Too many papers, too few reviewers: an unsustainable trajectory

We base this commentary on a direct experience: ten months after the initiation of peer review for one of our manuscripts submitted to a first-quartile journal, the process remains ongoing. This situation prompted us to reflect more broadly on a growing systemic problem in scientific publishing: reviewer fatigue and the increasing difficulty editors face in identifying qualified, willing reviewers. While peer review remains the cornerstone of scientific quality assurance, we believe its sustainability is increasingly threatened by an inherently imbalanced system that strongly incentivizes manuscript submission while offering little formal recognition for reviewing activity. In our view, reviewer fatigue is a multifactorial phenomenon. A key driver is the unpaid nature of peer review, which is typically performed during personal time in the context of rising clinical and administrative workloads, particularly in anesthesiology. This burden is compounded by the proliferation of scientific journals and the exponential growth in manuscript submissions, a trend further accelerated by the widespread adoption of artificial intelligence tools that lower barriers to manuscript production. Increasing subspecialization further narrows the pool of eligible reviewers, concentrating the reviewing burden on a limited number of already overextended experts. We also consider insufficient editorial triage an important and often underappreciated contributor. When manuscripts with fundamental methodological or conceptual flaws are routinely sent for external review, reviewer motivation declines and editorial timelines are unnecessarily prolonged. Additional factors - including limited training in peer review, lack of feedback, and absence of academic recognition - further erode the perceived value of reviewing. We discuss several potential strategies, including formal recognition systems, targeted use of AI for preliminary manuscript screening, and stricter desk rejection policies. In conclusion, we view reviewer fatigue as a systemic threat to the integrity and efficiency of peer review that demands urgent, balanced, and concrete action by the scholarly community.