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The conventional reviewing system of American biomedical journals determines where and when an author may publish, and hence may affect his career. Yet the system's effectiveness in validating reports, or the cost of such validation, has been little studied. Problems are inadequate review, unrealistic editorial expectation of what reviewers can do, and bias. Expert reviewers frequently disagree. Thus concurrence between two reviewers of each of some 500 papers submitted to the New England Journal of Medicine was only moderately better than a chance result. Costs of the reviewing system include time and effort involved, the possible violation of confidentiality, and occasional suppression of the novel advance. Despite deficiencies, the reviewing system is important to maintain standards. It could be improved if studies of its operation were carried out, if reviewers were better indoctrinated, if the work load of reviewers were lessened, if reviews were signed, and if the reviewing process were more rewarding to reviewers.