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Are Editors Determined to Sanitize Medical Journals?

Traditionally, editorials were opinion pieces that were written by the editors of a newspaper or journal. They often called for action, decried a certain state of affairs, or endorsed or criticized a potential law or candidate for public office. According to conventional journalistic standards, editorials were best delivered as unsigned essays, so that readers would focus on the message and not the author.

For decades, it was the message that motivated readers of medical journals to read editorials. If the editors of an esteemed journal took the time to put forth a thoughtful statement, the world of medicine paid attention. Important editorials like this still exist, and are issued from time to time.

But for most journals, the nature of “editorials” has changed. Many journal editors routinely place an “editorial” after each original research paper. The commentaries are not written by the editors, but typically by one of the people who reviewed the paper. Some have catchy titles, perhaps in the hope that some people might read them. (I am certainly guilty of this!)

What do these editorials say? How will readers benefit from looking at them?

Recently, I reviewed about 100 editorials in a totally unscientific survey across six journals in cardiology over a 2-year period. More than 80% of the editorials adhered to the following formula:

  • This is an interesting topic.
  • This paper represents a contribution to the medical literature.
  • The limitations of the work have already been discussed by the authors.
  • I have no major criticisms of the work.
  • More research needs to be done.

Does this sound boring? It is.

So why do these editorials exist? They serve two main purposes. First, the editorial serves to highlight the original research, so authors like them. Second, it allows the editor to reward some of their hard-working reviewers with some opportunity for recognition. For authors, reviewers, and editors, it is a win-win-win situation.

Who loses? All too often, it is the reader who loses. If readers were expecting enlightenment, a different perspective, or a contrary opinion from the editorial, more likely than not, they will be disappointed.

What if the study is terribly flawed and the editorialist does not take notice? Can readers submit criticisms or an alternative viewpoint?

They can certainly try, and I wish them luck.

If you want to raise concerns about a published article, you could write a letter to the editor. But you need to work fast. Most editors will not accept letters that are submitted more than 3-6 weeks following publication. And they decide what letters get published. Many are reluctant to acknowledge errors.

If you want to write a longer piece (i.e., an editorial) that is poised to disagree with a published article, you could send a request to the editors. But do not expect a positive reply. Even if you have valid criticism and points to make, the editors may not be receptive. Why would they publish an editorial that challenges their decision to have published the original work in the first place?

Of course, you could decide to write a critical editorial and send it to a different journal. But often that will not work. Many journals have a standing policy that they will not consider editorials that are critical of work published in other journals.

(Disclosure: I hold editorial positions at Circulation and the European Heart Journal.)

So if you have a contrarian point of view, what can you do?

You could decide to write a “perspective.” This is an editorial opinion that focuses on a topic rather than on a specific article, but it can certainly include concerns about a specific study. Many editors do not like these “perspectives” because they are bombarded with them. Yet, much to their credit, others create a special place for alternative opinions. (I proposed Circulation‘s “On My Mind” column, which has been met with great success.)

But if you submit a perspective as an opinion piece, brace yourself.

When your perspective is received by the journal, it is likely to be sent out for “peer review,” often to the specific people your paper criticizes. So do not be surprised if the reviewers do not like your opinion. When editors receive the negative reviews, they can simply reject your paper, because “it did not pass peer review.”

Imagine that. You write an opinion piece that is based on your interpretation of the medical evidence, but you cannot get it published, since it is reviewed by people whose work you are challenging.

Sounds like a Catch-22? It is.

The bottom line: It is really difficult to get a contrarian or unconventional viewpoint published in the medical literature.

I know. I try all the time.

In one example, I submitted eight consecutive viewpoints or contrarian perspectives to one subspecialty journal over a period of 2 years on various topics. The editors systematically rejected every one of them, even though the journal website states that it encourages “provocative or contentious” opinion pieces. Five were subsequently accepted for publication at journals with comparable or far higher impact factors; three are still under review.

What reasons did the editors of the journal cite for eight rejections? The emails informed me that my manuscripts did not achieve a high enough priority for acceptance. Amazingly, in one letter about one of my papers that had received very positive reviews, the editors wrote: “In the interest of diversity, we will not be accepting this well written piece.”


A paper rejected solely in the interests of diversity?

I am and have always been a vocal advocate for diversity. It is a critically important mechanism for the revitalization of human interactions and intellectual discourse.

But why would any editor usurp the banner of diversity and distort its meaning in order to discourage a diversity of opinions? Zero out of eight is not a path to diversity. And when did diversity become an excuse for conformity?

Intriguingly, in a few instances, my papers received a letter of interest or preliminary or full acceptance, but I was then sent a specific request from the editors to incorporate certain sentences that they had written for me that would allow the paper to conform to conventional wisdom. I declined, suggesting that the editors had overreached their mandate.

You can’t make this stuff up.

Reviewers are not supposed to reject a paper because it makes them uncomfortable. They are supposed to make judgments based on the strength or weaknesses of the author’s evidence and arguments. Sadly, many reviewers and editors have forgotten that thoughtful dissenting views are part of the lifeblood of journals and a core component of the mission of science.

The result: much of the medical literature has been sanitized.

Don’t get me wrong. On a personal level, I am not complaining. I do my homework. I fashion compelling arguments. I tend to be very persistent. My seniority allows for a certain privilege (rightfully or not). And my viewpoints and perspectives all eventually get published in highly-respected journals. But how typical am I? How many authors are so fortunate?

Just imagine what it is like for a less senior, less persistent, and less persuasive writer who wishes to present and can validly support an important contrarian viewpoint, but cannot find a receptive platform. How many early-career authors would refuse if they were asked to incorporate opinions that have been specifically requested by the editors as a condition of acceptance?

Medicine desperately needs a curated platform for open disagreement and civil discourse. Journal editors should embrace the concept warmly. Doing so will revitalize the science of medicine, and will dramatically enhance the diversity of opinions and the breadth of discussion. If we do not welcome contrary viewpoints, we will die listening to our voices in our own echo chamber. What a horrible death!

Packer recently consulted for Actavis, Akcea, Amgen, AstraZeneca, Boehringer Ingelheim, Cardiorentis, Daiichi Sankyo, Gilead, J&J, Novo Nordisk, Pfizer, Sanofi, Synthetic Biologics, and Takeda. He chairs the EMPEROR Executive Committee for trials of empagliflozin for the treatment of heart failure. He was previously the co-PI of the PARADIGM-HF trial and serves on the Steering Committee of the PARAGON-HF trial, but has no financial relationship with Novartis.