The ugly side of peer review.

Views on peer review are a lot like perspectives on surgery. Opinions on the pain associated with the procedure are a function of whether you are doing the cutting or being cut. Unfortunately, or I suppose fortunately from the surgeon's point of view, wielders of scalpels cannot be forced for the purposes of developing empathy to undergo every procedure they conduct (or at least not until we make some more progress in virtual reality). Surgeons, unlike peer reviewers, are forced to forego real-life experiences in favor of imagining the results of their efforts.

Peer reviewers on the other hand become peer reviewers (for our Journal at least) only after they have been on the receiving end of the process, and most reviewers, including this Editor and the Editorial Board members, continue to publish and experience the process as recipients of reviews even as they review the works of others. If you think that means we always find the process acceptable and view it with the cool logic of seasoned scientists, you had better think again!

Peer review is a messy process, and it produces more angst than an Ingmar Bergman movie. Unfortunately, I know of no acceptable substitute for the peer-review process. Before I became the Editor of Physical Therapy this journal never rejected a manuscript I authored or coauthored. Since becoming Editor, papers of mine have been rejected twice. Papers of Editorial Board members have also suffered similar fates. My reactions to rejection and feedback are just like those of other authors who submit manuscripts for publication, reactions that I think are almost universal. Perhaps the human genome codes for reactions to peer reviews (whether they are reviews of articles, grants, clinical practice, or job performance), and there appears to be precious little genetic diversity here. The sequence begins with an immediate reaction of hurt, which progresses to anger born out of frustration. Sometimes you speed through the first phase so quickly you never knew you were hurt because anger becomes so dominant.

You are seized by the notion that the fools offering you suggestions (1) did not understand what you wrote; (2) spent too little time examining relevant issues; (3) were confused by their own biases; and (4) came from uncertain parentage and know little of research, practice, or whatever else they were supposed to be reviewing. These observations are accompanied by a barely repressible desire to set a new world distance record using the reviewer's comments as a Frisbee, or to see if those inflammatory comments could be used as kindling.

Fortunately, this passionate phase during which denial abounds is often followed by bargaining. We selectively see value in some comments so that we may rationalize the fury that remains over remarks that we believe really miss the point. In this manner, we give our own views a mantle of credibility. Because we act as if we have given ground, we assume we must be bringing a reasoned view to our analyses. Unfortunately, this bargaining is usually a ploy to keep us from really looking at the comments with a dispassionate eye. Calm reflection comes only after a period of cooling down, the duration of which differs greatly based on our personalities, our need to see our paper published, or the degree to which we took the comments personally.

We know that we are not supposed to take the comments personally and good peer reviews should be written in a nonpersonalized manner, but who are we kidding? When we have put our life's blood into our efforts, we find it hard to disentangle our egos and identities from our work. But eventually we must do this and, make no mistake, that is neither easy nor something that comes without experience. People who see an article as their only potential publication are more likely to feel pain and experience fury than those who can look at an effort along a continuum and know that the next paper will be better. Imagine treating only one patient in a lifetime and failing to help that patient!

Some people never progress to the last phase because they throw their papers and the comments in a drawer where they he as silent monuments to apparent failure and very real frustration. This is a tragedy, because the last reaction is reasoned acceptance. During this phase you not only find that you agree with many of the comments, you are even embarrassed because you missed some mistakes. You still may, however, find areas of disagreement with the reviewers, but such contentions are now based on analysis rather than emotion. You no longer question the parentage of the reviewers, and you even may grudgingly admit that they have given you fodder for thought and ideas for this or other papers. There usually remains some lingering resentment, the kind of resentment we reserve for those who have told us what we needed to hear but did not want to hear.

During this final stage we cannot deny that no matter how much we liked or disliked the reviews, they resulted in our reevaluating our own work. Through reevaluation we grow and garner insights, even if we do little more than develop arguments to counter the comments of the reviewers. While this may not always bring peace, it does lead toward resolution and constructive actions that may make an existing paper better or a future work more credible and clear. I feel bad for those who do not come to this final stage and hope that more people will work through the tangle of emotions that too often keeps them from reconciling their views with the feedback they have been given. When authors fail to respond to reviewers, the process seems more like an inquisition than the source of new knowledge. Too many papers that can be revised are never re-submitted to this and other journals.

I am haunted by this thing we call peer review and never cease wondering how it can be improved. I look at reviews, comments of Editorial Board members, and my own comments, and I question whether they are reasonable and whether they have been appropriately expressed. Even after personally writing more than 1,600 letters to authors, I still approach each letter feeling a heavy burden. just as every person is someone's child, so is each manuscript someone's "child" and I attempt to treat it with respect and care. But the peer-review process requires candid remarks, and in the end decisions must be made. The reality of those remarks and the need for honest feedback deny us the opportunity to sugarcoat and to offer disingenuous and responsibility-shirking remarks - even if we wanted to. For those who have been hurt by the process, I offer my heartfelt apologies because the process is designed to refine and improve the author's work and to nurture growth, not just to judge. Any attempts to judge without providing constructive feedback diminish the process, rob authors and readers, and in our case diminish our credibility with a society that trusts us.

Discussions of peer review are often cloaked in such sanctimonious prose that one might think a religion was being described rather than a flawed process by which colleagues evaluate the work and performance of one another. This is a peer-reviewed journal, and we are proud of the process we use and grateful for the efforts of the nearly 300 people who contribute to such efforts, but we realize that it is far from perfect. I hope that all who have submitted or will submit papers to our journal realize that in the end we grow and our work improves through the dialogue engendered by the peer-review process. And, as we all know, growth rarely comes without some awkward and often painful moments, moments that we must learn to endure for a greater good.