You Call it High Academic Standards, I Call it Racism

I’m not a big fan of identity politics, where, in my opinion, allegations of racism are too often used as a political cudgel to bludgeon an opponent. But sometimes it really is important to call out blatant racism, especially when there is a greater societal good at stake, such as in this case protecting the integrity of peer-reviewed science. I had this very “opportunity” thrown at me just last week.

To introduce our journal, and its unique crowd sourced quality score (SIQ) to new physician authors, Cureus utilizes email to reach specific communities of authors who have published articles in other Open Access journals, inviting them to promote the scoring of their articles via social media and email. While away on business in Beijing last week, I was surprised to see one email and two voicemails on my phone from a (unknown to me) senior and accomplished author in other journals. His messages quickly revealed a surprising anger over having his article promoted by Cureus. I replied with a brief email explaining how the Creative Commons copyright system supported such fair usage by Cureus, but this merely precipitated yet another profanity-laced email volley. Not wanting to inflame matters further, and even more so wanting to understand the true source of his angst, I decided to call the author. To say the call was unpleasant would be an understatement. I am a neurosurgeon and have fairly tough skin but it is never fun to have all kinds of profanity thrown at you, especially when you’re sure it is unjustified.

I let him vent a little, as my primary goal was figuring out why he was so upset. No matter how patiently I asked this guy to explain the source of his anger, he repeatedly deflected. Finally, after having asked multiple times, this rather accomplished researcher frustratingly blurted out that he did not want his article promoted “alongside the University of Pakistan.” In that instant, everything became clear. There is no institution named The University of Pakistan. Cureus, however, recently published several articles from South Asian-based institutions, namely India and Pakistan. What I suddenly realized is that this person was merely pissed (and seemingly offended) that his “aristocratic” article (allow me some artistic license here) might appear alongside “unworthy” South Asian articles. To put it more bluntly, this otherwise truly accomplished author was just a racist old fool.

In an effort to defuse the situation I complied with his request to remove his article. Upon further reflection I now feel a deep sense of gratitude to this old racist for providing me the opportunity to expose how racism—implicit and overt (like this case), sadly lurks in the background of all peer-reviewed journals. Truthfully I am amazed that so many in this day and age are still clueless about what is happening in medical science. As I sit writing this in a world-renowned Chinese hospital, I am surrounded by the very type of medical excellence that my racist critic deems unworthy of his association. A close American friend of mine (and Cureus editorial board member) is one of the premier pediatric cardiac surgeons in the world, having invented several important heart operations. He has visited several South Asian hospitals that have refined his original operation, enabling them to operate on vastly more patients than him, and do so at less than 10% the price of a U.S. hospital. In light of this, it strikes me as complete foolishness to restrict such important medical knowledge. Scholarly racism is utterly self-defeating for authors, readers and the world at large.

Although I could find no formal studies documenting the extent of racism within scholarly journals, there is a modest body of research and other evidence pointing towards the existence of sexism, as well as prejudice against non-academic physicians, in the world of academic publishing [1-3]. Perhaps it is time to formally study the extent of racial bias in peer-reviewed journals. Any takers?

Recently, the CEO of an authoritative digital health website shared an interesting statistic with me: 40% of the articles published in the New England Journal of Medicine, arguably the most important medical journal, originate within a 200 mile radius of the journal’s headquarters. No one would disagree that Boston, New York and New Haven are centers of academic excellence, but the medical community that dominates the NEJM represents but a tiny fraction of world physicians, thus excluding an immense amount of clinical experience and knowledge. Although such willful blindness or elitism is not as blatant as the prejudice exhibited by my new acquaintance, does a hugely influential and even entitled societal institution like the NEJM not have a responsibility to open itself up to more of the world of medicine?

While I will continue to respect the world’s leading medical journals for the important work they publish, I remain proud that Cureus serves the vast numbers of physicians truly in the trenches of medicine who have been disenfranchised through what might be best termed “scholarly elitism.” Lastly, I want to thank this narrow-minded dolt for reminding me yet again why Cureus’ mission is so important to the world of medicine.

References:

1). Pololi LH, Civian JT, Brennan RT, Dottolo AL, Krupat E. “Experiencing the Culture of Academic Medicine: Gender Matters, A National Study.” J Gen Intern Med. 2012 Aug 31; [Epub ahead of print] PMID: 22936291. [PMC free article] [PubMed]

2) http://www.sciencemag.org/news/2015/05/plos-one-ousts-reviewer-editor-after-sexist-peer-review-storm

3) From abstract to impact in cardiovascular research: Factors predicting publication and citation. Eur Heart J. 2012 Winnik S, Raptis DA, Walker JH, Hasun M, Speer T, Clavien PA, et al. From abstract to impact in cardiovascular research: Factors predicting publication and citation. Eur Heart J. 5 June 2012 [Epub ahead of print] PMID: 22669850. [PMC free article] [PubMed]

The Long, Arduous Journey to Publication: It Doesn’t Have to be That Way

I recently co-authored an article submitted to Nature Urology, a subdomain of the Nature publishing group. It took roughly eight weeks of review before we received feedback from the editorial office. In December 2016 we were finally presented with several reviewer questions that had to be answered before a final decision could be made. After all outstanding questions and reviewer requests had been answered the article was finally, mercifully “accepted in principle” on February 3rd. That was far from the end of it, however, as another round of editing requests arrived on May 11th.

This time the requests came directly from the Nature editorial office. The majority of the requests concerned tightening up the narrative flow and bringing the article in line with their in-house style. At this time, we discovered that the edits already made by the editorial office were so extreme that the editors had to check with us to make sure the meaning of our words (and indeed the entire article itself) had not been altered by their editing process. All of this for arbitrary language and formatting issues.

On May 15th, with the article still unpublished, we were yet again asked to check affiliations and other minor aspects of the article. The article was finally published yesterday, May 23rd, roughly eight months after submission. (And it could have been worse!)

How does this kind of perfectionism serve the scientific community? Why does the editorial office of the Nature publishing group change the text of professional scientific authors in a way that even they are not sure if the scientific information is still correct? The editorial work of so-called high-end and high-ranking journals has reached a level where their interaction is beyond thoroughness. It is absurd to edit every paragraph, every sentence, and even every word. This does not serve the scientific community. Instead it unnecessarily prolongs the publication process to guarantee the house style of a specific journal. The scientific message does not change with this heavy editing, but an article may look better and therefore may be better sold by the publisher based on the work of scientific authors.

The process (and underlying philosophy) are different with Cureus. In short, we rely on the individual capabilities of our authors, who also retain their copyright. We want to make the publishing process fast and efficient, so while we provide a certain level of support to our authors, we do not intend to alter their scientific message. Instead, we appeal to their own sense of pride and responsibility for adequate language and general accuracy.

In the end it is the scientific community that will evaluate if the article is scientifically sound, informative and correct. If it is not, the article will be met with heavy criticism, both via a low SIQ score and negative comments attached to the article. This system is not only much faster but also unbiased and transparent. We want to keep the focus of scientific publishing on what we feel is most important – the fast, fair and uncomplicated dissemination of interesting findings around the world.

In the Name of Truth and Reconciliation: A Plagiarist’s Mea Culpa

Dr. John Adler, Founder and Editor-in-Chief of Cureus: Speaking as a physician-scholar and an editor-in-chief, damn do I hate plagiarists! The entire idea of plagiarism sucks the life out of something that I believe to be almost sacred. Idealism aside, fraudulent behavior among authors is all too common, and maybe even rampant, within the world of scientific journals. To combat such fraud, Cureus, like most credible journals, has made it a formal policy to aggressively police plagiarism when we encounter it, as stated explicitly in our guidelines for authors’ section:

“Cureus pledges to rigorously enforce all standards, and promptly follow up on any transgressions. In extreme cases, this may call for article retraction and the reporting of individuals to their employer, institution or some appropriate body for further investigation.”

To date, Cureus’ policy appears to have ended the careers (sadly) of some young ambitious physicians; it is the aspiring younger academic who in my experience appears most tempted to cheat, especially given Cureus’ liberal willingness to publish credible science. In response to the cheaters, Cureus’ editorial team has always sought to be ruthlessly punitive, believing it to be the best defense against future plagiarism. Once exposed to the leadership of their medical institution, a plagiarist’s career tends to end in the quiet of the night, which unfortunately does little to communicate the seriousness of such cheating to others.

Therefore, I recently made a decision (for better or worse and somewhat capriciously I might add) to not report a plagiarist to his senior leadership. In the name of “truth and reconciliation” I instead demanded that the attempted-plagiarist explain their underlying motivations so as to serve as a warning to future authors who might be similarly tempted. That is the impetus for the below anonymous blog post. It is my hope and prayer that future potential plagiarists might read this post and come to their senses before very possibly destroying their own medical careers.

My decision for leniency under the current situation was done with great hesitancy. I can rightfully be criticized as undermining our journal’s clear warning to authors. Therefore, I wish for the record to say that as long as I am Editor-in-Chief of Cureus I intend to never ever repeat such leniency towards a fraudulent submission. Any author who might be tempted otherwise, consider yourself to be hereby forewarned.

Anonymous Cureus user: Most residents desire to do research and get published in a journal, for both the academic benefits and to develop one’s resume when applying for future fellowship training. Being such a young ambitious physician, but also having no significant experience in publishing research, I recently made the biggest mistake of my professional life, and this error has haunted me every day since.

A couple of months ago I decided to publish a case report on an interesting patient I had just seen in the clinic. I decided to submit the report to Cureus. As I began to write I realized my research writing skills were seriously wanting. By chance I found a similar case and heavily “borrowed” portions of text; my only focus was on getting my first publication and I turned a blind eye to the consequences of such actions. In fact, I hardly changed any words or sentences and simply submitted this report to Cureus thinking that in this particular case the objective was the same.

Why did I do it? Regretfully I now have only stupid explanations to fall back upon. Nevertheless, it is worth saying that in the country where I was raised, the topic of plagiarism is never discussed or seriously acknowledged. Plagiarism just isn’t such a big deal.

Soon after submitting my manuscript I received an email from Cureus’ editor who told me that I plagiarized and he sent me a link to the original source. I was humiliated, and even more so now very scared. By all rights the editor could and maybe should have reported me to my program director. If that were to happen, I realized that it could very well end my career in medicine. So many years of hard work was potentially destroyed by a single incredibly stupid decision! I pleaded and begged the editor for mercy, and the consequence of that plea is the confessional blog you are now reading.

Once again I ask myself why did I do such a stupid thing? Thinking back now I realize I had been blinded by ambition and was totally dishonest to myself. It disappoints me to know my poor decisions mostly reflect my greedy nature and a willingness to get ahead without hard work; I was largely jealous of my friends and colleagues who were publishing. Blinded by such emotions, I failed to ask myself how dangerous such actions would be for my character, my occupation, my career and my family. In hindsight, had I thought deeply about the potential consequences of my careless act, I would have never done it, and that mistake taught me a very tough lesson.

As a resident, I already knew that laziness can make the difference between the life or death of a patient. However I failed to consider that laziness towards publishing medical research is potentially even more dangerous, as it can put many other lives at risk. My actions can only be described as utterly immoral and unethical; my behavior is completely inexcusable. Although it is the ethical right and privilege of the editor to report me to my departmental chair and residency director, I am sincerely grateful for the career-saving opportunity I have been afforded. I am determined that this painful lesson will lead to my honest behavior in the future, as God is my witness.

Scholarly Roulette: Impact Factor & Scientific Quality

A friend and colleague referred me to a recent publication that represents a major indictment of the peer-reviewed journal cartel.

This article summarizes a blog published by what is arguably a Cureus competitor, the open access-publishing house, Frontiers, which in this study could find no correlation between rates of rejection and journal impact factor.

Just for argument’s sake, let’s assume that impact factor does correlate with scientific quality. So if this study is correct, it means by extension that the rate of rejection also doesn’t correlate with quality. In turn this means that the standard peer review process (which totally dominates the journal industry) has no bearing on article quality. In other words, getting published, or not, appears to be a random event.

Accepting this fact (parenthetically one which I already subscribe to) means that despite all the process and rituals of scientific journal publishing, and the huge importance of this matter to society and academic tenure decisions, there is currently no objective index for assessing research article quality. Of course if one believes that impact factor is not a measure of quality, then the above random publication process is even more random than I implied in my argument! Based on this observation, I would like to sarcastically suggest we should rename this current process “scholarly roulette.”

Clearly there are huge shortcomings to the Frontiers study, such as selection bias and the non-medical nature of many scholarly journals. However, to a huge research community that has invested so much of their lives into the existing peer review process these type of findings must be dispiriting. Nevertheless, this current set of observations does resonate with our philosophy at Cureus, where we subscribe to the belief that as long as the medical science within is credible, there is no reason not to publish an article. In other words, we believe that we are, on average, no better equipped to discern quality than any other journal.

A big part of our confidence stems from Cureus’ unique post-publication SIQ scoring system. Although we are no smarter in finding scientific quality up front, we do believe that it is quite possible for the medical community-at-large to find quality over time, post publication. Nevertheless, to make this a reality, every reader has a role to play, which of course includes you!

The Anecdote is the Antidote for What Ails Modern Medical Science

Today I read with great interest an article in Vox.com entitled: “Fleming’s discovery of penicillin couldn’t get published today. That’s a huge problem.” As a long time academician and Co-Editor-in-Chief of Cureus, I could not agree more! Not only would Fleming’s discovery go unreported, but Jenner’s discovery of the first small pox vaccine or Connecticut dentist Crawford Long’s discovery of ether anesthesia would also be dismissed as trivial curiosities and anecdotes.

In a rapidly changing world of medical science, the process of peer-reviewed publishing has never been more important for validating medical knowledge, yet at the same time the arcane processes of peer-reviewed journals have never been more at odds with potential societal benefits. The altruism that is supposed to drive the publication of scientific research has been almost entirely co-opted by the peculiar needs of academic promotion and tenure, as well as the pecuniary demands of the scholarly publishing industry; the public good of medical knowledge has been reduced to a mere after-thought by both academia and the publishing industry. These two interest groups only seek seemingly important “big science,” and actually decry any role for mere clinical observation, which Cureus has in the past and the Vox authors now in the present both refer to, in a somewhat ironic, self-deprecating manner, as “small science.”

Despite the above dire (my word) situation in medical publishing, just maybe the proverbial pendulum is about to swing the other way. For example, the conventional wisdom is that we are entering an era of “personalized medicine,” a concept which at its core recognizes the unique genomic, proteomic, metabolomics and demographic, etc. profile of every patient. Embodied within this concept is the understanding that each of us will as patients undergo a unique clinical experience, not necessarily predicted by a priori knowledge, and that such observations will need to be documented if we are to build new scientific understandings. Assuming that to be true, the future of medical publishing may well be found in observational “small science.” If this is true, the important medical publishing of the future may be about to shift from “the few” elites reporting big science, to the power of the many, within the trenches of medicine, collectively reporting their humble clinical observations? For the record, Cureus aspires to lead this transition into the new world of small, yet very powerful, medical science.

Intellectual Fascism

I have been Co-Editor-in-Chief of Cureus for about three years and in this time I’ve learned a lot about how peer-reviewed journals function. It’s often said that in water polo the real game happens beneath the surface of the water. Similarly with journals, sometimes the serious action goes on behind the scenes. From its inception, Cureus was designed to minimize the role of politics in scientific publishing by way of its post-publication SIQ scoring process. Despite these ambitions, politics have occasionally crept into our efforts to publish great medical science. So it was with one recent article, and boy did the Cureus editorial staff learn a lot through this experience!

The article in question was written by several very accomplished clinical neuroscientists and involved a complex intersection of multiple scientific fields. Despite being evaluated by three reviewers, a clear error was noted in the published article by a reader; the error was of a political nature and not scientific in the least, but still an unambiguous error. An erratum was being prepared when a big hullabaloo broke loose in social media. Two individuals, whose specialty overlapped the erroneous article, attacked the article for its political misstatement, and by extension, Cureus’ journalistic integrity for missing this error during our pre-publication review process.

I immediately invited these critics to set the record straight via our liberal comment and scoring processes, but in a series of personal (and necessarily confidential) emails, the critics refused, insisting on remaining anonymous. Over the next several days they recruited a chorus of similarly-minded colleagues who insisted that the article in question represented serious scientific misconduct and demanded it be retracted… period! In light of these demands, Cureus, by virtue of its status as a peer-reviewed journal, was obligated to investigate under ICJME (International Committee of Medical Journal Editors) guidelines.

I personally oversaw the investigation, which started by recruiting seven truly world-class domain experts, who after reading both the original and the proposed corrected manuscripts, were to advise me; I deliberately included a couple of researchers suggested by the critics of the article. In parallel, I stumbled upon the existence of a listserv community of likeminded researchers including the two critics, whose major modus operandi is to fiercely act en-mass, hyena-like, oftentimes via social media, when certain partisan political issues arise, such as the article Cureus had unwittingly published.

If ever I witnessed intellectual fascism, this was it; the only thing missing was a goose-stepping mustached man. However, this was also to be a moment of truth for our young journal. Pending the advice of the seven domain experts, would Cureus stand up for open scientific discourse? Or would we join the ranks of cowering researchers?

After almost one month of analysis by the aforementioned unimpeachable panel of experts, some of whom are at the very pinnacle of their respective fields, it was determined that the Cureus article had erred badly (yet seemingly inadvertently) in misstating a political reality. However, the science itself was credible. As a result, an erratum addressing the erroneous facts was published and the original article retracted.

Ultimately this experience reminds me, and by virtue of this blog should remind all readers, that standing up for open and honest scientific discussion, devoid as much as possible from political considerations, is a constant struggle even in our supposedly democratic world. In fact I invite the very critics of the article in question to now publish their own scientific concepts with Cureus, which perhaps might even refute the published paper. The function of journals is not to anoint “scientific truths,” but to provide a forum for scientific truths to be discovered, and refuted.

We at Cureus are especially fortunate to have such a liberal post-publication comment and scoring system. This process, which is available to everyone, is intended to provide a voice for even the most contrarian scientific ideas. The power of the Cureus community-at-large remains a great potential strength. Please don’t be afraid. Step up and use it!

In Response to Allegations Concerning Internet Medical Society

Allegations were recently leveled against iMed.pub, an organization affiliated with one of our channel partners, Internet Medical Society. We take such matters very seriously. We have conducted a thorough investigation and we’re here to share our thoughts on this situation as we move forward.

After considering the allegations and speaking at length with the IMS channel administrator, Manuel Menendez, we can state that we believe in the sincerity of IMS’s ambition to publish credible medical scientific articles. While the accusations are certainly nothing to take lightly, we feel confident that work being submitted to Cureus via the IMS channel is of suitable quality and repute. Furthermore, via our wholly unique post-publication review and scoring system, Cureus is in a unique position to uncover fraudulent and illegitimate science, as we actively encourage our community to examine and review articles long after they’ve passed through peer review.

It is worth reminding all readers of scientific publications to always interpret the content with a skeptical eye, whether the article is published in Nature, The New England Journal of Medicine or Cureus. Healthy skepticism is always at the heart of science. It is only through the lens of time that scientific ideas can be truly validated, which is why we at Cureus advocate for our process of post-publication review via SIQ.

As a result, Cureus will continue to host the Internet Medical Society channel and looks forward to the channel’s continued success. As has been the case since our launch in 2011, Cureus will not tolerate plagiarism or illegitimate or untoward publication practices and will remain ever-watchful for any signs of potential transgressions.