p value of Peer versus Pear Review: Saving the Scalpel from Signatures

Surgeons perpetually innovating with a singular goal of improving patient-reported outcomes (PROs) have always been at the forefront of incorporating emerging horizons of basic sciences. The three aces, i.e., asepsis, anesthesia, and antibiotics, have put surgeons on winning table of healthcare stakes. Popular adoption of laparoscopic and other minimally invasive surgical sciences (MISS), have delivered the “Trump Suit” equivalent of bridge card game to surgeons, making them ambassadors of innovative application of science married to basic science fields such as computers, information technology, optics, pigment-based imaging in vivo during surgeries, motion picture editing, machine learning, and social sciences. Societal acceptance of these polymath traits of surgeon is reflected in universal adoption of MISS. This popular acceptance came ahead of any signatures of approval from peer review boards (PRBs) and without any level of evidence. This popular acceptance-based application of MISS was debated and given the scientific approval at the most prestigious global congress of surgeons following a “Presidential debate” between two science icons, Richard Satava and Bruce McFadyen. The congress was 2008 annual meet of “Society of Gastrointestinal and Endoscopic Surgeons (SAGES).”[1] The debate was titled, “Evidence-Based Surgery Is for Those Willing to Follow Behind—New Advances Can’t Wait” at SAGES 2008.[2] The polymath surgeon-scientist, dismissed as “boys with toys,” has been finally enabled to pursue research-based innovations.[3] This pursuit by surgeon aimed at improving PROs is an understanding that PRBs mirror the clearance from chair of surgery, akin to dealer having license to declare “Trump” in a game of “bridge whist.”[4,5] Such pursuits are rewarding not only for surgeon but science and society as well. The recognition by SAGES of the importance of limiting surgical energy to hemostasis and avoiding dissection outside established anatomical planes prompted the development of guidelines for the safe use of surgical energy, culminating in an invited editorial in surgical endoscopy, the leading journal of MISS.[6,7] The editorial described the traits of a scientist-surgeon having knowledge of basic sciences that can be translated to clinical benefits. These traits of translational science-driven surgeons are encapsulated to an acronym Imagineer, used now a self-descriptive word.[7] Surgeon-scientists distinguish themselves from clinicians by seamlessly integrating knowledge from both laboratory and clinical settings to identify research opportunities that enhance patient care and community health. A surgeon-scientist is defined as a surgeon actively engaged in translational research across a broad spectrum of fields.[8] The scientist-surgeon, aptly termed the “Imagineer,” has spearheaded the translation of fundamental research on microbiome, sterile inflammatory pathways, dietary molecules such as curcumin, and yoga into clinical applications, yielding robust evidence of benefits for postoperative convalescence defining PROs. An unfavorable ecosystem reflected in conduct of PRB stifles such pursuits, hindering advancements in science, the most common alibi being a demand for absolute proof in microconstituents of an idea at the foundation of hypothesis. The surgeon-scientist’s Imagineering, the innovative work, often lifesaving, can be hindered by the challenges of meeting PRB compliance rigidity. The experience with PRB reminds of Emerson who said, Society is always taken by surprise at any new example of common sense. What we trust and how we act should be more important for century-old harmless practices, rather than spending resources to find statistical algorithms for the trust. Beneficially applied basic science and trusted knowledge in surgical practice cannot always be reduced to numbers, text, or images, much to annoyance of statistics-grounded PRB.[9] Prevailing ecosystem of PRB has been seen to discourage younger aspiring surgeons to pursue academics and research. As the dwindling number of surgeon-scientists reduces the pool of potential mentors, aspiring young surgeon-scientists face an uncertain landscape. Many medical students and surgery residents, initially enthusiastic about developing a research program are often deterred by the significant challenges surgeon-scientists encounter, opting instead for clinical careers without a research focus. Following the rote learning-based education, they graduate to establish independent practice. Thus, prioritizing to have a better work–life balance, relinquishing the demands of research and writing that require evenings and weekends.[10] Thomas Sowell prophesized, “Too much of what is called ‘education’ is little more than an expensive isolation from reality.” Surgeons have gained their status of surgeon-scientist from being restricted to the management of diseases called external, i.e., on body surface as dictated by physician guilds, self-anointing themselves as internists with sole rights for internal medicine.[11] The future of research depends on our ability to nurture and support surgeon-scientist. In prevailing perceptions of PRBs not being favourable to surgeon-scientist, surgery leadership has expressed concerns being headlined as, “The extinction of Surgeon-Scientist,” “The surgeon-scientist a dying breed,” “Endangered academia” and A role for the surgeon-scientist? What does the “evidence’ tell us?” etc.[12] Postoperative convalescence-associated PRO pathways require integration of the emerging basic science understanding in surgical research. The surgeon-scientists with their unique understanding of translational science research need to be nurtured by supportive PRB. The concerns about ecosystem for research expressed in Western literature are an apt pointer toward Indian counterparts, which is insulated from such critique due to its overbearing statute with mandates intimidating enough for a careerist surgeon. It took a Nobel laureate of Indian descent to scratch the surface in saying that India cannot be a nursery of talent for research due to its cumbersome research environment.[13] Cover of an article is explicitly explanatory [Figure 1]. Many factors for this inconducive and cumbersome ecosystem have been discussed. What the young scientists fear to express, needs some introduction here. The choice of words to address concerns, i.e. ’Academic Bullying’ and ’Envy of Excellence’, though unconventional, convey, the helplessness of true idea generators. Several high-profile science institutions have been rocked by spate of bullying allegations.[14] Factors such as abrasive supervision, ostracism, gossip to target credibility, spreading malicious rumors, misinformation about achievements, hierarchical exclusion from formal networks, and sabotaging career pathways have been reported in these institutions. Bullying is seen in all walks of life, but the data are scary for academic science. The reported annual incidence of 25%–40% is significantly higher than 10%–14% among working population and 2%–19% for other universities. Most worrisome figures have been reported from neonatal intensive care units, more than half of almost 400 doctors and nurses having experienced bullying.[14]Figure 1: Illustration by Daniel Stolle“Envy of excellence” is even a worse nightmare for an aspiring surgeon scientist. It involves mobbing and systematic targeting and harassment of independent thinkers, high-achieving scientist-surgeons. Westhues describes it as group ganging with psychological aggression and isolation in influential academic committees.[15] This too, has been reported having higher prevalence in medical academia, with The Lancet journal sending a shout for global committee on Academic Behavior Ethics.[16] The issue remains alive as most of the addressing mechanisms have failed as these envious bullies leave no trace/trail.[17] Statistics is another common harassment tool in PRB interactions. This despite best of tools available online with highest degree of analysis in artificial intelligence-enabled or handheld pocket gadgets. iPhone being a favorite of most even at PRB meets. While Statistics is the grammar of science (Pearson), if tortured long enough, the data will confess to anything (Ronald Coase), revealing the suggestive, but concealing the vital (Aaron Levenstein). Still, statisticians prevail in PRB, falling in love with their models (George EP Box), using statistics like a lamp post, more for support than illumination (Andrew Lang). Our proposal to use natural probiotic bath (with Dahee, Indian fermented milk) as a potential tool to reduce risk of surgical site infections, raised a concern by PRB, what if some consenting study volunteer dies of MI (we are still searching literature, if it meant myocardial infarction or Milk intoxication!). Surprisingly, it was about using milk to make tea, mentioned in the famous “Lady Tasting Tea” experiment. The experiment designed by Muriel Bristol, a colleague of Fisher’s, who claimed she could taste the difference between tea made with milk added before or after brewing. The study, which used 8 cups of tea, tested her claim and laid the foundation for modern statistical hypothesis testing. Fischer later developed the analysis of variance, ANOVA, followed by the book that guides PRB experts, “The design of Experiments.” We many in scientific community follow the colonial mindsets and teaching forgetting that the best of mathematics and science travelled to Arab during the Islamic occupation of India. Many believe that there was no civilization with geographical domain roots 2000 years back, no ’believers’ of any kind 1500 years back, no Indian human records or history before invasions from its northwest or seas, no Indian fighting for independence before a specific person arrived and no scholarship beyond the dictates of few after 1947. The facts otherwise speak for themselves. The Arabs translated Indian books and carried it to Europe, undergoing renaissance from dark ages.[18] The mathematical fields were the best that humanity has ever had.[19] Indian renaissance will need studies beyond the dictated of the last 12 centuries to reconnect with our more advanced methods of scientific studies to redeem our own heritage in science.[20] Francesca Bray, Professor Emeritus at the University of Edinburgh, reminds us that the books that we refer to and cite were written by English or Dutch; they preferred to say they were the ones bringing progress and we believe them.[21] India believes in inclusion of wisdom from all sources. We must use the best from colonial education, but at the same time stop being skeptical of advance science having existed in Bharat, that is, India. Our skepticism should not be biased, finding unrelated fault lines in our own while ignoring a believer in racial intelligence difference, one who was eugenicist, supported scientific racism, and is also famous for his “sexy son hypothesis.”[22] The PRB and institutions need to redeem science from mockery of obstructive peer reviews. Let the surgeon-scientist thrive! Voltaire, a witty thinker, had this to say during the European Renaissance, “Our wretched species is so made that those who walk on the well-trodden path always throw stones at those who are showing a new road. Appreciation is a wonderful thing. It makes what is excellent in others belong to us as well. Every man is a creature of the age in which he lives, and few are able to raise themselves above the ideas of the time.” Disclosure This article was written by experiences and observations of changing mentor profile and their attitudes toward curious and sincere postgraduates starting their journey of professional life. The ‘trials and tribulations’ they face, their frustration with the prevailing research ecosystem, potentially leads them to surrender at the altar of PRB rigid structures. The peer ecosystem, mandated to navigate enthusiasm for research amongst younger generation, ends up putting the procedural cart before the surgeon-scientist horse. Their approach mirrors the procrustean cutting humans to size of the bed, akin to a polite adage, “trim the foot to fit the shoe”. The ecosystem results in defeating the self-belief of surgeon-scientist, thus eliminating the possibilities of their dreams or thinking out of the box. It is a timely call for introspection by our generation, whether we are being as good mentors as we had! We at Ganga Ram Hospital, Delhi, are blessed to have had guidance of such mentors in Late Prof. KC Mahajan and Prof. Kusum Verma now. A cartoon posted on social media by one of the authors excelling in academics with witty humor, crystalized the chain of observation leading to, thoughts of other authors [Figure 2]. Starting the title and a sentence with lower case is a reminder to make some Dutch friends.Figure 2: Peer review versus pear review