A case study in open peer review

Last year, BMC Anesthesiology published an article by Andrew Vickers and colleagues on the use of acupuncture for the pain caused by thoracotomy; it was a pilot study to examine whether a randomized controlled trial (RCT) was feasible. Thoracotomy is surgery to the chest to allow access to the lungs. Andrew Vickers is on the editorial boards for several of our journals, a respected statistician and trial methodology expert with an interest in testing complementary medicines. It was unlikely when he submitted the work that there would be any fatal flaws. However, we don't allow submissions from our editorial boards to escape peer review - and I've seen many manuscripts from editorial board members fail to pass muster.

Who would be suitable to review the manuscript? It's about acupuncture, so acupuncturists, right? Well, partly.

If we were to ask only acupuncturists to review, there are two potential drawbacks. Acupuncturists believe in the efficacy of acupuncture, otherwise they probably wouldn't be acupuncturists. If there were flaws in the study they might be inclined to give it the benefit of the doubt, whereas someone without a vested interest in the intervention under study might raise objections. The other issue is that they might be unfamiliar with pain relief in this particular setting. On the other hand, were we to only approach those who had never used acupuncture and who were otherwise experts in pain relief we would face two potential biases. For one, they might be skeptical that acupuncture works at all and thus be too picky, raising unreasonable objections to block publication. Another consideration is that they might themselves have a vested interest in the drugs used to relieve post-surgical pain, perhaps having received speaking fees or consulted for pharmaceutical companies.

To ensure rigorous and fair review, we needed someone who was familiar with acupuncture for pain relief, preferably with an additional experience of either randomized controlled trials, systematic reviews, or anesthesia for surgical interventions. Although it is not itself an RCT, the purpose of the trial was as a pilot to see if an RCT was feasible, and those who have conducted systematic reviews will have a good knowledge of critical appraisal. Secondly, we needed someone familiar with post-thoracotomy pain relief other than acupuncture, preferably with a knowledge of randomized controlled trials. Lastly, we needed someone with a familiarity with randomized controlled trials and anesthesiology for post-surgical pain, were either of the other two not themselves familiar with it.

BMC Anesthesiology is open access, but it is unusual among journals in another way. It has open peer review, as do all the medical journals in the BMC-series. By this we mean that the reviewers consent to their names being made to be known to the authors, and for their reports to be made public if the manuscript is accepted for publication. Open peer review allows me to sweep back the curtain, and reveal the peer review process, like a magician flaunting the secrecy of Magic Circle.

Among our reviewers were two complementary and alternative medicine experts, Betsy Singh and Hugh MacPherson. Betsy Singh has published on the use of several complementary medicines, including a systematic review of acupuncture for pain relief. Hugh MacPherson has published on ways to ensure the safety and accurate reporting of acupuncture trials, and is familiar with randomized controlled trials. We also had two reviewers who are researchers of pain relief, Deniz Karakaya and Jorge Dagnino. Deniz Karakaya is a thoracic surgeon has published on the use of conventional anesthetics in various procedures, including for post-thoracotomy pain. Jorge Dagnino has also published on the use of anesthetics for post-surgical pain, including thoracotomy. We had the full house.

What criticisms or points did they raise? Dr Singh had no complaints, and it isn't surprising to see a reviewer of a manuscript by Dr Vickers say this. Dr MacPherson was well-disposed to the study, but raised several points where the authors could better report details of their work, or better justify a statement. Dr Karayaka had only two relatively minor criticisms, asking for more detail on their procedures. Dr Dagnino raised the most objections, requiring many more methodological details, and questioning some of the conclusions. It is interesting to see that the two reviewers who asked the authors to make the most corrections were an acupuncturist and a traditional anesthesiologist. Both types of researchers applied their skills of critical appraisal to help the authors improve their work. Upon re-review, Drs Karayaka and Dagnino had some remaining questions, and the editorial staff determined that the authors' response to this second round of review was satisfactory and we proceeded with publication.

Although the study is limited in its scope and conclusions, inevitable for a pilot, uncontrolled study in only 36 patients, and although it would be easy to dismiss by many journals as not interesting enough to publish, we thought it necessary and valuable to have enough qualified reviewers to assess it, and we obtained the advice of four reviewers who together were qualified to judge all the main aspects of the work. Judging soundness (technical validity) isn't easy, and is more difficult than measuring the level of interest. It isn't that uninteresting though - more than 3,000 readers have accessed the article from our website in the past 10 months, and more will have read it on PubMed Central, a level of interest for which many blog writers would willingly give up a kidney.