Reforming the peer review process [PODCAST]

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“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.

He shares his story and discusses his KevinMD article, “Fairness in medical publishing: Reforming the peer review process.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. On the show, we have Andrew Spector. He is a neurologist, and he wrote the KevinMD article “Fairness in medical publishing: Reforming the peer review process.” Andrew, welcome to the show.

Andrew Spector: Thank you, Kevin. Thanks for having me.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Andrew Spector: Sure. So I’ll work backwards a little bit. Right now, I am a sleep medicine physician at Duke University in Durham, North Carolina, and sleep medicine’s been my passion for a long time. I figured that out in college, and I sort of spent my whole education working toward this position here. So I went to med school planning to be a sleep doctor, I went to residency planning to be a sleep doctor, and I did my fellowship and took this job. I’ve been here about seven and a half years, and I still love it.

Kevin Pho: Wonderful. And we’re speaking in the middle of January, in the midst of the worst wave of the pandemic. Now, from that standpoint, what are you seeing in your clinical practice?

Andrew Spector: Well, the biggest thing that happened in sleep medicine is that we rapidly switched to telehealth, which is something we in sleep medicine have been trying to do for a long time, and then finally we’re able to do it from a logistics standpoint with insurance companies and the regulations. So I’ve been doing a lot of telehealth now.

The patients are definitely having more trouble sleeping. I hear a lot about the phrase we’ve coined, “COVID insomnia,” and more trouble sleeping as related to the change in their routines and the stress of the moment, and there’s even some thought that having COVID can disrupt sleep. So I’m seeing the whole collection of those things. And then there’s the other population that, without having to get up to go to work, is loving the idea of staying home and sleeping in, and they can sleep ad lib now, which actually helps their sleep. So that’s the other side of it. It’s not all bad for everybody with regard to sleep.

Kevin Pho: Now, for those patients who have trouble sleeping because of COVID or the anxiety surrounding COVID, what kind of advice or treatment options are you giving them?

Andrew Spector: Well, I like to give people some reassurance. When stress is the cause of your trouble sleeping, it usually passes, and the worst thing that you can do is start to worry too much about your sleep. I reassure people that this will pass, and the more anxious you get about sleep itself, the worse you’re going to sleep. And so I try to just reassure people that they won’t die from sleep deprivation because of insomnia, that this will pass, and just try to prevent the anxiety about sleep from being its own perpetuating factor for the insomnia.

Kevin Pho: So let’s get into your KevinMD article now, “Fairness in medical publishing: Reforming the peer review process.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to write it?

Andrew Spector: Sure. So one of my jobs at Duke Neurology is that I serve as the vice chair for inclusion, diversity, and empowerment. In that role, I talk a lot about ways of improving even things like burnout and the culture of the workplace, all part of my scope in that vice chair role. One of the things that I look at specifically is unfunded work: people who get more and more jobs piled on and no time to do it, no financing to do it. And that’s big, even among my colleagues in the equity, diversity, and inclusion space. I usually abbreviate that EDI. Those working in EDI are sort of famous for doing this. It’s a thankless job. They don’t get a budget or a salary for doing it.

And I started looking at other things in our workplace that are similar to that, where you’re asked to do work and not given any time or compensation for it, and one of those things is peer reviews for journals. So a journal will email you and ask you, out of the blue, to review an article that they think you might be somewhat expert in, and you’re asked to do it within the next two weeks. You do it, you submit it, and a couple weeks later, they send it back to you, and you do it all over again. At the end of it, it’s great from a science standpoint, sort of, but it really does nothing for the reviewer.

My concern is not so much that we shouldn’t be helping advance the science, but realistically, the companies we’re doing this for are billion-dollar, multibillion-dollar companies. So we’re actually supporting an industry on the backs of our own expertise for free, and that’s where I start to get concerned. If this were entirely a nonprofit exercise, something that we’re all doing together for the collective scientific good, no problem. But if you’re going to be making billions of dollars in profit, well, then maybe the people doing the work ought to share in some of that.

Kevin Pho: Now, if this was any other industry, for instance, the law industry, if someone asked you for a consultation or for your time, you know, you could bill by the hour. Now, how compelled are you to do these peer reviews if a journal reaches you out of the blue?

Andrew Spector: The legal industry, or any other area of expertise, does not do these things for free, so it’s unclear why we’ve set up our industry to do that. And certainly, peer review is not the only avenue where that’s the case. But when I get these reviews, I have started asking and saying, “Well, is there any stipend for this?” Typically, what happens is they’ll say, “No,” and I’ll say, “Why not?” And I won’t ever hear from them again, so that’s usually the end of it.

Now, there are exceptions. I have reviewed for journals where I know the editor-in-chief personally and I feel like I’m doing a personal favor. I will still do it, but there has to be some sort of connection, some reason I’m doing it beyond a random email I get. That’s no longer enough to get me to do it.

Kevin Pho: Now, is it part of your responsibility, working for an academic medical center, to do a certain number of peer reviews on an annual basis?

Andrew Spector: So I’ve heard that there are institutions where they might look to that. Duke is not one of them. It doesn’t factor into my promotion criteria at all. If I didn’t do that, I don’t think it would hurt me in any way. I’ve not seen any expectation to do this. They certainly care about publications, and they want me to be the author, but nobody’s asking me how many peer reviews I’ve done for journals.

Kevin Pho: And would you say this is specific to neurology, or are you seeing this across the board among your various specialties in medicine? Do a lot of journals just reach out to physicians, academic physicians, and say, “Hey, do this peer review”?

Andrew Spector: Yeah, I’m not aware that it has anything to do with neurology in particular. I think this is broader than that.

Kevin Pho: So what’s the answer here, other than just saying no or asking for a stipend on a collective basis? No, what are some of the solutions to fix this?

Andrew Spector: Well, I think, like you said, the quickest answer is a stipend, that, you know, you’re hiring us to do a job, and we could do it for a stipend. But there are broader interventions that could take place. So for example, I start to wonder what exactly the journal is contributing. They’re making billions of dollars, so what is it? What role do they play? They’re not generating the intellectual product here. So what they’re doing is they’re coordinating the review process, and then they’re distributing the article. But we really don’t need that, because places like PubMed and other preprint servers and not-for-profit servers can host these articles for free.

And in terms of distribution, it doesn’t really help anymore to be mailing journals. If I need to research an article, I’m going to PubMed or Google Scholar or any number of other search engines, and I’m going to find it electronically. I’m not going to the library and pulling this paper copy. So all the paper copies are doing is taking up space, and the environmental impact of that has to be massive.

So we really could switch this all to an electronic format. For example, what if we were to post on preprint servers and have reviewers go online and offer their reviews? We could rank the articles. We could designate them as not peer-reviewed until enough people have gone on to these servers and reviewed them, and then it can change the label to being reviewed at that point. It doesn’t necessarily require a for-profit industry at all.

Kevin Pho: Walk us through the procedure of a peer review. How long does it take you, and exactly what do you do when you peer review an article?

Andrew Spector: So when you get the email to peer review, you accept the invitation, create yourself an account in their system, log in, and download all the paperwork they’ve sent you, which could include supplemental files and graphs and charts. Really, if you’re taking your job seriously, you’re going to spend a couple hours doing this, because you’re not only reviewing for content, you could be reviewing for language. I’ve peer-reviewed several that are difficult to read because they may not have been written by a native English speaker, which makes it harder to get through sometimes. You know, I have tremendous respect for anyone who can publish in a language that they aren’t native speakers of. That’s tremendous, but it does slow down the process for the reviewer.

After we make our comments, there are different forms that you’d fill out online, and different journals request different information from their reviewers. Some of them are more formatted than others, so the better ones will actually ask you specific questions to weigh in on, and that actually helps guide your review. Others are more open-ended, and they just ask for your thoughts in a nonspecific way, and you don’t even know exactly what they’re looking for from the review, because they may not have told you. All told, it’s a several-hour process. And then you make a recommendation at the end of it, and the recommendation is usually either to just accept it as is, or recommend that it needs to be revised, or rejected. So those are usually your choices at the end of a review.

Kevin Pho: And to be clear, this is just added work to what you already do, and your academic center doesn’t give you dedicated or protected time to do this. Is that correct?

Andrew Spector: Correct. There’s no chance that I would do this other than on a weekend, on my own time. I mean, that’s really the only block of time where I’d be able to get two to three hours on my own to sit down and do a good job of this. I mean, that’s not to say I couldn’t do a bad job of it faster, but if I’m going to take the job seriously, it’s going to take several hours.

Kevin Pho: And why do you think so many physicians do this?

Andrew Spector: You know, it certainly goes to the altruism that is inherent to a lot of doctors, but sometimes I think it goes too far. You know, they just give away their worth for nothing, and that leads to a point where they’re getting taken advantage of.

Kevin Pho: And from your experience and from your colleagues, do you find a lot of physicians are starting to push back on this, or is this something that you think is just going to continue to go on?

Andrew Spector: I unfortunately don’t see a lot of pushback. I think this is so ingrained in us that I think people aren’t questioning the status quo quite enough, and that was the reason for the article, just to get people thinking, “Hey, wait a second. Maybe medicine doesn’t have to be unique in its degree of altruism.”

But you hit on it. You hit on it: Altruism, I think, is a big part of it. I don’t think it’s self-interest, which says a lot for the physician community, that we’re willing to do this. But I don’t think that in an era of burnout as high as it is, we should be adding on more and more, and money is related to burnout. In fact, my colleagues and I wrote a piece for your site, Kevin, a couple years ago on this very subject, that money isn’t going to fix burnout, but adding on unfunded mandates like that can contribute to burnout, and at least showing the respect that we value your time can help mitigate some of that impact.

Kevin Pho: We’re talking to Andrew Spector. He is a neurologist, and he wrote the KevinMD article “Fairness in medical publishing: Reforming the peer review process.” So, Andrew, what’s the response to your article, or whenever you talk to other physicians about this and maybe you suggest, “Hey, maybe we shouldn’t be doing this”? What’s the response from your colleagues, from your friends, and from this article?

Andrew Spector: Well, so far, I think there’s a pretty good agreement in terms of the existence of a problem. The response I’m getting is more of a debate as to what to do about it and how to handle the response, and I am very open to different solutions. I proposed one in the article, but that’s not the only one that we could think of. So I think people tend to be in agreement: “Yeah, maybe we shouldn’t be free labor for these billion-dollar industries anymore.” But what to do about it tends to be where we start to get into interesting discussions. I love hearing their ideas.

Kevin Pho: So if a physician is listening to this podcast and they receive an unsolicited request to do a peer review, what’s your advice for them?

Andrew Spector: Well, if they’re not particularly interested and really desperate to do it, they can either say no or do what I’ve started doing, which is just asking for a stipend. Maybe if they start getting enough requests, they’ll realize that this is something that they’re going to have to start doing, and it’s putting this on the radar of the publishing houses that their era of free labor is coming to an end.

Kevin Pho: And my final question, Andrew: What’s your take-home message you want to leave with the KevinMD audience?

Andrew Spector: So my take-home message is specifically that you, as a clinician, are a highly trained professional, and no other industry would expect you to work for free. So you deserve this. You do not have to be altruistic all the time. This is your profession, and we can’t keep giving away our expertise for free.

Kevin Pho: Andrew, thank you so much for sharing your time and insight, and thanks again for being on the show.

Andrew Spector: Thank you, Kevin.

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