Our world endured unimaginable tragedy and encountered many consequential challenges in the past year. Together we experienced the relentless global advance of the SARS-CoV-2 infection, following fast on the heels of the opioid epidemic that had already taken many thousands of lives in the United States and other countries. The underinvestment in science, limitations of public health systems, and impact of disparities were exposed as the infection touched, and then so often took, so many lives. We felt helpless as we watched people die in isolation. We survived while others did not, and we will always carry in our memories the elders, children, medically ill people, people in cities and on the frontier, and the heroic clinicians and essential workers who succumbed to the virus.
Filled with sadness over so much unnecessary death, we watched in horror as George Floyd was handcuffed, pinned to the ground, and killed by a police officer on a Minneapolis street. We grieved as we learned much more about the pervasive pattern of violence toward people of color and nonmajority identity. With these experiences came deeper understanding that feeling safe and protected in the world, an expectation of such great significance at this moment in time, has always been limited to a privileged few.
In this time of loss and insecurity, we watched wildfires burn over 6 million acres of the western United States, 1 killing dozens and displacing tens of thousands of people. 2 We watched hurricanes sweep the southern and eastern coasts, destroying homes and causing hundreds of thousands of people to be evacuated. 3
We tried not to cry as we watched news clips of COVID-19 survivors being discharged from the hospital to the applause of their caregivers. And we wept openly as families in cities throughout Italy, then throughout the world, sang each evening to thank health care and essential workers for their sacrifices in the service of others.
This past year, faculty, health system leaders, trainees, and staff across academic medicine pivoted and adapted as best they could to these unprecedented challenges. And, as they made their way through each difficult day, they wrote. Academic Medicine, along with other scholarly journals, received hundreds and hundreds of submissions from authors reflecting on their experiences and ever so generously seeking to pass forward what they had learned.
In the first 8 months of 2020, our journal received 866 more submissions than during all of 2019. We received our first COVID-related manuscript in late February 2020, and by October, we had received more than 1,500 COVID-related submissions. Authors shared meaningful stories, experiences, literature reviews, and research, reflecting the significance of this moment in our history. We received hundreds of Perspectives, research reports, and letters examining inclusion, antiracism, social justice, and health disparities. Articles on these topics were published in a supplement 4 on eliminating discrimination in health professions learning environments, together with a communication to the field 5 written by members of the journal’s editorial board with lived experience of racism. Our editorial team has been honored to learn about the extraordinary work and great contributions of our colleagues.
Our Journal, Academic Medicine
According to Clarivate Analytics, 6Academic Medicine is ranked as the preeminent journal in the category of education, scientific disciplines and as third in the category of health care sciences and services. Academic Medicine was also the most-cited health professions education journal in 2019. The journal received 17,605 citations in 2019, and the 2019 impact factor was 5.354. Submissions to the journal have grown steadily over the past decade and, as noted above, increased dramatically last year.
We heartily encourage authors to write for Academic Medicine, 7 and yet the journal’s rejection rate is necessarily high and is increasing, given a consistently limited space for published work. In 2020, fewer than 10% of submissions overall were accepted for publication. We are challenged to select those manuscripts that fall within the purview of the mission of the journal, are of the highest importance and quality, and do not overlap significantly with other manuscripts already in the queue. Many thoughtful articles of high quality are not accepted for publication by our journal. On behalf of all of the editorial team and staff, we wish to acknowledge that the decisions not to advance certain submissions, especially those conveying personal stories of inspiration, heroism, injustice, and tragedy, were particularly difficult for us this past year.
The Journal’s Editorial Processes
Because publishing in Academic Medicine is so very competitive, our editorial processes must be especially thoughtful, mindful, and fair. We recognize that editorial decisions are judgments—judgments that we take very seriously and understand to be shaped by a number of factors. In this editorial, we discuss some of the processes that help ground our decisions and minimize the influence of bias. We identify some of the key issues that come into play when judging the merits of submitted manuscripts during editorial and peer review processes, including the early triage of manuscripts and decisions after review. By these means, we hope to provide greater transparency regarding editorial decision making in Academic Medicine. Providing greater transparency is very important to us for many reasons, including our commitment to supporting authors across the diversity of disciplines, backgrounds, and developmental periods that comprise our field.
Identifying and responding to bias
Editorial decision making is based on the potential merits and limitations of individual submissions. There are many potential biases that can operate in editorial decision making. These include conflicts of interest, such as a direct reporting relationship between an author and editor or reviewer, 8 an institutional relationship in which the editor or reviewer has the same employer as the author, 8 and personal biases. Editors’ and reviewers’ personal biases may be for or against certain topics or approaches, 9 for the orthodox and against the unconventional, 9 against authors who seem overproductive, 9 against negative results, 10,11 or for or against certain political agendas. 11 Biases can cause editors and reviewers to be dazzled by an author’s reputation, 10,12 the nature of an author’s credentials, 12 the fame of an author’s institution, 9,10,12 the flashiness of an author’s title, 12 or even an author’s territorial or geographic location. 7
The first step that editors take in managing their biases is to accept that they exist and may be possible influences on decision making. The second and much more challenging step is to look for information that may counter biases that may be present when forming initial impressions. This latter step requires a sincere willingness to reconsider one’s first “take” on a manuscript. Performing a new literature search, rather than relying on one’s presumed or past knowledge of a topic, can be helpful. Conferring with a fellow editor for an independent consultation may also be valuable. For research reports, it is essential to use established criteria for evaluating the validity of methods and the importance of results, 13 including standards for reporting qualitative 14 and quantitative research, and to follow best-evidence standards. 15 We endeavor to use each of these practices, as applicable, to safeguard against bias in the initial assessment of manuscripts sent to the journal for consideration.
Early screening of submitted articles
In 2020, about one-third of all manuscripts submitted to Academic Medicine were sent out for review. The decision of whether or not a manuscript should go out for review is based primarily on an initial examination of the manuscript’s fit within the scope and focus of the journal. 16 An ineffective study question or design, suboptimal data collection, a weak discussion or conclusion, or poor writing are other common reasons for rejection at this stage. 16 Occasionally we receive a submission that is so time sensitive that we do not advance it through a review and decision process that can take many weeks. For research reports, the decision is based on the study design and its appropriateness and alignment with the research question. For Perspectives, the decision is influenced by the persuasiveness and rigor of the essay’s rationale, the quality of the writing, and the appropriateness and sufficiency of the cited literature. Perspectives that come across as opinion pieces lacking a scholarly basis, either in conceptual or empirical literature, are better suited for other venues and not advanced for publication. This initial screening process occurs to save the time of expert reviewers, especially this year when reviewers for health professions journals have been asked to evaluate a much larger number of submissions, and to prevent authors whose manuscripts were rejected from losing time in the review process so they may more quickly find a more suitable journal to submit their work to.
The relevance of a manuscript to the journal’s mission 16 is determined in part by the importance or seriousness of the issues at stake and their embeddedness in the literature. 17 We endeavor to advance work that is novel, rigorous, and valuable, even if it appeals only to a narrow readership in our field. Thus, the manuscript’s goals should be well defined and placed in context of how they add to the available literature. Empirical work may add to the literature by replicating earlier studies, to allow a reassessment of confidence in earlier findings, to improve on methodological approaches, or to address gaps in knowledge.
We recognize that no study is perfect and that financial and other practical resource limitations may preclude optimization of study design. Educational research is insufficiently funded. 18 In particular, although randomized controlled trials are justifiably heralded as a high-quality design in quantitative educational research, 19 there is a paucity of randomized controlled trials, given the costs in both time and money and the challenges of undertaking such research. Negative results from trials on consequential topics can be important to publish to protect against bias favoring positive results.
Expert review processes
Expert review is a vital service to academic medicine. 20 We lean on expert reviewers for their counsel about whether to proceed with publication and for their recommendations on how a manuscript might be improved. Expert reviewers consider the same issues identified above in the initial screening process, including their own assessment of the importance and quality of submitted manuscripts. Expert reviewers also take a deeper look at the strengths and weaknesses of manuscripts, including careful consideration of study methods when evaluating research reports. 21
The Academic Medicine website (academicmedicine.org) provides information and training for reviewers. Peer review resources include advice, tips, and practical strategies for reviewing, as well as a practice review exercise. This information is intended to improve the peer review process by familiarizing reviewers with best practices, by assisting in the organization and communication of recommendations, and by enhancing an understanding of the criteria used to evaluate submissions. These resources foster an increase in the quality and reliability of peer review and reduce potential bias.
Sometimes peer reviewers’ comments contain overly critical or disparaging language. 22 Among other reasons, this language could reflect personal bias, 22 as opposed to an openness to new findings that challenge personal beliefs. An overly positive assessment of a manuscript might also reflect bias. In addition, Academic Medicine has not been in the practice of removing authors’ names and affiliations from manuscripts under review, and the prestige of the author or affiliation, or lack thereof, may be biasing. Reviewers are expected to recognize and manage their biases to prevent them from distorting decision making. We do not assign reviewers to manuscripts with authors from their same institution. A friendship, former mentorship or collaboration, or other personal experience with an author may represent an overlapping role that can result in a conflict of commitment or dual loyalty problem on the part of the reviewer. If reviewers believe that their objectivity is overly compromised for whatever reason, they are strongly advised to recuse themselves from the reviewing process.
We also invite reviewers to let us know, and to recuse themselves, when they do not have sufficient expertise to evaluate a particular submission or when they think there is a question regarding their ability to fairly judge a manuscript. For each review, we ask reviewers if they have read our reviewer guidelines, including those about conflicts of interest, and if they agree to adhere to them. In addition, we direct reviewers to the Council on Publication Ethics ethical guidelines for peer reviewers, 23 which address the responsibilities of being a reviewer and how to ethically conduct a review and write up comments.
The editors and editorial staff carefully consider all reviews when deliberating on an article. The most helpful reviews are those that identify the strengths and potential value of a submission while also assiduously identifying limitations, including those that can be rectified in a revision. At this stage, we generally make a decision to ask for a revision or to reject; acceptance without revising is exceptionally rare. A decision to ask for a major or minor revision allows the manuscript to progress. Importantly, an invitation to revise a manuscript does not represent a commitment from the journal to publish the revision. The decision to accept a manuscript for publication—at any stage—depends on the overall contribution, value, and strengths of the current version of the manuscript. Even if identified issues have been addressed, additional reviews and revisions may be necessary. The process is admittedly arduous, has few guarantees, and is intended to ensure high-quality work that is timely, trusted, and helps to advance the field of academic medicine.
We aspire to include at least 2 editors, and sometimes more, in decisions on all submitted manuscripts. Deputy, associate, and assistant editors and members of the editorial staff are involved in these decisions; the editor-in-chief ultimately oversees all decisions. The editor-in-chief will seek additional counsel from any one of the editors when there is uncertainty. This “2 sets of eyes at a minimum” practice is in place to increase the quality and reliability of our decisions and to reduce the possibility of bias or significant errors at this later stage of decision making.
Several additional factors contribute to our efforts to strengthen and safeguard our decision making. As editors, we disclose duties or relationships that may influence our roles and judgments. We will also recuse ourselves from editorial decisions when there is a conflict of interest or relationship with authors that may unduly compromise objectivity, in accordance with established guidelines. It is important to note that the editor-in-chief has complete editorial independence from the Association of American Medical Colleges, the journal’s sponsor, and from the publisher. The journal also has an independent oversight committee, available to provide advice and feedback to the editors and to ensure that our work reflects the highest standards.
We are eager to continue to improve our processes, and we routinely discuss relevant issues and methods in our biweekly editorial team meetings. We take authors’ appeals of our decisions very seriously. When appeals are received, another (“arm’s length”) editor will perform a second and independent review to look for bias or errors in the original review process. We may include editorial board members and additional reviewers in this process as well. Finally, we welcome feedback from authors, reviewers, board members, and readers to help examine and improve the approaches we have implemented at the journal.
Editorial decision making entails careful processes of review and a series of judgments that are informed by many factors and considerations. Some factors relate to the quality of the submission and its fit within the journal’s scope, mission, and priorities. Considerations that are beyond the awareness of the author may also play a role, such as the presence of similar manuscripts that have already been accepted for publication. In sum, the journal receives many submissions—often excellent ones—that we do not accept for publication. And because we must reject so many manuscripts submitted to Academic Medicine, we work especially hard to minimize the influence of bias in our decision making. Our editorial team has put a number of safeguards in place, as described here, to help ensure careful and fair review of submissions to the journal. In making our decisions, we are fortunate to have the combined support and borrowed wisdom of an outstandingly skilled and collegial group of editors, editorial staff, reviewers, editorial board members, and oversight committee members.
We have great admiration and gratitude for all in the field who engage in educational research and scholarly writing. We deeply appreciate authors’ decisions to select Academic Medicine as a place for sharing their work. Tasked with safeguarding the integrity of Academic Medicine, we are accountable to our readers and authors to do the best we can to make well-reasoned and well-justified decisions. Being involved in the acceptance of articles for publication is tremendously rewarding for authors, reviewers, and editors alike. We also recognize that the editorial process can seem very opaque and that authors may experience a sense of personal vulnerability, given that we must reject many submissions. On behalf of our full editorial team, we thank all of you who submit to Academic Medicine and all of our readers for your trust in our journal.
In this past year, colleagues throughout academic medicine and the health professions turned to our journal to share their work. Academic Medicine continues to serve as a forum for exchange and learning in support of all aspects of the field of academic medicine, which aims to improve the health of people and populations through leadership and innovation in science, education, clinical care, community engagement, and evidence-informed health policy. Our authors have much to communicate regarding just how important this work can be in advancing health and promoting health equity, particularly in a time of extraordinary need and challenge throughout the world.
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