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Review
The peer review process: a primer for JNIS readers
Joshua A Hirsch,1 Laxmaiah Manchikanti,2,3 Felipe C Albuquerque,4
Thabele M Leslie-Mazwi,1 Michael H Lev,5 Italo Linfante,6 J Mocco,7
Ansaar T Rai,8 Pamela W Schaefer,5 Robert W Tarr9
For numbered afﬁliations see
end of article.
Correspondence to
Dr Joshua A Hirsch,
NeuroEndovascular Program,
Massachusetts General
Hospital, Harvard Medical
School, Boston, MA 02114,
USA; [email protected]
ABSTRACT
Peer review of scientiﬁc articles submitted for publication
has been such an integral component of innovation in
science and medicine that participants (be they readers,
reviewers, or editors) seldom consider its complexity. Not
surprisingly, much has been written about scientiﬁc peer
review. The aim of this report is to share some of the
elements of that discourse with readers of the Journal of
NeuroInterventional Surgery (JNIS).
Received 30 March 2015
Accepted 31 March 2015
INTRODUCTION
For more than 200 years, clinicians and researchers
have published their work in scientiﬁc and medical
journals.1–3 With changing production paradigms,
an ever-greater number of investigators worldwide
have contributed scientiﬁc articles. In 2010, Bastian
and colleagues4 noted that 75 trials and 11 systematic reviews were published every day. In 2012,
there were 28 000 scholarly, peer-reviewed journals
collectively publishing nearly 2 million articles a
year. The PubMed website indicates that almost 21
million articles have been published in biomedical
journals.5
In 2009, working with the British Medical Journal
(BMJ) group, the Society of NeuroInterventional
(NI) Surgery began publication of the Journal of
NeuroInterventional Surgery (JNIS). The main
purpose of JNIS was to be an academic, peerreviewed journal focusing on publishing scientiﬁc
articles to advance the ﬁeld of NI surgery. As a result,
NI specialists look to JNIS for discussions of trials,
new techniques, and breakthroughs, among other
topics of interest. Therefore, we provide this assessment of the peer review process to advance the JNIS
mission.
HISTORY
To cite: Hirsch JA,
Manchikanti L,
Albuquerque FC, et al.
J NeuroIntervent Surg
Published Online First:
[please include Day Month
Year] doi:10.1136/
neurintsurg-2015-011781
In 1655 Denis de Sallo published the ﬁrst collection of scientiﬁc essays in the Journal des Scavans.6
In this journal, De Sallo reported the ﬁndings of
others in an effort to communicate knowledge.
Peer review did not exist at that time.7 8 It was only
in 1731 that the Royal Society of Edinburgh published ‘Medical Essays and Observations’ using
what is now considered to be the ﬁrst peer review
process.7 8 Manuscripts were mostly distributed, by
the editor, directly to individuals with expertise in
the articles’ subject matter with the purpose of
selecting articles for their innovation and interest.7
Like many advances in science and medicine, peer
review was not immediately appreciated as a breakthrough.8 An exemplar of that point is Albert
Einstein, who published over 300 journal articles
between 1901 and 1955, including his miracle year
of 1905 when he introduced new ways of understanding space, time, energy, momentum, light, and
the structure of matter. In the course of his entire
career he probably had only a single paper peer
reviewed, in 1936, for a submission he jointly
wrote about gravitational waves. The paper
received negative reviews, and Einstein rejected in
writing both the idea of an anonymous expert
reviewer selected by the editor and that expert’s
comments, eventually submitting the paper elsewhere.9 His response suggests someone unfamiliar
with the fundamental tenets of peer review. One
can speculate that had Einstein lived today his view
of peer review might have been somewhat
different.
The Royal Society of Edinburgh was careful in
making clear that the stamp of peer review did not
necessarily mean the work was better than
non-peer-reviewed publications. They thus provided a disclaimer stating that peer review did not
guarantee truthfulness or accuracy. They emphasized further that the purpose of the journal was
solely to disseminate creative and important
ideas.7 8 As today, the submitting authors were
responsible for the quality and veracity of their
own research.7 8
As the peer review process has been embraced
over time, its development has occurred in ﬁts and
starts.6–8 10 Different journals apply varying
approaches to peer review. Until 1976, the Lancet
did not implement peer review. At that time,
Journal of the American Medical Association
(JAMA) sent their submissions to an internal review
panel and, on rare occasions, to outside experts.11
In contrast, the BMJ—with whom JNIS shares a
common publisher—has sent every non-editorial
submission to a recognized expert since 1893.10 By
the late 20th century, peer review has become
standard and is used by almost all biomedical
journals.8 10 11
PEER REVIEW
The modern peer review process has a variety of
constituents.8 10 11 Authors expect to receive a fair
and unbiased critique. Journals need to ensure the
integrity and accuracy of the material that they
publish. The lay public relies on the integrity of the
publication process to inform themselves and their
providers of innovative and optimal treatments.
The common thread for maintaining the quality
and integrity of research is the peer review process.
In essence, it provides a formal opportunity for
authors to gauge reaction to their work, as well as
allowing for revisions and subsequent correction of
errors before publication. At its best, peer review
Hirsch JA, et al. J NeuroIntervent Surg 2015;0:1–4. doi:10.1136/neurintsurg-2015-011781
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Review
allows the editors and expert reviewers to apply with diligence
and care their unbiased knowledge, expertise, and interpretation.8 10–12
The peer review process, nevertheless, is not without its
ﬂaws.8 Cantekin et al13 in an analysis of the peer review,
exposed a variety of problems leading to imperfection and bias.
Some of these include reviewer conﬂict of interest, breach of
conﬁdentiality, and non-disclosures of funding sources.8 14–16
An additional problem that can arise in peer review is reluctance
on the part of reviewers or editors to accept papers that express
views contrary to currently held norms.15 17 18
The foundation of the selection process for articles submitted
to JNIS, and most other academic journals, is the work of volunteer reviewers. After agreeing to review an article, reviewers are
given a deadline to perform their analysis. Distinct comments
are solicited for both the authors and the editors. When the
associate editor is satisﬁed with the number and quality of the
revisions, he or she will make a recommendation to the editor
in chief (EIC). The EIC plays an important role in establishing
uniformity between the associate editors. The EIC makes one of
the following recommendations: accept, accept pending minor
revisions, accept pending major revisions, revise and resubmit,
and/or reject (box 1). If revisions are requested, they are
returned with an annotated pdf and a cover letter dealing with
the reviewer queries, typically, on a point-by-point basis. At
JNIS, reviewers are blinded to the authors’ identities, but the
editors are not. Other review formats exist, ranging from
blinded editors and reviewers, to completely open review.8
The majority of the scientiﬁc community considers peer
review to be valuable.7 8 10 11 19 In a 2009 survey of 4000
people involved in research, although 84% believed peer review
to be an important, arguably necessary, process for the dissemination of accurate scientiﬁc information, only 69% were satisﬁed
with current peer review systems.19 Despite the questions this
survey raised about perceptions of peer review, however, it is
noteworthy that fully 91% of respondents believed their last
paper had been improved by the peer review process.
PEER REVIEW BIAS
Bias may be deﬁned as a systemic prejudice that prevents the
accurate and objective interpretation of scientiﬁc studies.8
Indeed, it has been suggested that the objectivity of peer review
has been affected in many different ways. These include, but are
not limited to, differences in belief or ideology, aversion to new
ideas,20 and conﬂicts of interest. Other potential concerns also
include cursory/superﬁcial reviews by reviewers with decreasing
motivation and enthusiasm for reviewing over time,21 the occasional need for associate and chief editors to ‘over-ride’ the
unanimous recommendation of reviewers to reject papers that
may be ‘hidden gems’, and the poor ability to train reviewers to
improve the quality of their reviews and eliminate bias.22 23
The inability to allow dissenting views to be published in journals has become a major concern.8 18 Members of the NI community have had this angst several times in recent years.
Speciﬁcally, in 2009, when the vertebroplasty versus controlled
intervention trials were published, and again in 2013, when the
three inconclusive major intra-arterial stroke therapy trials were
published in the New England Journal of Medicine, content
experts were not given the opportunity to publish contemporaneous counterpoints. Rather, we were left to write short letters to
the editor that were frequently rejected—while at the same time
these studies became sensationalized by the lay media, to the
detriment of our patients.17
2
Box 1 Various steps in publication of a manuscript in
the Journal of NeuroInterventional Surgery (JNIS):
submission, peer review, and publication
1. Pre-submission phase (investigators)
▸ Research including data review and synthesis
▸ Initial manuscript preparation
▸ Internal review by authors
▸ Final manuscript signed off by all authors
▸ Submission to JNIS, including patient consent forms
2. Post-submission phase
I. Immediate post-submission phase ( journal)
▸ JNIS receives the manuscript
▸ Editorial manager logs and acknowledges receipt
▸ Quality check by editorial manager and editor in
chief: articles may be rejected at this point
II. Editors
▸ Editor in chief assigns manuscript to an associate
editor
▸ Editors review manuscript quality and conﬁrm
relevance to the journal
▸ Editors decide on relevant experts to consider peer
review
III. Peer review
▸ Peer reviewers examine the manuscript for study
design/methodology, validity, accuracy, originality,
signiﬁcance, quality of English, etc
▸ Peer reviewers will often ask for additional
comments, to have queries answered, for additional
references cited, and/or more rigorous statistical or
other additional expert review
IV. Associate editors
▸ Consider reviewer comments
▸ Make recommendation to editor in chief to reject/
revise/accept
3. Post associate editor recommendation
I. Editor in chief sends a letter with his/her decision about
the paper
▸ Authors respond to comments and suggestions
▸ Authors revise manuscript
▸ Authors resubmit with a cover letter dealing with
the reviewer comments/questions and a marked up
manuscript
II. Editors
▸ Final decision to accept/reject manuscript
4. Post-acceptance at JNIS
▸ Proofs with requested 48 h turnaround
▸ Publication online ﬁrst
▸ Publication in print
Adapted and modiﬁed from Manchikanti et al.8
Bunner and Larson carried out pioneering work looking at
the quality of the peer review process from the perspective of
authors and editorial board members.14 Approaching 80%, a
large proportion of those who responded to the survey, indicated that they knew what to expect from the peer review
process, 19% indicated that they did not have a speciﬁc sense,
and approximately 3% indicated that they did not know what
to expect.14 For manuscripts that were accepted, 84% of
authors viewed their reviews favorably, whereas for manuscripts
that were rejected, 50% viewed them unfavorably. Perhaps more
Hirsch JA, et al. J NeuroIntervent Surg 2015;0:1–4. doi:10.1136/neurintsurg-2015-011781
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Review
surprising, almost 30% of authors felt that reviewers did not
have an accurate understanding of the paper’s topic; an additional 34% felt the reviewer comments were insufﬁcient, and
about 30% felt that the reviewers failed to provide suitable suggestions for revision. Most importantly, Bunner and Larson14
indicated that almost 50% felt the critiques were unfair and
biased.
TYPES OF PEER REVIEW BIAS
Put simply, reviewer bias is a violation of the ideal impartiality
that a reviewer or editor has in evaluating a submission.
Impartiality in this context is the ability for any reviewer to
interpret and apply evaluative criteria consistently for any given
manuscript.6–8 10–14 16 Peer review, however, can be difﬁcult to
study systematically, as the process is typically subjective and
secretive.22
Gilbert et al24 in 1994 and Jayasinghe et al25 in 2003 showed
that speciﬁc classes of reviewers are systematically tougher or
softer24 25 on identical submissions.26 For example, reviewers
from the USA tend to be more lenient than their colleagues
from the UK, Germany, or Australia.8 Moreover, until quite
recently, there has been a well-studied, strong positive bias of
reviewers to favor positive, rather than negative study
results.27 28
Editors must pay speciﬁc attention to these issues for impartial assessment and publication.
Content-based bias
As the name suggests, this links directly to content of part or all
of the manuscript. Content-based bias may reﬂect reviewers and
editors preferring to see submissions that cite their own work.
Cognitive cronyism exists when favoritism is given to submissions that share similar schools of thought.8
Conﬁrmation bias
Conﬁrmation bias is the tendency to gather, interpret, and
remember evidence in ways that afﬁrm previously held beliefs.
In the peer review system, conﬁrmation bias is understood as
reviewer or editor bias against manuscripts where the thesis and/
or results disagree with the perspective of the reviewer or
editor.8 This type of bias goes towards the heart of the peer
review process, wherein evaluations are performed independently of “desires, value perspectives, cultural and institutional
norms and presuppositions, expedient alliances and other interest.” In a telling article, Ernst et al,29 found that reviewers who
had previously published materials in favor of what they termed
a controversial clinical intervention looked at a manuscript
where the data supported the use of that technique with a
friendlier eye than those who had produced manuscripts that
did not support the use of that technique.
bias raises potential downstream problems because it will—by its
nature—lead to errors in effect size measurements in later
meta-analyses.30 Publication bias is hypothesized to occur
because clinicians and researchers can disagree about the importance of research that produces negative outcomes.30 However,
the authors of this manuscript believe that, more recently, a
‘reverse’ form of publication bias may be at play in the neurointerventional literature, in that some notable recent NI published
trials have indeed highlighted negative results—gaining great
notoriety and providing considerable sensationalism.8 18
Bias of conﬂicts of interest
Perhaps the most self-evident forms of bias, a ‘conﬂict of interest’ occurs when participants in the publication process have a
personal interest that might inappropriately inﬂuence their judgment, regardless of whether or not their judgment is actually
affected.3 8 15 18 Editors and reviewers may be more openminded to research from friends, collaborators, or clinicians,
particularly if the report supports the professional world view
of the reviewer or editor. Conversely, editors and reviewers may
be more likely to reject a submission from a clinician whom
they dislike, who supports a competing idea, or who opined
negatively on a manuscript written by the current reviewer in
the past. Conﬂicts of interest can be difﬁcult to detect.
FORMS OF PEER REVIEW
Double-blind peer review
Double-blind peer review is preferred primarily because of its
perceived objectivity and fairness.8 31 Challenges include the
difﬁculty of making a review truly double blind. In a survey of
1500 editors in chemistry, most respondents felt that double
blinding was pointless and, by implication, an unnecessary step,
because the particular content and the references chosen indirectly make the author’s identity clear. Moreover, a number of
empirical studies showed that reviewers can successfully identify
authors 25–40% of the time. In a subspecialized ﬁeld like neurointerventional surgery, we believe this observation has validity.
Open peer review
With this approach, the authors and reviewers are known to
each other. This has the obvious beneﬁt of increasing transparency and the possibility of speeding up the review process. Since
1999, the BMJ has asked potential reviewers to identify themselves and declare any competing interests. The reviewers are
not disclosed to BMJ readers at the time of publication. One
might consider this approach as a single-blind review. JNIS
worked with our BMJ publishers to develop the system we use
today—namely, double blind, without identifying reviewers and
authors to each other.
FRAUD AND PEER REVIEW
Conservatism bias
This is a bias against innovative or landmark research. In its
most dangerous form, conservatism bias threatens scientiﬁc progress in a very basic and understandable way.20 30 Speciﬁcally,
this type of bias can limit funding and public sharing of theories
that deviate from mainstream hegemony and result in authors
facing a higher burden of proof requirement to get their publications accepted.
Publication bias
Alleged publication bias is the tendency for journals to publish
research demonstrating positive, rather than negative, outcomes.8 18 27 28 If these assumptions are accurate, publication
When one considers the purpose and methodology of peer
review, one can argue that it is not necessarily designed to
detect fraud. Bearing that in mind, and recognizing that the critique may not be fair, the peer review approach, has been criticized by some participants for its inability to detect fraud.6 8 To
that point, Godlee et al32 intentionally introduced eight speciﬁc,
arguably detectable, weaknesses into a research article. They
then sent the ﬂawed paper to 200 reviewers. Subsequent analysis of the reviewer comments showed that, on average only
two of the inserted weaknesses were identiﬁed.
Peer review cannot ensure that the paper does not have any
mistakes. Rather, alternative mechanisms of surveillance and veracity conﬁrmation may occasionally need to play a role in
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Review
ensuring the integrity of academic literature. Indeed, a researcher
was recently imprisoned for falsifying data in clinical trials.8
6
CONCLUSION
8
Peer review is a critical element of our routine scientiﬁc discourse. JNIS, like many journals, could not function in its
current format without it. It has served the medical/scientiﬁc
community well for over 100 years.6–8 13 16 For a process that is
so fundamental to our specialty and academic activities,
however, it is sobering to think how much is assumed and how
little we actually know about the biases and limitations inherent
to peer review. The editorial staff at JNIS believe in peer review
and favor the approach that we have crafted with the BMJ—
most notably, that the authors and reviewers are blinded to one
another, but not to the editorial staff.
Author afﬁliations
1
NeuroEndovascular Program, Massachusetts General Hospital, Harvard Medical
School, Boston, Massachusetts, USA
2
Pain Management Center of Paducah, Paducah, Kentucky, USA
3
Department of Anesthesiology and Perioperative Medicine, University of Louisville,
Louisville, Kentucky, USA
4
Barrow Neurological Institute, Phoenix, Arizona, USA
5
Department of Diagnostic Neuroradiology, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts, USA
6
Department of Interventional Neuroradiology, Miami Cardiac and Vascular Institute,
Miami, Florida, USA
7
Mount Sinai Health System, Icahn School of Medicine, New York, New York, USA
8
Department of Interventional Neuroradiology, West Virginia University,
Morgantown, West Virginia, USA
9
Department of Radiology, University Hospitals Case Medical Center, Cleveland,
Ohio, USA
Contributors JAH and LM composed the initial draft. All authors reviewed and
made editorial suggestions that resulted in the ﬁnal draft.
Competing interests None declared.
7
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Provenance and peer review Commissioned; internally peer reviewed.
26
27
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Hirsch JA, et al. J NeuroIntervent Surg 2015;0:1–4. doi:10.1136/neurintsurg-2015-011781
Downloaded from http://jnis.bmj.com/ on July 6, 2015 - Published by group.bmj.com
The peer review process: a primer for JNIS
readers
Joshua A Hirsch, Laxmaiah Manchikanti, Felipe C Albuquerque, Thabele
M Leslie-Mazwi, Michael H Lev, Italo Linfante, J Mocco, Ansaar T Rai,
Pamela W Schaefer and Robert W Tarr
J NeuroIntervent Surg published online April 17, 2015
Updated information and services can be found at:
http://jnis.bmj.com/content/early/2015/04/17/neurintsurg-2015-01178
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