Participation in academic publishing is widely regarded as essential to physician-scholar identity. Authorship, peer review, and editorial service are embedded within expectations for promotion, tenure, and professional legitimacy.
Yet for many physician-researchers, the lived experience of publishing increasingly feels misaligned with the values that academic medicine espouses: service, stewardship, and the ethical dissemination of knowledge. The system that undergirds contemporary scholarly communication in medicine merits careful examination for its structural assumptions and consequences.
THE CURRENT PUBLISHING ENVIRONMENT
Physician-researchers often conduct research while juggling demanding clinical responsibilities. They frequently obtain funding through public or institutional sources, yet publication typically requires additional unpaid labor. Physician-researchers draft manuscripts during evening hours, on weekends, or during protected academic time that is often disrupted by clinical duties. Once submitted, manuscripts enter peer review, which largely depends on volunteer labor by expert clinicians and scientists.
Review cycles commonly span months or longer and may involve multiple rounds of revisions. Increasingly, authors are also asked to pay article processing charges (APCs) for open-access publication, even as readers — clinicians, trainees, and patients — may encounter access barriers to research produced with public support. These practices reflect an academic publishing ecosystem that externalizes labor and cost while retaining control over access and legitimacy.
Uncompensated Peer Review and Opportunity Cost
Peer review remains central to scientific credibility and academic medicine’s self-regulatory ethos. However, the labor model underlying peer review warrants scrutiny. Reviewers are rarely compensated, provided protected time for this work, or meaningfully recognized beyond annual, aggregated acknowledgments that do not document the scope, quality, or impact of individual reviewing contributions.
Because peer review is typically performed outside scheduled clinical or academic duties, it carries a substantial opportunity cost, often displacing time otherwise devoted to patient care, teaching, scholarship, or professional recovery, becoming absorbed into evenings, weekends, and other personal time. These contributions are essential to journal quality yet remain uncompensated.
Framing peer review solely as a professional obligation obscures its role as essential, unpaid labor that sustains a profitable publishing network. Indeed, the publishing industry earns substantial revenue and profit margins — comparable to major technology and consumer goods companies — despite relying on unpaid scholarly labor for content and quality control.(1)
The Emergence of Artificial Intelligence
In this context, it is not surprising that journals and publishers are increasingly exploring artificial intelligence (AI) to support and streamline peer review. As noted by editors of JAMA Network journals, hybrid strategies are being considered in which AI functions as an assistive tool for summarization and quality checks. At the same time, humans retain ultimate responsibility for assessment and decision-making.(2) Such developments reflect adaptive responses to reviewer scarcity and workload, rather than wholesale replacement of human expertise.
Still, the increasing reliance on AI in peer review introduces important limitations and risks. AI systems lack the clinical judgment, contextual awareness, and ethical discernment that physician-reviewers bring to the evaluation of medical research. Algorithmic assessments may overemphasize surface features such as structure, language, or statistical form while missing clinically meaningful nuances, methodological subtleties, or implications for patient care.
Moreover, AI tools are trained on existing literature and may inadvertently reinforce prevailing biases, narrow epistemic diversity, or disadvantage novel, interdisciplinary, or equity-focused work. Without transparency regarding how AI tools are trained, validated, and deployed, their use in peer review risks obscuring accountability in a process that relies fundamentally on trust, expertise, and professional responsibility.(3)
Prestige, Incentives, and Structural Entrapment
Journal prestige is often cited as justification for the current publishing model. Publication in high-impact venues confers visibility, legitimacy, and professional advancement. For physician-researchers, this prestige affects promotion and tenure, grant competitiveness, credentialing, and even professional reputation. As a result, participation in the publishing system is difficult to decline, even when its inefficiencies and inequities are widely recognized.
The same entities that control pricing and access also function as arbiters of scholarly legitimacy, reinforcing a cycle of participation that is difficult for individual physician-researchers to disrupt.
Open Access and Redistribution of Burden
Open-access publishing was introduced to democratize access to knowledge. However, it has frequently shifted the financial burden from readers to authors. APCs can be substantial and are often borne by investigators or their institutions, with variable support from funding agencies.
Although open access advances principles of transparency and dissemination, its current implementation may preserve profitable revenue streams for publishers without addressing the underlying reliance on unpaid labor or broader inequities in scholarly communication.
Implications for Knowledge Translation and Patient Care
The consequences of the current model extend beyond academic careers. Delays in peer review, publication, and access impede the timely translation of evidence into clinical practice. For physician-researchers committed to evidence-based care, restricted access to clinically relevant research raises ethical concerns.
When dissemination of medical knowledge is slowed or gated by cost, patients ultimately bear the downstream effects. A system that constrains access to publicly funded research is difficult to reconcile with academic medicine’s commitment to societal benefit.
Administrative Burden and the Compliance Paradigm
Even after acceptance, authors face extensive formatting and administrative requirements. Journal-specific rules for figures, references, and structure — often inconsistent across venues — consume additional time and attention, reinforcing a compliance-driven culture in which procedural adherence can overshadow substantive scholarly contribution.
For clinicians already navigating documentation burdens and regulatory complexity, these requirements compound professional strain.
TOWARD A MORE ETHICAL AND SUSTAINABLE MODEL: A CALL TO ACTION
Academic publishing is often described as “broken” or “troubled.”(4) Yet from an economic perspective, it functions as designed: It externalizes labor costs, maintains control over scholarly legitimacy, and generates substantial revenue. The misalignment lies not in execution but in objectives. The current model prioritizes publishers’ financial sustainability over the sustainability of the clinician-scholars who produce and vet medical knowledge.
Meaningful reform will require coordinated action across stakeholders in academic medicine:
1. Recognize and Support Peer Review Labor. Institutions and publishers should explore mechanisms to formally recognize and compensate peer reviewers, whether through academic credit, protected time, or financial remuneration.
2. Reevaluate Promotion and Tenure Metrics. Academic medicine must reassess its reliance on journal prestige in promotion and tenure decisions. Valuing diverse forms of scholarly contribution — including implementation science, educational scholarship, and community-engaged research — regardless of publication venue, could reduce dependence on a narrow set of high-prestige journals.
3. Encourage Institutional and Collective Negotiation with Publishers. Medical schools, health systems, and professional societies should engage publishers collectively to advocate for transparent pricing, reasonable APCs, and access models aligned with medicine’s public mission.
4. Support Ethical Integration of AI in Peer Review. As AI tools enter editorial workflows, their use should be transparent, evidence-informed, and governed by ethical standards that safeguard privacy, integrity, and accountability. Without human responsibility, transparency, and confidentiality as non-negotiables, AI-enhanced peer review risks efficiency at the expense of ethical legitimacy.
5. Treat Knowledge as a Public Good. Medical knowledge — particularly when publicly funded — should be treated as a public good. Access policies should reflect this principle, reducing barriers for clinicians, trainees, patients, and the public.
6. Recognize Scholarly Knowledge Translation Beyond Traditional Journals. Academic medicine should also recognize scholarly knowledge translation that occurs outside traditional journals. Physician-researchers increasingly disseminate evidence, contextual analysis, and professional insight through curated, peer-informed digital forums, such as KevinMD, MedPage Today, and Doximity.
When these contributions are grounded in evidence, subject to editorial oversight, and demonstrably influential in clinical discourse or policy discussions, they represent meaningful forms of scholarly impact. Incorporating such work into promotion and tenure evaluations — alongside traditional publications — would better align academic incentives with medicine’s educational and public-facing mission.
CONCLUSION
Physician-researchers remain deeply committed to advancing medical knowledge and improving patient care. Yet commitment should not require acquiescence to systems that extract unpaid labor, delay dissemination, and restrict access to evidence.
The question before academic medicine is no longer whether the publishing model is inconvenient or inequitable; it is whether a system misaligned with professional values can continue to claim legitimacy without meaningful reform.
Addressing this challenge will require collective leadership, institutional courage, and a willingness to rethink long-standing assumptions. The credibility of academic medicine, especially its service to patients, depends on it.
References
An Y, Williams MA, Xiao M. The cost of knowledge: academic journal pricing and research dissemination. SSRN. December 22, 2024. http://dx.doi.org/10.2139/ssrn.4691124 .
Perlis RH, Christakis DA, Bressler NM, Öngür D, Kendall-Taylor J, et al. Artificial intelligence in peer review. JAMA. 2025;334(17). https://doi.org/10.1001/jama.2025.15827 .
Ebadi S, Nejadghanbar H, Salman A.R. Khosravi H. Exploring the impact of generative AI on peer review: insights from journal reviewers. J Acad Ethics. 2025;23:1383–1397. https://doi.org/10.1007/s10805-025-09604-4 .
Smith R. The trouble with medical journals. J R Soc Med. 2006;99(3):115–119. https://doi.org/10.1258/jrsm.99.3.115 .