Unless you are over 90 you probably cannot recall a time when peer review was not regarded as an essential qualitative process in the evaluation of manuscripts for inclusion in medical journals. It was and is still believed that peer review ensures that presentations of putative scientific merit will be carefully assessed by disinterested yet committed and qualified experts whose judgments enhance the quality of published papers.

Inasmuch as these review exercises have become so well entrenched as a standard of investigative rigor and the consensus about its pros (seemingly many) and its cons, (relatively few except for the transitory disappointment of rejected authors) so well accepted that critical evaluations of its merits and drawbacks have until recently received scant attention. Yet today the established patterns of publication of scientific articles are being challenged by several developments, (1) the rapid diffusion of electronic open access protocols and journals, (2) the effect on journal reading patterns with the increasing subspecialization of content and (3) the multiple modes available for the rapid transmission of information both to subscribers and to the general public. These developments have elicited the cracking if not the total breaking of conventional models for the delivery of discovery and revisions, the two stocks in trade of basic scientists and clinical investigators.

Everything is now on the table open for inspection in the ongoing ferment about how new knowledge in medicine is announced and deployed. The once hallowed rules and rituals of peer review are now under particular scrutiny. Yet this should be of no surprise to us, for in times of disruption occasioned by advances in communication, periodic assessment is required to ascertain contemporary relevance and possibly the need to renovate, revamp or eliminate traditional assumptions, attitudes and algorithms that govern behavior.

Peer review today is still applied with similar tenacity to journal submission and grant applications. The history of its deployment in both spheres has not been smooth over the 150 year period between its introduction at the end of the Napoleonic era and its general acceptance after World War II. Its gradual penetration into the schedules of scientific publications has been characterized as haphazard at first; originally it was the domain of enthusiasts only. But by fits and starts, generally without formal concerted effort, it eventually permeated the mindset of editors and publishers of medical journals. After the war the expansion of medical studies in general and the coincident increases in the specialization of investigations not only spawned new journals but also stimulated the establishment of vigorous standards of quality. Hence, peer review conducted by individuals of akin credentials to investigators offered a means for the sustenance of scientific excellence. Currently, medical periodicals professing to become prominently regarded by present and potential contributors and readers alike as a source of new knowledge cannot be so regarded without having peer review as a standard method of manuscript evaluation.

Now, what are the presumptions of peer review specifically? What are the traits that for the most part still are essential for the establishment and maintenance of esteem for both journals and their authors? A manuscript is submitted to an editor who then distributes it to two or more so-called experts for their careful analysis of its scientific content including, often today, an analysis of the statistical means used to test the significance of the data, an assessment of the validity of the hypothesis presented and examined by the authors, the import of the study with respect to its novelty, its relevance in conjunction with general topics within the purview of the journal, and for some investigations, its application for the improvement of patient care. As part of their charge, peer reviewers often check references, critique the quality of images and legends and comment upon the pertinence and skillfulness of the narrative.

The insights these experts bring to the process can improve the paper. Moreover, the citations they offer can lead to revisions which make it more acceptable for publication. Furthermore, negative comments made without rancor and invidiousness can serve to stimulate the authors to seek more data, to sharpen their nar^r

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