The Hidden Labor Crisis Behind Peer Review in Academic Medicine

Peer review has long been described as the cornerstone of scientific publishing, the quiet mechanism that separates rigorous evidence from wishful thinking. Yet a new perspective piece in the Journal of General Internal Medicine argues that this cornerstone is resting on a surprisingly narrow foundation. Emma M. Tillman, a Research Associate Professor in the Division of Clinical Pharmacology at Indiana University School of Medicine and a scientific editor at the journal Pharmacotherapy, examines the growing burden of peer review from an unusual vantage point: that of a mid-career clinician-scientist who sits on both sides of the editorial desk. Her analysis suggests that the system sustaining scientific quality depends on the voluntary, largely invisible labor of a small fraction of the academic workforce, and that this imbalance may be quietly reshaping how quickly medical knowledge reaches patients.

The numbers behind the imbalance are striking. Estimates cited in the commentary suggest that roughly 20 percent of reviewers complete as many as 70 to 90 percent of all peer reviews in the biomedical literature. That concentration means a subset of highly productive investigators receives a disproportionate share of review invitations, while a large portion of the scientific community contributes little or nothing to the process. For clinician-scientists, the burden is compounded by the structure of academic medicine itself. Peer review competes directly with protected research time, clinical productivity expectations, teaching responsibilities, and administrative duties. Unlike publications, grants, or clinical revenue, it rarely receives formal recognition in promotion decisions, annual evaluations, or workload allocation, creating what Tillman describes as a misalignment between what institutions depend on and what they actually reward.

Tillman’s own experience illustrates how quickly the workload escalates. Over the past five years she has authored approximately ten peer-reviewed publications annually, and as her output grew, so did the invitations. She recounts accepting one review invitation in the evening only to find three additional requests waiting the following morning. Many invitations fall outside her expertise and are easy to decline, but many align closely with her published research. Increasingly, she notes, the decision to accept or decline rests not on expertise alone but on time constraints, competing priorities, and the perceived prestige of the journal, a dynamic that introduces an element of arbitrariness into participation even among researchers who strongly believe in the importance of peer review.

The editorial side of the process reveals a parallel crisis. Studies of editorial databases suggest that editors frequently must invite six to ten potential reviewers to secure the two or three who agree to participate, with acceptance rates typically ranging from 30 to 60 percent. Tillman reports that in some instances she has sent more than 30 invitations before securing the two reviewers needed to complete a review. Each declined or unanswered invitation represents additional time spent identifying, contacting, and waiting for alternatives, often in parallel across multiple manuscripts. The cumulative effect is a system in which delays stem not from any single failure but from small inefficiencies repeated across thousands of submissions, slowing editorial decisions and postponing the dissemination of clinically relevant findings.

Interestingly, the empirical picture is more nuanced than the widespread perception of decline. While editors consistently report growing difficulty recruiting reviewers, some analyses suggest that overall participation in peer review may be more stable than commonly assumed. The real problem, the commentary argues, is structural rather than behavioral. Editors identify potential reviewers primarily through recent publications and reviewer recommendation systems, which means the same researchers who publish most actively are also those most frequently asked to review. Over time this creates a self-reinforcing loop: those who review more become more visible and are invited again, while colleagues who participate less remain outside the loop entirely.

The consequences extend beyond editorial inconvenience. When qualified reviewers are scarce, editors may broaden their searches beyond the most obvious experts, sometimes resulting in reviews by individuals whose expertise only partially overlaps with the manuscript or who have limited reviewing experience, potentially affecting the depth and rigor of the evaluation. For clinician-scientists, the strain may be particularly acute. Clinical responsibilities already limit discretionary time, yet their combined clinical and research expertise makes them among the most sought-after reviewers. Although the specific contribution of peer review to burnout has not been well studied, Tillman notes that adding another uncompensated scholarly responsibility to an already demanding workload may reasonably contribute to work-related stress, particularly given the documented associations between physician burnout and the quality of patient care.

What makes the situation paradoxical is that peer review offers genuine professional benefits that are difficult to quantify. Reviewing manuscripts exposes faculty to emerging science before publication, sharpens critical appraisal skills, broadens methodological expertise, and can improve their own scientific writing. For many reviewers, these intrinsic rewards, along with a sense of reciprocity toward a system from which they have benefited, are the primary motivation for continuing to participate. But reciprocity raises its own question: how much reviewing constitutes a fair contribution? Informal norms, such as completing two to three reviews for every manuscript one publishes, remain anecdotal and inconsistently applied. There is currently little empirical guidance about what a reasonable reviewing workload looks like across disciplines, career stages, and faculty roles.

Tillman argues that the sustainability of peer review should be reframed as a workforce challenge for academic medicine rather than a purely editorial problem. She outlines a combination of cultural, structural, and procedural changes that could help. Institutions could formally recognize peer review as scholarly service, documenting it in annual evaluations, promotion decisions, and workload allocation, and could provide protected time for reviewing rather than treating it as work completed after hours. Formal peer-review training and mentorship, including co-reviewing with experienced mentors, could expand the reviewer pool while improving quality. Journals could offer nonfinancial incentives such as continuing medical education credit, society membership discounts, or acknowledgment programs, and reviewers who decline could be encouraged to recommend qualified alternatives, helping editors fill slots more efficiently.

None of these strategies alone will resolve reviewer burden, and the commentary is explicit that the goal is not to persuade already overextended faculty to accept more invitations. Instead, the aim is a system in which responsibilities are more broadly shared, appropriately recognized, and better supported by journals and institutions alike. Journals depend on timely, thoughtful reviews; institutions depend on rigorous peer review to evaluate scholarship; and faculty depend on a system that is both sustainable and equitable. Better aligning these shared interests, Tillman suggests, may distribute the workload more fairly while preserving the quality and integrity of scientific publishing.

Her personal conclusion offers a practical ethic for individual researchers. Early in her career she felt obligated to accept nearly every invitation within her expertise; today she intentionally limits her reviewing to manuscripts for which she has both the expertise and sufficient time to deliver the kind of review she would hope to receive as an author. A prompt decline, she argues, is itself a professional courtesy that frees editors to find alternatives quickly, and saying no is not a failure of scholarly citizenship, whereas saying yes to more reviews than one can complete well may be. Until institutions and journals build clearer expectations, most faculty will continue opening their inboxes each morning, quietly weighing whether to accept or decline, decisions that collectively sustain, and strain, the entire apparatus of scientific trust.

Subject of Research: Peer review workload, recognition, and sustainability in academic medicine

Article Title: How Much Peer Review Is Enough? Rethinking Scholarly Service in Academic Medicine

Article References: Tillman, E. M. (2026). How Much Peer Review Is Enough? Rethinking Scholarly Service in Academic Medicine. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10875-9

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10875-9

Keywords: peer review, academic medicine, clinician-scientists, scholarly publishing, workforce, faculty promotion, reviewer recruitment, burnout, journal editing, scientific integrity, workload recognition, Indiana University