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Medical publishing under review.

Peer review, intended to filter research and improve the quality of manuscripts, is not without limitations. The process from submission to final publication can be arduous, and timelines can range from a few months to more than a year. Formatting requirements vary between journals. Following rejection, resubmissions are delayed by 2 weeks to 3 months due to reformatting. Globally, authors spend 23.8 million hours formatting articles, with estimated annual costs exceeding $1.1 billion dollars. Peer-reviewed research generates profit for journals and can be expensive for researchers, especially if open access. In 2019, Elsevier— one of the largest global publishers of scholarly journals—made a profit of $1.2 billion USD and based on net margins was more profitable than bank, pharmaceutical, tobacco, and oil sectors. In the current system, scientists are forced to pay thrice for research: first to apply for funding that will cover the costs of designing and conducting the research; second for publication fees, especially if open access; and third to volunteer time, often with lost revenue, as a peer reviewer. The quality of the peer review itself, can vary as there are no benchmark qualifications required for peer review and journals typically do not offer reviewers standard tools to assess study quality or validity. The current peer review system is not designed to detect scientific misconduct. Driven largely by the publish or perish scientific culture, a small number of researchers go as far as to fabricate data. Two highimpact medical journals retracted publications on drug treatments for COVID-19 after post-publication concerns regarding fraudulent data were raised by readers. To test the peer review system, a deliberately flawed manuscript was sent to 304 journals and was accepted by 157, highlighting the challenges in data authentication. Scientific misconduct can extend to the review process itself due to conflicts of interest. Authors can recommend allies as reviewers to receive favourable reviews; author-recommended reviewers are more likely to recommend acceptance than editor-selected reviewers. Even legitimate reviewers can be biased when there are competing interests, providing delayed or harsh reviews to stall publication of a manuscript. Editors may be biased by relationships with the authors or with industry. More than half of 713 editors of high-impact journals received payments from industry, which may influence editorial decisions. The limited diversity on editorial teams has meant that journal research priorities and publications do not always reflect those of diverse researchers and populations. In an analysis of thousands of submissions to a biosciences journal between 2012 and 2017, women and authors from continents outside North America and Europe were under-represented as editors, reviewers and senior authors. Editors and peer reviewers were more likely to accept manuscripts from authors of the same gender and country as themselves, especially when the team of editors and reviewers were all men. The peer review process can contribute to publication bias when editorial teams favour positive trial outcomes. In an analysis of Food and Drug Administration reviews of antidepressant agents, 36/37 positive studies and only 3/36 negative studies were published. In an analysis of 4600 publications, more than 85% reported positive results. The pressure to publish positive findings can influence research design, outcome selection, post hoc analyses, reporting, and marketing.