The Daily Dose • Saturday, March 19, 2022

Publish or Perish? Maintaining the Integrity of Authorship, Peer Review, Scientific Research, and Academic Promotion

Jane S. Moon, MD

The intersecting worlds of academic publishing and academic promotion were examined in depth during the Anesthesia & Analgesia-sponsored Journal Symposium, an Aligned Session with IARS, AUA, and SOCCA, on Friday, March 18, at the IARS 2022 Annual Meeting. The Editors-in-Chief of three major anesthesia journals — Evan Kharasch, MD, PhD (Anesthesiology), Hugh Hemmings, MD, PhD (British Journal of Anaesthesia), and Jean-Francois Pittet, MD (Anesthesia & Analgesia) — elucidated key issues in scientific publishing: authorship inflation, peer review, and research misconduct, respectively. Cynthia Wong, MD, Chair of the Department of Anesthesia at the University of Iowa, suggested avenues for mitigating a driver of publication misbehavior — the pressure to publish for academic promotion.

In his presentation entitled “Authorship: What Counts, Who Counts, Who Cares?,” Evan Kharasch, MD, PhD, Editor-in-Chief of Anesthesiology and Professor and Vice Chair for Innovation in the Department of Anesthesiology at Duke University School of Medicine, tackled the “vexing problem” of defining and upholding criteria for authorship (Kharasch et al., 2021). He began his talk by displaying a steady rise in the average number of authors per article in both anesthesiology and general medical journals over the past 55 years (Kharasch 2022). Dr. Kharasch attributed this inflation not to increasing research complexity but rather to growing competition for recognition, promotion, and grants.

Decrying this trend, he emphasized the importance of authorship in its conferral of credit, and highlighted the inseparability of credit from responsibility. He called for greater integrity in identifying authors and defined several unacceptable forms of authorship — gift, guest, and ghost authorship. While he acknowledged the absence of a universal definition of authorship, he drew upon various committee statements to establish the minimum requirements: substantial and intellectual contribution, as well as accountability for the work done.

Dr. Kharasch affirmed that “authors, institutions, and journals all have a role in ethical authorship.” Authors should understand authorship as intellectual, not transactional, and take seriously institutional and publication-specific definitions of authorship. Institutions should establish authorship standards and consider setting different publishing expectations for research faculty and “professional practitioners.” Journals should also define and publish authorship criteria and pay attention to authorship during peer review. Stating that “[a]uthorship misbehavior is learned,” Dr. Kharasch emphasized the duty of mentors “to teach responsible authorship” and the duty of trainees “to learn responsible authorship.”

Hugh Hemmings, MD, PhD, Editor-in-Chief of the British Journal of Anaesthesia and Professor and Chair of the Department of Anesthesiology at Weill Cornell Medicine, then presented “Peer Review: Strengths, Weaknesses, Opportunities and Threats,” reviewing the advantages and disadvantages of the process by which peer experts critically assess the scholarly merit of a manuscript or grant proposal. At its best, Dr. Hemmings explained, peer review can promote high-quality research, prevent the publication of unwarranted claims, occasionally identify scientific misconduct, and provide authors with useful feedback for improvement. At its worst, peer review can be riddled with delays; place disproportionate demands on a limited pool of expert reviewers; provide little academic recognition for the voluntary work of reviewers; preserve the status quo; be characterized by an inconsistent quality of reviews; and be marred by uncivil discourse or the personal biases of editors or reviewers. Over time, some journals have adopted an “open review” process that reveals both author and reviewer identities to promote civil, transparent discussion. Dr. Hemmings identified as threats to peer review the rise of predatory journals that lack a legitimate evaluation process, as well as the occasional appearance of fake journals or reviews.

In spite of these inherent flaws and external threats, peer review has remained the gold standard for evaluating scientific publications and grant proposals. Dr. Hemmings affirmed that most editors, publishers, institutions, and funding agencies still respect the process. He concluded his talk by suggesting some possible opportunities for improvement: better training for authors, reviewers, and editors, as well as more public recognition of the work of reviewers on behalf of journals.

Jean-Francois Pittet, MD, DEAA, Editor-in-Chief of Anesthesia & Analgesia and Professor of Anesthesiology at the University of Alabama at Birmingham, followed Dr. Hemmings with a presentation entitled “Show Me the Data: Fabrication and Misconduct,” which highlighted the significance, causes, and repercussions of scientific misbehavior. He provided several examples of misconduct, including the creation of artificial data or inconsistent conclusions, the splicing together of data from different studies to masquerade as results from a single trial, and the manipulation of digital data images to alter their interpretation. According to Dr. Pittet, data manipulation or fabrication was the cause of almost 50% of article retractions in anesthesiology. The absence of ethical approval accounted for 28%. Possible reasons for scientific misbehavior at the faculty or trainee level included a lack of personal integrity, the pressure to publish for academic promotion or security, insufficient training in research methods, or poor guidance from senior investigators.

Dr. Pittet praised the peer review process and denounced publication in predatory journals as a “covert form of research misconduct.” He emphasized the importance of study reproducibility, citing a 2019 article (Avidan, Ioannidis, Mashour 2019) that focused on improving “inferential reproducibility,” or the reproducibility of discussion sections, in publications. Dr. Pittet concluded his presentation by highlighting the pursuit of truth as the core principle of scientific research and affirming that “researchers are innocent until proven guilty — not the contrary.”

Cynthia Wong, MD, Professor and Chair of the Department of Anesthesia at the University of Iowa, rounded out the symposium with her presentation entitled “Clinical Anesthesiology Faculty: Pressure to Publish for Promotion.” She provided a different perspective on the issue of publication pressure by calling for a reevaluation of traditional promotion criteria as the basis for advancement in academic anesthesiology.

Dr. Wong began her talk by identifying a core problem in academic medicine today: the lack of a definition of “scholarship” for most academic physicians today, who are not traditional scientists and are thus not on a tenure track (Lubitz 1997). If a distinction is being made between tenure- and nontenure-track faculty, she argued, a parallel distinction in promotion criteria should also be made. In Dr. Wong’s opinion, traditional promotion criteria, which are better suited for scientific researchers, should not apply to physicians who are primarily clinicians, educators, or administrators.

Traditional criteria for promotion emphasize quantity over quality of publications, authorship order, journal impact factor, grant funding, and national or international recognition (Rice 2020). Holding all academic physicians, who are mostly clinician-educators, to traditional standards may place undue pressure on them to publish, possibly incentivizing unethical practices like plagiarism, author inflation, duplicate publications, and the use of ghost writers.

Dr. Wong concluded her presentation on a hopeful note, describing the current state as a “transition period” for academic medicine. She encouraged academic anesthesiologists to pursue scholarship that matters to the individual physician as well as to the medical community, and then to find creative ways to report it. Clinical reviews, patient education materials, annotated bibliographies, editorials, books/chapters, clinical reports, educational websites, or contributions to the lay press were provided as less traditional avenues for scholarly publication. Dr. Wong affirmed a movement toward “multidimensional incentive systems” that value productivity, reproducibility, knowledge sharing, and the overall betterment of society.

Finally, this highly engaging Journal Symposium ended with a lively Q&A session moderated by Thomas Vetter, MD, MPH, Deputy Editor-in-Chief of Anesthesia & Analgesia. The various topics discussed included the importance of establishing authorship expectations and criteria early on; the vulnerability of trainees and junior faculty to authorship abuse; impact factor as an imperfect measure of journal quality or impact; the shared commitment of journal editors to publish trustworthy evidence and to educate the specialty; and the need to think of better ways to reward academicians of all types.