Journals employ several strategies to artificially raise the impact factor, which initiates a positive feedback loop by incentivizing more scientists to submit to them. Some editors have been caught trying to induce authors to increase the number of citations from their journal to further raise the impact factor. One investigation found that a collaboration of Brazilian journals had agreed to highly cite each other’s articles to fraudulently raise each of the journals’ impact factors.

Critics argue that citations are barely a reflection of the quality of the research and that the impact factor is easily manipulated by taking articles that are more likely to be highly cited or ‘sexy’ than highly meaningful. Reviews of common topics can contain hundreds of references (and authors have been known to cram them with self citations) and are more highly cited than original research articles that may eventually lead to a new discovery or finding. Also, research in controversial areas, such as a study published in Science that demonstrated brain damage by the drug Ecstasy, or the infamous paper published in the Lancet which purported to show a link between vaccines and autism, are more likely to be highly cited because of interest generated in these subjects (both studies were subsequently retracted).

Medical publishing’s growth is actually one of its greatest challenges. With more than half a million papers published annually in biomedicine alone, it is no wonder that physicians are increasingly feeling overwhelmed with the avalanche of information they find themselves facing. The new hubs of publishing are India and China , where new journals are being formed almost daily. My inbox usually receives several invitations a day to join editorial boards of journals I've never heard of, completely unrelated to my specialty.

And all of these journals need to be concerned with maintaining accuracy. The current system of peer-review, which originated in the 18th century, is now stressed. After a journal decides to consider a paper, it is sent to unpaid, anonymous reviewers in the same specialty to review. Physicians are busy and it's difficult for them to be able to effectively analyze a paper for accuracy. The only real upside for the reviewer is the synthetic prestige that comes with being an anonymous reviewer, which may not be enough to muster a consistent and thorough effort. The flaws of the current system were exposed in a sting by a reporter for Science who had a fraudulent and comically bad paper, from a fake alias and institution, accepted in the vast majority of journals he had submitted to without any meaningful review.