking, the fetters of paper-based decisions, or fear of taking on the status lucratus of the American Medical Marketing Machine (AMMM)?

As famed New York Times columnist and Princeton Nobelist Paul Krugman has sometimes written: “Be afraid; be very afraid,” but only if your health and the health of your patients matter to you.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.