Gatekeepers: Peer Review and Privilege

The writer and activist Rachel Cargle has written about privilege: “Who has written the books...who gets to be part of the canon? Who are knowers, and who gets to be known?"?

This past year marked the 40th?anniversary of my graduation from medical school.??I chose a non-traditional career path after residency; I’ve had some unusually diverse experiences across the entire healthcare ecosystem: a combination of public health, business, and clinical leadership experiences, working for nonprofit, private sector and entrepreneurial ventures.??I’ve been pretty successful, more so in terms of accomplishments than economics, and I've learned a few things along the way.

I try to share what I’ve learned, my insights and real-world experience designing and implementing frameworks and operational solutions to many of the challenges that are repeatedly studied – and published about -- but with which we struggle to overcome. I present at conferences, write blog posts and sit on advisory boards; however, despite more than 20 submissions of viewpoints, perspectives, and commentary, I have never been able to publish in a medical journal (notwithstanding my having been a global executive in one of the world’s largest medical publishers).

At first, I thought I was a failure. Was it my writing style???Was there an aspect of training I missed???Is there some secret handshake or password I never got because I left the academy??I wrote, and rewrote, and finally a few pieces went into peer review, only to be rejected, again.

Coming from the private sector, where qualifications and task-related roles are carefully vetted before being assigned, I found reviewers comments extremely frustrating.??I do understand the volunteer nature of the role, but the first level of frustration was the request for more references when there was a clear limit on the number of references for the type of article I was submitting. The second level of frustration were reviewers whose comments made it clear to me that they were completely unfamiliar with the topics I was presenting?(“I had to Google the word the author used”) yet were compelled to critically weigh in based on their fallacy of comprehension. The third level of frustration was the demands by reviewers that I unpack the logic of my theses?(“…you should explain who Rachel Cargle is and why she is relevant to your point”), which indicated to me that they didn’t bother to read my references (nor know the word count of my article type).??The fourth level were those reviewers who had a critical suggestion to expand my thesis into a related area that they thought relevant ("Great essay on Italian food with wonderful recipes, but the author should have explored the myth of pastas Chinese origin”).?Finally, there was the reviewer who actually had background in the area about which I was writing, but felt compelled to show they were smarter than me by pointing out how much they knew, and therefore, since they knew it, my contribution was unnecessary.

The science of ecology tells us that?species cannot evolve without diversity in their gene pool; those with limited genetic?variation are less able to adapt to changing environmental conditions.??Looking at healthcare are a species; we would?benefit considerably if we would diversify our conceptual DNA.???

Despite medicine’s capacity to master complex science and make life-changing – and potentially life-taking -- decisions and actions, we may not necessarily be competent to evaluate the value and power of concepts from outside of the academy, resulting in unconscious, but significant bias in their selection, approval, and support.??This phenomenon seems to be true for peer review, influencing what see, and don’t see, in our professional publications.??

The painter?Walter Sickert once said,?“Perhaps the importance that we must attach to the achievement of (any individual or group) may properly be measured by the answer to the following question: Have they so wrought that it will be impossible henceforth, for those who follow, ever again to act as if they had not existed?”??Given this perspective, can we deny that the current model of medical publishing is a biased gatekeeper of?“...who gets to be part of the canon …and who gets to be known”?

Ambitious goals for improving the quality of health of individuals and communities will not be achieved by limiting the scope of what we publish to the familiar, but by responsibly supporting the diversity and equitable influence of perspectives outside of our current view. Perhaps our productive evolution as a profession has been?restricted by the process by which we gatekeep access to diverse ideas within, between, and across disciplinary boundaries.

REFERENCES

[i]?“I Refuse to Listen to White Women Cry’. Washington Post September 11, 2019

https://www.washingtonpost.com/news/magazine/wp/2019/09/11/feature/how-activist-rachel-cargle-built-a-business-by-calling-out-racial-injustices-within-feminism/??Accessed Nov 3, 2022

[ii]?What Is A RACI Chart? How This Project Management Tool Can Boost Your Productivity. Forbes Advisor March 25, 2022?https://www.forbes.com/advisor/business/raci-chart???Accessed Nov 3, 2022

[iii]?Cleland,?E.?E.??Biodiversity and Ecosystem Stability.?Nature Education Knowledge?2011;?3(10):14