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When a manuscript arrives, a staff member checks to make sure that all materials required for submission are included (see "Information for Authors," which is posted on our Web site and appears in most issues of the Journal ). If everything is present, the article is logged into our computerized manuscript-tracking system. The first stop the manuscript makes on its editorial journey is on the desk of the editor-in-chief, who reviews each submission (in his absence this is done by the executive editor) and decides on the basis of its general content whether it is appropriate even for consideration for publication. For example, we rarely publish the results of studies based solely on investigations in animals, and we tend to avoid papers that would appeal only to a very specialized audience. We usually return papers in these categories to their authors right away, since it would be unfair to hold them for review when there is little or no likelihood we would publish them. Each of the remaining scientific manuscripts is assigned to an associate editor with expertise in the subject area covered by the study, who makes an independent assessment of the value and validity of the paper. If the associate editor believes that even with favorable reviews the paper would not be published because it lacks novelty or importance, or if he spots a major flaw in experimental design or performance, the paper is given to a deputy editor for a second opinion. If the editors concur that publication in the Journal is unlikely, the manuscript is returned to its authors.
If, on the other hand, the associate or deputy editor believes that the paper may merit publication, it is sent to two of our many outside reviewers. These volunteers are the lifeblood of our peer-review process. They are asked to provide a frank evaluation of the scientific validity of the manuscript, insight into its freshness, clinical impact, and timeliness, and an overall opinion of its worthiness for publication. Theirs is the key step in manuscript evaluation. As editors, we are grateful to all our reviewers for their continued contribution to the rating process. We are careful not to refer to them as "referees," which would suggest that the decision to publish a paper rests entirely with them. It does not. The reviewers provide critiques and advice that the editorial staff uses in making decisions. But we make the decisions. Furthermore, reviewers of a manuscript do not always agree, and it thus falls to the editors to evaluate the reviews and make a decision. The process is similar to that in many patient care settings. As an attending physician, you may request a number of consultations from your colleagues, but in the end you as the attending physician make the call on the basis of what you believe to be in the patient's best interest. We do the same, acting in the best interest of the Journal.
When both outside reviews are returned, the associate editor then assesses the manuscript again, along with the comments of the reviewers. He may seek additional opinions from other reviewers, or he may discuss the manuscript at a meeting of the entire editorial staff. At this meeting a decision is made either to reject the paper or to proceed with further editorial consideration, including, if appropriate, a formal review of the statistical or experimental methods. In some cases, the editorial staff may recommend additional review by outside reviewers. On completion of this process, the manuscript is usually returned to its authors along with a letter inviting them to revise it and to respond to certain questions. When all the requested information has been received, the manuscript is reconsidered by an associate editor and a deputy editor, and it may be discussed again with other members of the editorial staff. We then make our final decision to accept or reject the paper. In the end, our decision is based on our best assessment of the manuscript's merits — the veracity of its findings, its potential interest to our diverse readers, its timeliness and potential impact on medical practice or biomedical research. Although we have received guidance from many people along the way, the decision we make is simply our own best judgment about the best interests of the Journal 's readers and ultimately, sick patients. We acknowledge the necessarily subjective nature of our decisions and do our best to make well-informed and unbiased ones that will advance the field. We try to decide as speedily as possible, but not at the expense of making faulty or unwise decisions.
When a manuscript is rejected, we are willing to entertain an appeal from the authors, although it is uncommon for us to change an editorial decision. An appeal is more likely to be successful if the authors make a concerted effort to revise the manuscript in accordance with the reviewers' comments. When a decision to reject a paper is based largely on editorial priorities, however, even careful attention to the reviewers' criticisms is not likely to result in an acceptable paper.
We recognize that the peer-review process is not perfect, but we earnestly believe that it is the best way to select and publish the most important medical research. Peer review is labor-intensive and sometimes time-consuming, but without it physicians themselves would have to assess the validity of new medical research and decide when to introduce new treatments into practice. Surely this would not be in the best interest of patients, who expect and deserve only the best medical care that physicians can offer.
We appreciate that, from the perspective of a submitting author, having a manuscript in the review process is like having a child away at camp. The manuscript must fend for itself, but it is always reassuring to know how things are going. We have therefore instituted a new manuscript-tracking service for authors, PaperTRAIL (Paper Tracking through Interactive Links), which is available on the Web at http://www. nejm.org/papertrail. This service allows the corresponding author of a submitted paper to track his or her manuscript as it progresses through our review system. On the Web site an author can see when a paper was logged into our manuscript-tracking system, when it was assigned to an editor, when it went out for review (but not the names of the reviewers), when the reviews were returned, and when we have made an initial or subsequent decision. For reasons of security, we post only limited information, and access requires that the user enter both the name of the corresponding author and the manuscript number assigned by our office. Furthermore, to protect the identity of our reviewers, the data base this system uses resides on a server that is physically distinct from that of our own manuscript-tracking system.
We understand the importance of a submitted manuscript to its authors. The PaperTRAIL system will provide reassurance that a manuscript is moving through the review process. We invite you to submit your best research to us; we will treat it with respect, and now you can follow it on its journey.
Edward W. Campion, M.D.
Gregory D. Curfman, M.D.
Jeffrey M. Drazen, M.D.
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