Commentary| Volume 119, ISSUE 3, P193, March 2006

Dear Editor

      On occasion, I receive a letter explaining that a recently-rejected manuscript has been seriously misunderstood by our reviewers. First, I apologize to all who have submitted work that was not accepted for publication by The American Journal of Medicine. Let me explain our peer review process and why an otherwise excellent undertaking might not appear in the Green Journal.
      As editor-in-chief, I examine every submission and consider the originality and complexity of the research, the size of the study population, the quality of the methods and statistical analysis, and finally, the way the manuscript is constructed: the writing style, grammar, spelling, organization, and compliance with the Journal’s published Guide for Authors. A manuscript can be rejected for failing in any one of these areas. In addition, I ask myself whether the material would be useful to our audience of internists, most of whom are very active in the treatment of patients. Would the information contained in the manuscript help them with these duties?
      Has the topic been covered recently in the Green Journal or one of the other outstanding medical journals? If it has, readers may have relatively little interest in a repeat performance. Or a manuscript may be rejected because it is too specialized or theoretical for our readers, perhaps making it better suited to a subspecialty journal. We sometimes offer the authors electronic publication on our website. Approximately 50% to 60% of manuscripts are immediately rejected because the subject addressed is of generally low priority to the Journal or because only a select group of readers would find the information to be of practical use.
      Unfortunately, the Journal does not have the resources to rewrite manuscripts that have important faults in their style, grammar, and spelling. Poorly-written manuscripts that are difficult to understand may be sent back to the authors for revision before review. If English is not the author’s native language, it is advisable to turn this task over to a professional translator.
      If a submission passes my initial scrutiny, I may send it out for a secondary peer review by one of our associate editors with expertise in the area under discussion. They may recommend the acceptance or rejection of the manuscript—or they may suggest other peer reviewers to whom we should send the submitted material. Alternatively, I may select 2 or 3 additional peer reviewers. Likewise, papers with sophisticated statistical analyses are carefully examined by our biostatistical editor to ensure that the data has been properly handled.
      Eventually, all reviews return to me. I scrutinize the responses and take another close look at the manuscript before coming to a conclusion. Clearly, if both peer reviewers advise rejection, then that is almost always my decision as well. Similarly, if they each propose acceptance, I generally rely on these opinions. What if the 2 reviewers are at odds or both agree—with a low degree of enthusiasm—that a manuscript is in need of a major overhaul? Conflicting reviews generally result in a third peer review to break the tie. In the end, if I remain unsure about what to do with a specific paper, I often will bring it to an editorial board meeting, where we can all discuss the pros and cons of publication.
      All of this shuttling of a single manuscript from one expert’s hands to another’s has been greatly facilitated by our publisher, Elsevier, who recently installed a completely electronic system for manuscript submission and review. (For more information, see: This new computer tool has greatly expedited the entire publication process. It also prevents the loss of manuscripts through multiple mailings, a woeful occurrence that we and other journals have experienced in the past.
      So, dear, prospective authors—please do not be angry or hurt if we do not accept your paper for publication. It may represent an outstanding effort that would be better targeted to a different audience, or we might have something similar already moving through the publication process. Many highly-talented individuals associated with the Green Journal and Elsevier work diligently every day to produce the best possible clinical and scientific product for our readership. If we did not accept a previous manuscript, please send us your next endeavor. We are always looking for contributions to the various sections appearing in each issue of The American Journal of Medicine: editorials, reviews, images, brief communications, clinical research, and commentaries about academics and practice. We promise to give these submissions our full attention.