A Peer-Reviewer’s Plea

“What we’ve got here is a failure to communicate.” Cool Hand Luke

Brian J Gleberzon, BA, DC, Associate Professor, Applied Chiropractic and Clinical Sciences Departments, Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON M2H 3J1, bgleberzon@cmcc.ca

Introduction

Over the past several years, I have had the privilege to be asked to review manuscripts for several organizations (such as the Association of Chiropractic Colleges-Research Agenda Conference and the Canadian Chiropractic Association) journals (including the JCCA, Journal of Manipulative and Physiological Therapeutics, Chiropractic and Osteopathy and Clinical Chiropractic) and publishers (Elsevier). During that time, two things have become abundantly clear to me. The first one is that preparing a manuscript such that it survives the peer review process and is ultimately judged suitable for journal publication is a much more difficult thing to do than it may first appear. The second is that many prospective authors make the entire process much more difficult for themselves than it otherwise has to be.

Recently, Dr. Lisa Killinger and I published a commentary entitled ‘The Journal Article Cookbook’¹ that sought to assist would-be authors in manuscript preparation by providing detailed step-by-step instructions. Even with that article in hand, it seems that the ‘instructions to authors’ section found in every journal may not have communicated clearly what submissions should contain, and what they should not. Like Paul Newman’s iconoclastic character, we have a failure to communicate. This brief editorial is a plea from one peer-reviewer to prospective authors to stop making the whole process so painful by following some (hopefully) simple advice.

Mimicry is the sincerest form of flattery

If you are trying to have a manuscript accepted in a journal such as the JCCA, it is imperative that your manuscript conforms to the JCCA format. The easiest way to ensure this conformity is to examine a representative article in the journal and to copy its format exactly. It is shocking how often prospective authors do not follow this very easy and seemingly self-evident step.

Journal article submissions are usually data studies, systematic reviews or case studies. Most novice authors, especially if he or she is a field practitioner, will probably submit a case study or perhaps a case series for peer review. If this is the case, search the journal for a case study (see, for example,2–7) and lay the manuscript out in the same format. Start with a brief introduction, then provide details of the patient’s history and physical examination (see below), diagnosis (which should be supported by the interview and examination) and plan of management. This should be followed by a discussion that reviews what has previously been published about this clinical condition, focusing on diagnostic and management issues germane to chiropractic practice. This means a literature search will have to be performed and properly referenced (see below). Unfortunately, many submissions have scattered content that is difficult to follow, appearing as jolts throughout the manuscript, conforming to no format seen in any journal article, trade paper or magazine.

What exactly happened, and what exactly did you do?

The best case studies are those that describe exactly what questions were asked during the patient interview, and what assessment procedures were performed during the physical examination that led to the diagnosis provided. Many manuscripts I have recently reviewed gloss over these very important details. Even if a question or test did not garner any useful information (they were ‘unremarkable’), it is important to let a reader know that the question or test was asked or performed, respectively. Likewise, and perhaps most importantly, the case study should specify exactly what type of care was provided for the patient, to the extent of describing each spinal adjustment (i.e. use of instrumentation such as an Activator) or manipulation (i.e. lumbar roll, supine cervical rotary) or modality (i.e. ice, heat, ultrasound, TENS) used.

Literature searches and references

I love references. I just love’m. But how are they found, which ones should be used and how are they cited? The answer to the first question is to conduct a literature search. There are very useful data bases (such as www.chiroindex.org), but even then a relevant article may be missed. The best advice I can give is to consult someone who knows how to do literature searches the best – librarians. He or she can devise a search strategy that employs search engines that glean all relevant databases, and can provide an extensive list of articles to obtain and review. Some of these may not be useful, but some will be pivotal – so much so that the articles cited in those articles are often worth retrieving as well. The search strategy must be described in the manuscript, including databases accessed and keywords used.

The manuscript should include references that both support and refute the plan of management implemented, and the ones that are in peer-reviewed journals are trust-worthier than articles from non-peer-reviewed sources. Internet references are often unsubstantiated and must be used cautiously (if at all) and the date they were accessed provided. Personal communications can also be used, albeit sparingly, if the statement cited is denoted as being a ‘personal communication.’

Referencing styles differ from one journal to another. This does not mean one is better than another one is, or that one is ‘wrong’ and the other one ‘right.’ They are just different. It is imperative, however, that the manuscript conforms to the referencing style employed by that journal to which the article is submitted (in the case of the JCCA, a ‘Vancouver style’ of referencing articles is used). There are no exceptions to this policy, and no excuse for not formatting the references correctly. I can assure you that few things annoy a peer reviewer more than having to correct the structure or punctuation of a submitted document’s references, so if you’re doing it incorrectly, stop it. Just stop it. Please.

Watch you language

In the realm of chiropractic, many words and phrases are so emotionally invested that an author should either steer clear of them altogether, or specify the context under which they are being used. The term ‘subluxation’ illustrates this concept. Subluxation has many contextual meanings, spanning the gamut of functional or structural entities, to tonal-based, reflexive-based or even nutritional-based entities – and that’s just in the world of chiropractic.⁸ Our medical and osteopathic colleagues use the term differently altogether. If the term ‘subluxation’ is used, it must be defined. Likewise, the terms ‘manipulation,’ ‘spinal adjustment,’ ‘treat,’ and ‘diagnose’ all carry with them emotive overtures, at least among some segments of the profession.¹ Some forethought must be used in either including or avoiding these terms, and a definition of how they are used should always be included.

In much the same way, some submitted manuscripts refer to specific clinical entities or terms not typically found in the common health care lexicon. While it is certainly appropriate to use a new, unique clinical term that has emerged from another discipline when clinical circumstances dictate, it must be realized that not everyone (including a peer-reviewer) may be familiar with that terminology. If a phrase or diagnosis is on the emerging cusp of a health care discipline, a citation for it must be provided.

Although unintentional, some suggested plans of management could be construed as being either sexist or ageist by implying that, for example, a woman or older person should be given a lighter weight to use for strengthening exercises than would a man or younger person. Instead of venturing into potentially murky non-politically correct waters, an author should suggest that a patient’s functional status, rather than his or her age or sex, be the barometer used in determining the weight or number of repetitions recommended for a patient’s home care exercise regiment.

Preaching from the pulpit

It is not uncommon for authors of clinical trials or laboratory experiments to extrapolate their data to clinical practice in the ‘discussion’ section of a manuscript, attempting to both infer applicable scientific conclusions and suggesting other avenues of related research investigative initiatives. But there is a fine line between extrapolating data and editorializing. Although well intentioned, authors should avoid personal commentaries and opinions. An author should not presume to speak on behalf of the entire profession by chastising, for example, the chiropractic research community for their perceived supine acquiescence of medical dominance or government interference. If an individual feels compelled to offer an opinion about this or that issue, they should do so in a journal’s editorial or commentary section.

Things are much different with respect to case studies. The cardinal sin is to draw any conclusions from what happened during the interaction with the patient. Even though the patient’s chief complaint may have completely resolved under the care plan provided, no conclusions can be drawn that would suggest that that clinical approach would work for other patients with the same chief complaint. By their very nature, case studies are narratives of what happened to a particular patient under a particular care plan by a particular practitioner. Case studies cannot differentiate between the efficacy of an implemented plan of management independent of a placebo effect or natural history.⁷ This is not to say that case studies are not important. Quite the contrary: Case studies are being recognized as integral components of the evidence-based health care movement, with some author’s opining that field practitioners are much more likely to be guided by a well described case study in their practices than a complex randomized controlled study because the former has greater external validity and more closely mimics what happens in the ‘real world’ than the latter.^7,9–11 That said, it is simply not appropriate to claim that a case study has ‘proven’ that the clinical condition described can be effectively managed by the therapy provided.

Summary

Peer-reviewers such as I take no joy in returning a harshly worded critique of a submitted manuscript, especially if we can see that the prospective author tried his or her best to prepare it. My plea, perhaps speaking on behalf of many of my peer-reviewer peers, is please ensure that, at a minimum, a manuscript submission does not contain any of the aforementioned problems described. By doing so, the entire peer review process can be a lot less painful for both the peer reviewer and the prospective author.