Infectious Diseases in Clinical Practice:
Reflections of an ID Specialist
St Mary's Hospital, Montreal, Quebec, Canada.
Address correspondence and reprint requests to Joe Dylewski, MDCM, St Mary's Hospital, 3830 Lacombe, Montreal, Quebec, H3T 1M5 Canada. E-mail: email@example.com.
It now arrives by E-mail, the polite rejection notice that drives a dagger through my heart. "Thank you for considering our journal but we receive too many good submissions to publish them all. Please try again." Thirty years ago, when I first started submitting manuscripts, I could tell if my manuscript had been accepted by the size of the envelope sent back by the editor. A regular-sized envelope meant acceptance, whereas the large envelope usually meant the return of the manuscript complete with the reviewers' comments. On occasion, I would be allowed to resubmit an amended version based on the reviewers' critiques, but this was a mixed blessing. Before the availability of word processing, every change required typing the manuscript over again which was very time consuming for someone without secretarial assistance and limited typing skills. Nevertheless, it was worthwhile to have the satisfaction that something that I had observed in my clinical practice could be of interest to my peers. A rarer but even greater thrill was to see some of my work referenced in textbook chapters. This provided a personal validation for taking the time to research and write articles, although I was not on an academic track. In fact, most of my professional life has been spent doing clinical consultations in a community teaching hospital. I have worked in a solo practice for most of my career, and I have performed close to 20,000 infectious diseases consultations. Most of these are routine, but every so often, something new and exciting happens. I might get asked to see a patient with an unusual manifestation of a common disease or an uncommon organism in a common disease. This is when I become stimulated. Does anyone else know about this? Should they? What does the medical literature say? Perhaps it is worth reporting. All I need is a few weeks of spare time to research the subject and write several drafts before finally submitting it to a group of my peers for "constructive" criticism. I know enough not to waste their and my time on well-described cases that offer little novelty. I am not thin skinned, and I can take their comments in stride. All I ask for is the opportunity to present my case. However, getting published is extremely difficult particularly if you are not associated with a high-profile academic institution.
During my specialty training at 2 well-known programs, I was fortunate to have several manuscripts published, although the importance of some of the topics was questionable. I suspect having some well-known physicians as coauthors did not hurt. Having had early success, I believed that I should continue to try and make contributions to the scientific literature. However, I did not take into consideration the variability of the review process. I wish to enlighten you with some of the reviewers' comments over the years and how these have often led me to question whether it was worth the effort.
In one of my submissions, I described a case of bacteremic meningococcal cellulitis. I cited that there had only been a total of 10 cases reported, mostly in women. One of the reviewers wanted to know why there was a female predominance and if I could elaborate on the possible hormonal influence on this condition! The same reviewer wanted to know the false negativity rate of throat cultures for meningococcus. Unfortunately, I could not find a reference to answer this query. In another instance, a reviewer commented on my report of irreversible erythromycin toxicity by claiming that erythromycin does not cause ototoxicity, although I had provided ample literature that it did. The novelty in my paper had been the irreversibility of the ototoxicity, and this was lost on the reviewer. When I submitted a case of necrotizing fasciitis associated with Klebsiella pneumoniae liver abscess, 1 reviewer claimed to have seen many cases in his practice, whereas the other reviewer claimed that the entity did not exist. Editors must have a very difficult time when 1 reviewer comments on how well I made my point on a case of Epstein-Barr virus-induced acute renal failure, whereas the other reviewer claims that Epstein-Barr virus is not associated with acute renal disease. This same reviewer also wanted me to expand on liver disease in mononucleosis which was not the purpose of the paper. The first reviewer had been upset about my claiming "more recent references" on polymerase chain reaction testing that actually dated 1999 and 2002. He wanted more recent references than those. The only problem was that there were not any. There are not many reports on the subject, and that was the prime reason for trying to report my case. Then, there was the "anti-Spock" (from StarTrek) reviewer who asked me how I could be sure that brain computed tomographic scan was really normal when the radiological report claimed that it was. I was unable to respond to that bit of twisted logic.
I have argued my position with the various journal editors at times with some success. In 1 case, I received the comments that my case report/review article was well written but that I had not added anything new. My reply to the editor was that he probably would have sent my paper out to be reviewed by an expert in the field who may not have found anything new but that most of his readers were not experts and might find some new information. The paper was published.
I have also lost my restraint particularly with an editor who would not even send my manuscripts out for review. I could accept that the first one was not novel (it was the review article above), but the second one was unique and was subsequently published elsewhere. After the second rejection, I responded by thanking the editor for his kind form letter of rejection and asking him if I would have been more successful if I hailed from the editor's hometown. Approximately 2 years after my rejection, a similar review article on my first paper was published by the same journal, this time with a well-known coauthor.
I am certain that editors of journals have a very difficult job finding people willing to review submissions, and as such, they feel an obligation to act on their recommendations. What is unfortunate is that many reviewers forget the forest for the trees. They dwell on minutiae and miss the bigger picture. Does this article add to the scientific knowledge either as the first description or as a reminder of an unusual event? What suggestions can I give to the author to strengthen the paper? Would other physicians be interested in this? I am aware of several colleagues who have become discouraged at trying to have their work published by the perceived unfairness of the process. As for me, I am a fighter, and I will to continue to argue my points with any editor or reviewer willing to listen. I have learned that the opinions of 1 set of reviewers and editors often differ from another. Perseverance is called for.
I still remember that when I was a research fellow and I first encountered problems getting published, I was advised by a good friend of mine that the road to Stockholm is a long and winding one. I know it is a road that I will not get to travel, but that should not stop me from trying to be a contributor to the medical literature.