Inside the Black Box: Medical Decision Making

mdmMedical Decision Making (MDM) is a peer-reviewed journal published 8 times a year offering rigorous and systematic approaches to decision making that are designed to improve the health and clinical care of individuals and to assist with health policy development. MDM presents theoretical, statistical, and modeling techniques and methods from disciplines including decision psychology, health economics, clinical epidemiology, and evidence synthesis. Editor-in-Chief Alan Schwartz gives us his insights into this journal.

What makes you go “Wow!” or “Yuck!” when first read a submission?

  1. “What’s new?” – What will I learn from this paper that I didn’t know before?  A paper presenting an original approach to a problem, or an extension of past approaches, or a first replication of a previously unreplicated finding is exciting to read. At Medical Decision Making, what’s new is usually a new method for studying or improving decisions, but sometimes it’s an exemplary application of prior methods. (Of course, some journals, like PLOS One, have explicitly chosen not to use this criterion).
  2. “What’s true?” – How do I know that I can rely on the results? Are the methods rigorous, sound, and appropriate for the question? Did the authors interpret their findings appropriately, without overgeneralizing?
  3. “So what?” – Why was this study proposed in the first place? What motivates the research question, and is it an important question in the context of the field and our currrent knowledge?
  4. “Who cares?” – Is this paper right for the readers of my journal, or does it belong somewhere else? A straightforward clinical trial comparing two drugs — or a basic psychology study of non-medical decision — probably doesn’t belong at Medical Decision Making.

What are the common mistakes people make when submitting/publishing? 

My top three:

  • Failing to motivate the research question or ground it in a theoretical or conceptual framework. Theory is important.
  • Overstating the conclusions and ignoring limitations.   Your paper doesn’t have to be the final word or solve every problem.
  • Sending to the wrong journal (violating the “who cares?” principle)

What are your best tips on how to successfully get published? Be open to feedback. Before you send a paper out, it should be the best paper you can write, so you should have had friends and mentors read and criticize it. If you can anticipate issues that a critic might raise, address those forthrightly. When you receive reviews, pay attention to them. If you don’t understand something a reviewer says, don’t ignore it — ask the editor for guidance.

How are reviewers selected? At Medical Decision Making, as at many journals, we have experienced reviewers on our editorial board and in our reviewer database. We find new reviewers through suggestions from authors (yes, you may suggest potential reviewers, and yes, we will often invite at least one of your suggestions if we agree that they really have specific content expertise) and through looking at the paper’s citations and related literature ourselves and seeing who else is working in the same area.

Our goal is to ask for reviews from experts whose reviews not only advise the editor on the disposition decision but are valuable to the authors, whether or not we publish the paper.  We’re fortunate at MDM to have really outstanding reviewers, and many first-time authors comment on how helpful the reviews have been.  We also score our reviews, and reviewers who do a poor job tend to get selected against in the future.

How can a young researcher become a reviewer? When is the best time during one’s PhD to start doing so? I’m a big proponent of reviewing both papers and grant applications; I think you learn a lot from reading very good (and sometimes poor) writing, and from comparing your review with those of the paper’s other reviewers and the editor (at MDM, we cc our decision letters to the reviewers). One good way for PhD students to get some experience with this is to do a “mentored review” with their advisor when their advisor is asked to review a paper. Many journals will allow the invited reviewer to share the review with a student as long as the invited reviewer supervises and takes responsibility for the review. Post-PhD, as a postdoc or junior faculty, if you haven’t already been asked to review for a journal that you’d like to, you can often contact the editorial office and ask to be added to the reviewer database. Of course, submitting a paper to the journal and filling out your author profile with a good set of keywords for your expertise is also likely to lead to reviews in the future.

What constitutes a good (i.e., well explained/written) review, from an editor’s standpoint? Or what makes one a good reviewer? This is a matter of editorial taste, but I really like to see a review that begins by looking at the big questions and pointing out the strengths of the manuscript (or at least of what the authors hoped to achieve through the study), and then moves on to detailed constructive criticism about methods, and presentation and interpretation of results. The review should conclude with minor concerns or suggestions for improving the writing.

Some little things that are very helpful: Number the points in the review to make it easier for the author to respond point by point. Refer to parts of the manuscript by page number and line number to help the author locate exactly what you’re asking about. Make it clear to the author when you’re making a suggestion (e.g. please describe the factor rotation strategy in more detail) and when you’re asking a (non-rhetorical) question (e.g. why did you expect patients to be more influenced by attribute range than attribute context?)  Don’t say (in the
comments to the author) whether the paper should be rejected or accepted – that’s the editor’s job. Definitely don’t recommend rejection privately to the editor and then write a wholly positive review for the author.

How do you resolve conflicts when reviewers disagree? Reviewers advise; editors decide. I’ll admit to a little bias: when good reviewers disagree, I think that means there’s something important to work out, and I’ll usually ask the author to help the reader understand both perspectives and how the author chose to resolve them. There isn’t a single right way to study something.  On rare occasions, reviewer disagreement lends itself to inviting one or both reviewers to write an editorial about the study, if we’ve decide to publish it.

What’s the best/worst way to react to a revise and resubmit, and worse, to a rejection? A revise and resubmit is a positive signal, especially from a paper journal that has a limited page budget. It usually means that the editor thinks there’s something important in the paper to make it worth spending more editorial and reviewer time on, and that you’re capable of addressing the reviewer concerns. So that’s easy – always resubmit, and always include a cover letter addressing each point made by each reviewer. That can mean explaining why you didn’t choose to make a suggested change, but pick your battles: a wholly unresponsive revision is not going to go very far with the editor.

Medical Decision Making also has a category of initial decision called “reject and resubmit”. This means that the editor doesn’t want the paper or a revision of it, but thinks there might be a different, related paper you could write that would be competitive. The new paper gets the full peer review treatment, usually with different reviewers.

A flat rejection – well, when I get those, I usually shake my fist at the sky, eat a piece of chocolate, and get a good night’s sleep. Then I see what useful information I can get from the reviews and improve the paper to send it elsewhere. Uncertainty is a fundamental
fact of life.

The worst way to react to a rejection is to send a nasty email to the editor-in-chief to try to bully him into reconsidering the decision and to threaten that you will never send your priceless work to that journal again. Yes, that happens (especially early in my term).
We have an appeals process if it’s clear that a reviewer or editor deeply misunderstood something, but that’s not it.

Is there a paper you were sceptical about but turned out to be an important one?I think I’m still too early in my editorship to know. In about 3 years, though, I’d be interested in looking at that — collecting the top 10 important papers we’ve published based on reader response and looking back at my notes to see how many of those I only assigned to an associate editor reluctantly.

As an editor, you get to read many papers and have an insight emerging trends, what are the emerging trends in research topics/methodologies? That’s one of the best parts of the job. Right now, MDM is publishing a lot of innovative work in simulation models and value of information analysis methods. Approaches to utility models are emerging in which econometric and behavioral research are triangulating on phenomena that call into question some longstanding simple assumptions of health state valuation — for example, that the proper unit on which to assess utility is the individual decision maker. And there’s a lot more interest in dual process theory and decision psychology/behavior economics manipulations of the decision environment in order to understand and improve health decisions.

What are the biggest challenges for journals today? There’s a great debate going on right now about open access models for science journals and how publishers do or don’t contribute to science, but in some ways, I think that’s just the opening act for a larger discussion of the value of an expert peer review process vs. open publishing and crowdsourced reviewing. I want to see good science clearly communicated, and journals need to demonstrate to their readers that they are promoting those ideals.

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