Abstract
To introduce this topic, a brief review of the peer-review policy of High Altitude Medicine & Biology is warranted. Every item published in the Journal is subjected to peer review. For regular scientific articles, there are always two reviewers, but in instances when there is disagreement between the two reviewers, a third opinion is sought. The acceptance or otherwise of a manuscript is based on the recommendations of the reviewers. The editor-in-chief has little to do with the decision.
Happily, the quality of the reviews is generally very good, this statement being based on many responses from authors. The Journal is very fortunate to have a large cadre of people who are willing to give a substantial amount of time to producing comprehensive and objective reviews. It might be added that very occasionally an e-mail to a potential reviewer is ignored and there is no response. Fortunately, this occurs infrequently and oddly enough seems to be most common among the most senior reviewers.
Although regular scientific articles always receive at least two reviews, some contributions to the Journal, such as Letters to the Editor, Historical Manuscripts, or Book Reviews, may receive only one. Occasionally, a manuscript is submitted that is clearly outside the scope of the Journal, and this is then not peer reviewed but returned to the author.
All this is a preamble to an interesting issue that recently arose about one of the articles written for the Clinician's Corner feature: Do Lung Disease Patients Need Supplemental Oxygen at High Altitude?, published in the Winter 2009 issue of the Journal. It was sent out to two experts for peer review. One review was very complimentary with two or three suggestions for improvements. But the other review from a senior and well-respected person began as follows:
It seems quite dangerous to make clinical recommendations in the absence of adequate data. If I were the author, I would focus the essay on the need for more comprehensive research, providing the physiological justification for the need to study such things as the factors listed above [intended altitude, duration of stay, rate of ascent, level of physical activity contemplated, pathophysiology of the lung disease, and comorbidities being the most important]. I would de-emphasize the recommendations themselves, perhaps limiting them to saying that the need for data means that firm recommendations are not possible therefore, best be conservative until proven otherwise.
On the one hand, this is a very reasonable response and probably many people would agree with it. On the other hand, physicians who are approached by either patients or the doctors advising them are frequently placed in a position where they need to give some sort of advice. Indeed, the author of the article responded as follows:
I recognize this concern but have to respectfully disagree with the reviewer about whether to include recommendations in this particular essay. Clinicians advising travelers to high altitude are often seeking advice about how to handle particular patients and, with appropriate caveats, I think it is appropriate to provide guidance for them. There are many areas of clinical medicine and high altitude travel for which we lack data but clinicians still need to make decisions and some guidance is appropriate provided the limitations are recognized.
Of course, advising patients with lung disease about whether they need supplemental oxygen at high altitudes is by no means the only situation for which a clinical decision is requested when there is insufficient evidence to prove a recommendation right or wrong. Such occasions frequently arise in clinical medicine. But advising patients with preexisting disease about the dangers of going to high altitude can be a particularly difficult area because of the great paucity of data. Understandably, there are no controlled trials of the outcome of patients with various types of lung and heart disease or other conditions, such as diabetes mellitus. But the fact is that some patients are adamant that they will go to high altitude, and the advising clinician simply has to make the best decision that he or she can. It will be interesting to see whether the Clinician's Corner feature of the Winter 2009 issue provokes any responses from readers.