Peer review in medical journals: Beyond quality of reports towards transparency and public scrutiny of the process

• The peer review process determines the selection of studies that will inform health care decisions.
• The single-blind model (reviewers unknown to authors) is adopted by most biomedical journals.
• Blinding also reviewers (double-blind model) is tricky and does not improve reports' quality.
• Open peer review ensures transparency about study reports that may influence clinical practice.
• Also the editorial process should be made public, avoiding an excessive focus on reviewers' role.

Published medical research influences health care providers and policy makers, guides patient management, and is based on the peer review process. Peer review should prevent publication of unreliable data and improve study reporting, but there is little evidence that these aims are fully achieved. In the blinded systems, authors and readers do not know the reviewers' identity. Moreover, the reviewers' reports are not made available to readers. Anonymous peer review poses an ethical imbalance toward authors, who are judged by masked referees, and to the medical community and society at large, in case patients suffer the consequences of acceptance of flawed manuscripts or erroneous rejection of important findings. Some general medical journals have adopted an open process, require reviewers to sign their reports, and links online pre-publication histories to accepted articles. This system increases editors' and reviewers' accountability and allows public scrutiny, consenting readers understand on which basis were decisions taken and by whom. Moreover, this gives credit to reviewers for their apparently thankless job, as online availability of signed and scored reports may contribute to researchers' academic curricula. However, the transition from the blind to the open system could pose problems to journals. Reviewers may be more difficult to find, and publishers or medical societies could resist changes that may affect editorial costs and journals' revenues. Nonetheless, also considering the risk of competing interests in the medical field, general and major specialty journals could consider testing the effects of open review on manuscripts regarding studies that may influence clinical practice.