CHEST VOLUME 75 I NUMBER 3 I MARCH, 1979
reviews is not only impractical but unnecessary since alternate methods are available. The concept of open dialogue in the pre-publication phase of scientific communication is a vital element in the preservation of scientific integrity and originality. However, this type of peer review does not require drastic change in current review procedures. In a recent communication2 I noted that it is possible to facilitate open lines of communication among authors, referees, and the editorial board. Undeniably important work has been refused publication by erroneous judgments of editorial boards and I have urged authors to contact my office if they believe that the referees' analyses were in error. There has been a gratifying response to this invitation and authors more frequently than ever before voice their concern with aspects of the reviewer's report Obvious misunderstandings or reviewers' errors can be corrected quickly. More subtle differences may require that I return the paper to the reviewer with a detailed rebuttal by the investigator. Frequently, it is best to send the manuscript and the author's objections with the consultant's critique to a third or fourth reviewer. A spirited dialogue may ensue and I have experienced no difficulty in arranging candid editorial debates between the authors and the reviewers, even though the reviewers are never identified. Responding to an author's rebuttal, one reviewer noted, "Through such a mechanism I think that scientific questions can be sorted out in many cases and should always be available as a recourse. to... the author of a manuscript which has been refused publication."2 Dialogue which is conducted through the means of an editorial office can be comprehensive and enlightening to both parties. Most important, it protects the referee's right to refuse to participate in such dialogue. Hell bath no greater fury than the scorned author. A torrent of letters, some abusive, may be bestowed upon a referee by disappointed investigators. This is indeed small thanks for services rendered without financial remuneration! The editor provides a screening mechanism insuring that only constructive and reasonable letters of complaint are submitted to the consultant. H the reviewer refuses to answer or indicates that he is too busy to engage in even the most
EDITORIALS
Identification of Reviewers
A Statement of Policy
editorial reviews be signed by the consulShould tant? A reviewer recently returned his critique with these comments, "In accordance with my personal policy, it is my preference that my review be returned to the authors with my signature. It is my belief that unsigned reviews tend to be excessively critical and more biased and prejudiced because a reviewer may hide behind anonymity." I have received several requests of this nature in the past few months and it may be helpful to describe the current editorial policies of this periodical. The proponents of disclosure contend there is no place in science for anonymity. Commoner1 urges that reviews should not only be signed, but that they should be published. He suggests that such publication would convert the peer review process into an open dialogue that would contribute to the progress of science. Commoner contends that since the reviewers' mistakes are protected by anonymity, they are less likely to be corrected in advance by selfcriticism. He believes that the review process should be two-sided, that is, both sides should be required not only to criticize, but to reply to criticism. Other advocates maintain that the system of anonymous review permits and even encourages slipshod reviews, expressions of personal bias, conclusions unsubstantiated by data, and occasionally thoughtless or even vicious criticism. Opponents of signed reviews (and I am in this group) assert that anonymity assists the reviewers in being forthright and constructively critical. In this era of fragmented specialization, each medical "fraternity" of investigators working in highly specialized fields has become increasingly narrow. Thus, it is predictable that colleagues and friends will be asked to judge each other's work; disclosure of the referee's identity may impair critical comments. Commoner suggests that publication of signed reviews would prevent immoderate commentary, but would not impede careful analysis. Would the public appearance of the critique and counter-criticism achieve these goals? I submit that publication of 295
instructive dialogue, instructive dialogue, there there remains remains the the opportunity opportunity to submit to submit initial initial reviewer's reviewer's comments comments and and the the auauthor's response response to to other other referees. referees. thor's An editor editor could could be be placed placed in in an an untenable untenable posiposition tion if if consultants consultants sent sent their their comments comments directly directly to to authors even authors even if if these these comments comments did did not not include include final final recommendations recommendations submitted submitted to to the the editorial editorial board. Priorities Priorities for for subject subject material material and board. and editorial editorial format vary format vary from from year year to to year year and and sometimes sometimes from from month to month to month. month. Either Either adulatory adulatory comments comments or or hyper-critical statements hyper-critical statements within within the the reviewer's reviewer's text text may inadvertently may inadvertently place place undue undue pressure pressure upon upon edieditorial boards torial boards since since their their decision decision must must be be based based upon aa balanced upon balanced view view of all consultants' consultants' reports reports and and requireimmediate needs immediate needs of of that that journal. journal. Legal Legal requirements ments may may necessitate necessitate preliminary preliminary study study by by the the editor in editor in consultation consultation with with counselor counsel or publisher. publisher. Most of of these these objections objections can can be be obviated obviated if if aa conconMost sultant identifies identifies all material sultant material he he wishes wishes to to have have transmitted to transmitted to the the author. author. This This advance advance information information assists the assists the editorial editorial board board in in preparing preparing diplomatic diplomatic and more and more insightful insightful responses responses to to the the author. author. is the the most most equitable equitable policy policy to to pursue: pursue: What is What identification identification or or anonymity? anonymity? Our Our policy policy is is to to proprovide maximum vide maximum flexibility Bexibility for for reviewers. reviewers. II believe believe that that we we must must protect protect the the evident evident wishes wishes of the the consultants to to remain remain anonymous. anonymous. HowHowmajority of consultants majority ever, it ever, it is is possible possible to to honor honor the the requests requests of of those those rere(and the the list list appears appears to to be be growing) growing) who who viewers viewers (and desire the desire the editor editor to to transmit transmit signed signed reviews. reviews. II ask ask only that only that the the reviewer reviewer communicate communicate with with my my office office if he if he wishes wishes to to have have his his identity identity known known or or if if he he wishes to wishes to write write directly directly to to the the author. author. The The peer peer rereview system view system has has faults, faults, but but it it has has played played an an indisindispensible role pensible role in in recent recent decades decades in in assuring assuring excelexcellence of biomedical lence biomedical research. research. Medical Medical journalism journalism is is in aa period in period of of unusual unusual ferment ferment and and cautious cautious adopadoption of tion of new new methods methods is is indicated. indicated. Proponents Proponents and and opponents of signed opponents signed reviews reviews should should share share obserobservations in vations in the the months months ahead ahead and and this this may may help help determine if determine if one one method method is is unequivocally unequivocally superior superior to the to the other. other. Alfred Soffer, Alfred Soffer, M.D., M.D., F.C.C.P. F.C.C.P. nlinois Park Ridge, Park Ridge, nlinois
11 Commoner Commoner B: B: Peering Peering at at peer peer review. review. Hospital Hospital Practice Practice 13:25-29, 13:25-29, 1978 1978 The open open editorial editorial office. oftice. Chest Chest 73:125, 73:125, 1978 1978 22 SoHer Soffer A: A: The
The Diagnosis The Diagnosis of of Success Success
S Surgery urgery for for coronary coronary arterial arterial bypass bypass has has been been utiuti-
lized lized for for over over ten ten years years in in the the treatment treatment of ischemic heart ischemic heart disease. disease. Despite Despite the the performance performance of 296 29& EDITORIALS EDITORIALS
over 70,000 over 70,000 of of these these procedures procedures annually, annually, the the benebenefits of fits of this this operation operation are are still still questioned questioned 11 In fact, fact, the the methods of methods of diagnosing diagnosing perioperative perioperative myocardial myocardial ininjuries are are still being juries being questioned questioned (( see see article article by by et al al on on page page 300). 300). Recently, Recently, scanning scanning of of Rucker et Rucker infarcts has infarcts has been been proposed proposed as as an an improved improved techtechnique for nique for making making this this diagnosis, diagnosis, and and proponents proponents have suggested have suggested that that this this should should be be aa routine routine part part of the work-up the work-up for for perioperative perioperative cardiac cardiac injury. injury. The The purpose of purpose of this this editorial editorial is to to try to to place place in in perspecperspective the tive the procedures procedures available available for for diagnosing diagnosing periopperioperative cardiac erative cardiac injury injury and and to to suggest suggest the the optimal optimal studies for studies for the the diagnosis diagnosis of of success success in in surgery surgery for for myocardial revascularization. myocardial revascularization. Obviously, Obviously, because because economics must economics must be be considered considered in in recommending recommending any any form of form of testing, testing, the the optimal optimal studies studies should should be be those those which are which are fewest fewest in in number, number, safest safest for for the the patient, patient, and lowest and lowest in in cost cost that that will will provide provide the the needed needed ininformation. formation. Basically, four to the Basically, four things things can can happen happen to the heart heart as as aa result first alternaalternaresult of of coronary coronary arterial arterial surgery. surgery. The The first tive is tive is that that the the conduits conduits for for bypass bypass are are placed placed withwithout out injury injury to to the the myocardium myocardium and and that that these these conconduits duits function function to to correct correct the the deficits deficits in in perfusion perfusion that that lead lead to to the the operation. operation. The The second second alternative alternative is is that that the the grafts grafts are are implanted implanted without without injuring injuring the the myomyocardium cardium but but that that the the grafts grafts fail fail to to remain remain patent. patent. A A third alternative third alternative is that that localized localized muscular muscular death death (myocardial infarction) (myocardial infarction) results results from from the the operation. operation. These localized These localized injuries injuries are are probably probably due due in in most most cases to cases to technical technical error error (ie, ( ie, poor poor anastomoses) anastomoses) or or emboli. The emboli. The fourth fourth possible possible basic basic outcome outcome is is that that there is aa total there total or or global global myocardial myocardial injury injury resulting resulting from poor from poor myocardial myocardial protection protection during during the the perforperformance of mance of the the surgical surgical procedure. procedure. This This type type of of injury injury can occur can occur with with patent patent or or nonpatent nonpatent grafts. grafts. In actual In actual practice, practice, aa combination combination of of these these four four basic alternatives basic alternatives frequently frequently results results from from an an operaoperathree of of four four grafts grafts tion. A tion. A procedure procedure may may result result in three being patent, being patent, with with correction correction of of aa deficit deficit in in perfusion perfusion to most to most of of the the heart. heart. The The occluded occluded fourth fourth graft graft may may be associated be associated with with aa localized localized infarction. infarction. H this H this infarction is infarction is small, small, the the net net result result of of the the operation operation may be may be an an improvement improvement in in myocardial myocardial function, function, and and the operation the operation may may be be considered considered to to be be aa clinical clinical success; however, success; however, if if the the infarct infarct is is large, large, there there may may be be aa deterioration deterioration of of cardiac cardiac function, function, leading leading to to worsening of the worsening the patient's patient's clinical clinical condition condition or or death. death. Since the Since the total total effect effect on on the the heart heart following following bypass bypass surgery is surgery is often often aa mixture mixture of of good good and and bad, bad, the the single most single most important important test test for for the the evaluation evaluation of sursurgery for gery for coronary coronary arterial arterial bypass bypass is is clinical clinical observaobservation. Relief tion. Relief of of symptoms symptoms and and prolongation prolongation of of life life are are the ultimate the ultimate tests tests which which this this procedure procedure must must face. face. CHEST, 75: 3, MARCH, 1979 CHEST, 1979
reviews is not only impractical but unnecessary since alternate methods are available. The concept of open dialogue in the pre-publication phase of scientific communication is a vital element in the preservation of scientific integrity and originality. However, this type of peer review does not require drastic change in current review procedures. In a recent communication2 I noted that it is possible to facilitate open lines of communication among authors, referees, and the editorial board. Undeniably important work has been refused publication by erroneous judgments of editorial boards and I have urged authors to contact my office if they believe that the referees' analyses were in error. There has been a gratifying response to this invitation and authors more frequently than ever before voice their concern with aspects of the reviewer's report Obvious misunderstandings or reviewers' errors can be corrected quickly. More subtle differences may require that I return the paper to the reviewer with a detailed rebuttal by the investigator. Frequently, it is best to send the manuscript and the author's objections with the consultant's critique to a third or fourth reviewer. A spirited dialogue may ensue and I have experienced no difficulty in arranging candid editorial debates between the authors and the reviewers, even though the reviewers are never identified. Responding to an author's rebuttal, one reviewer noted, "Through such a mechanism I think that scientific questions can be sorted out in many cases and should always be available as a recourse. to... the author of a manuscript which has been refused publication."2 Dialogue which is conducted through the means of an editorial office can be comprehensive and enlightening to both parties. Most important, it protects the referee's right to refuse to participate in such dialogue. Hell bath no greater fury than the scorned author. A torrent of letters, some abusive, may be bestowed upon a referee by disappointed investigators. This is indeed small thanks for services rendered without financial remuneration! The editor provides a screening mechanism insuring that only constructive and reasonable letters of complaint are submitted to the consultant. H the reviewer refuses to answer or indicates that he is too busy to engage in even the most
EDITORIALS
Identification of Reviewers
A Statement of Policy
editorial reviews be signed by the consulShould tant? A reviewer recently returned his critique with these comments, "In accordance with my personal policy, it is my preference that my review be returned to the authors with my signature. It is my belief that unsigned reviews tend to be excessively critical and more biased and prejudiced because a reviewer may hide behind anonymity." I have received several requests of this nature in the past few months and it may be helpful to describe the current editorial policies of this periodical. The proponents of disclosure contend there is no place in science for anonymity. Commoner1 urges that reviews should not only be signed, but that they should be published. He suggests that such publication would convert the peer review process into an open dialogue that would contribute to the progress of science. Commoner contends that since the reviewers' mistakes are protected by anonymity, they are less likely to be corrected in advance by selfcriticism. He believes that the review process should be two-sided, that is, both sides should be required not only to criticize, but to reply to criticism. Other advocates maintain that the system of anonymous review permits and even encourages slipshod reviews, expressions of personal bias, conclusions unsubstantiated by data, and occasionally thoughtless or even vicious criticism. Opponents of signed reviews (and I am in this group) assert that anonymity assists the reviewers in being forthright and constructively critical. In this era of fragmented specialization, each medical "fraternity" of investigators working in highly specialized fields has become increasingly narrow. Thus, it is predictable that colleagues and friends will be asked to judge each other's work; disclosure of the referee's identity may impair critical comments. Commoner suggests that publication of signed reviews would prevent immoderate commentary, but would not impede careful analysis. Would the public appearance of the critique and counter-criticism achieve these goals? I submit that publication of 295
instructive dialogue, instructive dialogue, there there remains remains the the opportunity opportunity to submit to submit initial initial reviewer's reviewer's comments comments and and the the auauthor's response response to to other other referees. referees. thor's An editor editor could could be be placed placed in in an an untenable untenable posiposition tion if if consultants consultants sent sent their their comments comments directly directly to to authors even authors even if if these these comments comments did did not not include include final final recommendations recommendations submitted submitted to to the the editorial editorial board. Priorities Priorities for for subject subject material material and board. and editorial editorial format vary format vary from from year year to to year year and and sometimes sometimes from from month to month to month. month. Either Either adulatory adulatory comments comments or or hyper-critical statements hyper-critical statements within within the the reviewer's reviewer's text text may inadvertently may inadvertently place place undue undue pressure pressure upon upon edieditorial boards torial boards since since their their decision decision must must be be based based upon aa balanced upon balanced view view of all consultants' consultants' reports reports and and requireimmediate needs immediate needs of of that that journal. journal. Legal Legal requirements ments may may necessitate necessitate preliminary preliminary study study by by the the editor in editor in consultation consultation with with counselor counsel or publisher. publisher. Most of of these these objections objections can can be be obviated obviated if if aa conconMost sultant identifies identifies all material sultant material he he wishes wishes to to have have transmitted to transmitted to the the author. author. This This advance advance information information assists the assists the editorial editorial board board in in preparing preparing diplomatic diplomatic and more and more insightful insightful responses responses to to the the author. author. is the the most most equitable equitable policy policy to to pursue: pursue: What is What identification identification or or anonymity? anonymity? Our Our policy policy is is to to proprovide maximum vide maximum flexibility Bexibility for for reviewers. reviewers. II believe believe that that we we must must protect protect the the evident evident wishes wishes of the the consultants to to remain remain anonymous. anonymous. HowHowmajority of consultants majority ever, it ever, it is is possible possible to to honor honor the the requests requests of of those those rere(and the the list list appears appears to to be be growing) growing) who who viewers viewers (and desire the desire the editor editor to to transmit transmit signed signed reviews. reviews. II ask ask only that only that the the reviewer reviewer communicate communicate with with my my office office if he if he wishes wishes to to have have his his identity identity known known or or if if he he wishes to wishes to write write directly directly to to the the author. author. The The peer peer rereview system view system has has faults, faults, but but it it has has played played an an indisindispensible role pensible role in in recent recent decades decades in in assuring assuring excelexcellence of biomedical lence biomedical research. research. Medical Medical journalism journalism is is in aa period in period of of unusual unusual ferment ferment and and cautious cautious adopadoption of tion of new new methods methods is is indicated. indicated. Proponents Proponents and and opponents of signed opponents signed reviews reviews should should share share obserobservations in vations in the the months months ahead ahead and and this this may may help help determine if determine if one one method method is is unequivocally unequivocally superior superior to the to the other. other. Alfred Soffer, Alfred Soffer, M.D., M.D., F.C.C.P. F.C.C.P. nlinois Park Ridge, Park Ridge, nlinois
11 Commoner Commoner B: B: Peering Peering at at peer peer review. review. Hospital Hospital Practice Practice 13:25-29, 13:25-29, 1978 1978 The open open editorial editorial office. oftice. Chest Chest 73:125, 73:125, 1978 1978 22 SoHer Soffer A: A: The
The Diagnosis The Diagnosis of of Success Success
S Surgery urgery for for coronary coronary arterial arterial bypass bypass has has been been utiuti-
lized lized for for over over ten ten years years in in the the treatment treatment of ischemic heart ischemic heart disease. disease. Despite Despite the the performance performance of 296 29& EDITORIALS EDITORIALS
over 70,000 over 70,000 of of these these procedures procedures annually, annually, the the benebenefits of fits of this this operation operation are are still still questioned questioned 11 In fact, fact, the the methods of methods of diagnosing diagnosing perioperative perioperative myocardial myocardial ininjuries are are still being juries being questioned questioned (( see see article article by by et al al on on page page 300). 300). Recently, Recently, scanning scanning of of Rucker et Rucker infarcts has infarcts has been been proposed proposed as as an an improved improved techtechnique for nique for making making this this diagnosis, diagnosis, and and proponents proponents have suggested have suggested that that this this should should be be aa routine routine part part of the work-up the work-up for for perioperative perioperative cardiac cardiac injury. injury. The The purpose of purpose of this this editorial editorial is to to try to to place place in in perspecperspective the tive the procedures procedures available available for for diagnosing diagnosing periopperioperative cardiac erative cardiac injury injury and and to to suggest suggest the the optimal optimal studies for studies for the the diagnosis diagnosis of of success success in in surgery surgery for for myocardial revascularization. myocardial revascularization. Obviously, Obviously, because because economics must economics must be be considered considered in in recommending recommending any any form of form of testing, testing, the the optimal optimal studies studies should should be be those those which are which are fewest fewest in in number, number, safest safest for for the the patient, patient, and lowest and lowest in in cost cost that that will will provide provide the the needed needed ininformation. formation. Basically, four to the Basically, four things things can can happen happen to the heart heart as as aa result first alternaalternaresult of of coronary coronary arterial arterial surgery. surgery. The The first tive is tive is that that the the conduits conduits for for bypass bypass are are placed placed withwithout out injury injury to to the the myocardium myocardium and and that that these these conconduits duits function function to to correct correct the the deficits deficits in in perfusion perfusion that that lead lead to to the the operation. operation. The The second second alternative alternative is is that that the the grafts grafts are are implanted implanted without without injuring injuring the the myomyocardium cardium but but that that the the grafts grafts fail fail to to remain remain patent. patent. A A third alternative third alternative is that that localized localized muscular muscular death death (myocardial infarction) (myocardial infarction) results results from from the the operation. operation. These localized These localized injuries injuries are are probably probably due due in in most most cases to cases to technical technical error error (ie, ( ie, poor poor anastomoses) anastomoses) or or emboli. The emboli. The fourth fourth possible possible basic basic outcome outcome is is that that there is aa total there total or or global global myocardial myocardial injury injury resulting resulting from poor from poor myocardial myocardial protection protection during during the the perforperformance of mance of the the surgical surgical procedure. procedure. This This type type of of injury injury can occur can occur with with patent patent or or nonpatent nonpatent grafts. grafts. In actual In actual practice, practice, aa combination combination of of these these four four basic alternatives basic alternatives frequently frequently results results from from an an operaoperathree of of four four grafts grafts tion. A tion. A procedure procedure may may result result in three being patent, being patent, with with correction correction of of aa deficit deficit in in perfusion perfusion to most to most of of the the heart. heart. The The occluded occluded fourth fourth graft graft may may be associated be associated with with aa localized localized infarction. infarction. H this H this infarction is infarction is small, small, the the net net result result of of the the operation operation may be may be an an improvement improvement in in myocardial myocardial function, function, and and the operation the operation may may be be considered considered to to be be aa clinical clinical success; however, success; however, if if the the infarct infarct is is large, large, there there may may be be aa deterioration deterioration of of cardiac cardiac function, function, leading leading to to worsening of the worsening the patient's patient's clinical clinical condition condition or or death. death. Since the Since the total total effect effect on on the the heart heart following following bypass bypass surgery is surgery is often often aa mixture mixture of of good good and and bad, bad, the the single most single most important important test test for for the the evaluation evaluation of sursurgery for gery for coronary coronary arterial arterial bypass bypass is is clinical clinical observaobservation. Relief tion. Relief of of symptoms symptoms and and prolongation prolongation of of life life are are the ultimate the ultimate tests tests which which this this procedure procedure must must face. face. CHEST, 75: 3, MARCH, 1979 CHEST, 1979
