Two publication methods, publish-ahead-of-print (PAP) and preprints, are now routinely being used to make case reports and research claims visible to clinicians, journalists, and policymakers prior to formal publication in a journal issue and, in the case of preprints, before peer review. These publication modalities can significantly decrease the time between manuscript completion and availability to readers, a feature that is especially consequential in high-stakes, time-sensitive clinical environments such as emergency care. Their growing use in publication raises questions about research quality and data interpretation, the strength of recommendations from cases of note, and the equity of access to manuscripts. WHAT ARE PREPRINTS AND PAP Preprints are manuscripts posted to public servers prior to peer review. They are increasingly indexed and discoverable alongside peer-reviewed literature, making them easy for clinicians and patients to find, but are often indistinguishable in appearance from final peer-reviewed journal articles to most readers (Fleerackers, Ratcliff, Wicke, King, Jensen, 2025). PAP articles are manuscripts that have completed peer review and been accepted, assigned a DOI, and placed online prior to formal pagination and issue assembly (Advanced Emergency Nursing Journal, 2025). They are citable scholarly literature, sometimes later copyedited or corrected when the formatted version goes live. Although PAP and preprints are sometimes confused as being the same, the difference is critical; a preprint is public but not yet vetted and PAP is vetted but not yet final. WHY THIS MATTERS When early data or results leak into professional rumor channels, social media, or mass media, and then become part of bedside decisions or hospital memos, our patients can feel effects of inaccurate or weak findings. Because emergency care protocols and decisions (e.g., time-critical reperfusion policies, sepsis bundles, and trauma algorithms) are periodically rewritten and updated on the basis of new evidence, the publication of early-stage findings in preprint form can have a downstream influence on bedside decision-making, institutional policy, and public communication before those findings have been through the peer review process and vetted (Fleerackers et al., 2025). The COVID-19 pandemic made this visible at scale where policies and protocols were repeatedly updated based on data made available in preprint manuscripts and PAP articles (Singh Chawla, 2024). The emergency setting also shares information faster than other specialties. Entire practice pathways (e.g., PE workup, sepsis bundles, and stroke large-vessel protocols) have turned instantly on evidence published from preprint and PAP publications. STRENGTHS AND WEAKNESSES OF PREPRINTS Preprints maximize speed, access, and early feedback and break the barrier to manuscripts being read due to paywalls. On the contrary, they allow null or negative results to be shared and enable early critique before errors become permanent in the literature (COPE Council, 2018). The trade-off is that their public availability allows unvetted claims to circulate with the same visual appearance of vetted scholarship. Downstream practice, policy, or public belief can move on the basis of provisional and low-quality evidence and recommendations and have negative consequences on patient outcomes (Fleerackers et al., 2025). STRENGTHS AND WEAKNESSES OF PAP PAP shortens the gap between acceptance of the manuscript for publication and availability to readers. For authors, PAP establishes priority and citability. For clinicians and educators, it enables timely availability of peer-reviewed findings. The risks are subtle in that PAP versions sometimes differ from the final version after copyediting or corrections, producing two “live” versions of record. Media outlets and secondary writers of white papers, memos, and guidelines can incorrectly treat “accepted” as “final.” The distinction can become invisible once the PDF travels electronically. ETHICS AND EQUITY OF PREPRINTS AND PAP A provocative preprint can move through Twitter, professional networks, and unit huddles long before anyone has reviewed the manuscript for accuracy. Once ideas enter practice space, they are hard to retract (COPE Council, 2018). None of this is happening in a neutral incentive environment. Authors are pushed to show work early and funders and academic institutions sometimes require it. Major grant funders normalize preprint and many clinical journals now allow or encourage it while PAP is becoming the standard in high-throughput journals. Also, the media rewards novelty, not peer-reviewed recommendations. Those pressures encourage fast publication and not waiting for certainty, meaning the system naturally oversupplies speed and under-supplies accuracy, and patients inherit the consequences. Equity arguments cut both ways. Preprints remove paywalls and let more people see science early, which is good. But they also amplify whoever already has reach and public credibility, which can shift attention away from merit. In other words, speed is not automatically good or bad; its ethical conundrum depends on how clearly we mark the grade of the evidence and what we do with it. The likely destination of preprints and PAP is not prohibition but structured transparency with accurate and persistent labeling of evidence quality, active links between versions, and social norms around how clinicians treat manuscripts that have not been vetted. IMPLICATIONS FOR AUTHORS AND READERS When citing Explicitly state in-text when a citation is based on a preprint. Avoid using preprints as sole basis for practice recommendations. When citing preprint or PAP, consider noting “preprint” or “PAP” on first mention if the distinction is salient to interpretation (International Committee of Medical Journal Editors, n.d.). When reading Triage preprints and ask questions early. (a) Does this claim, if acted on wrongly, have an irreversible downside? (b) Is the effect size implausibly large for the domain? (c) Is the design aligned with the claim or is it an inference masquerading as a practice claim? When sharing If posting a preprint to a repository, include a plain-language practice disclaimer in the abstract or cover note (e.g., “Not peer-reviewed; do not use for clinical decisions”). When the peer-reviewed version is published, update the preprint with a link to the vetted version. For editors and reviewers Require disclosure of preprints prior to considering the manuscript for publication (COPE, 2018). Preprints and PAP are here to stay, and they move ideas into circulation fast. That speed helps in time-critical settings, but it also means unproven claims can shape practice, protocols, and headlines before anyone has reviewed them for accuracy. The right answer is not to slow everything down but to be transparent about what stage the evidence is in when we use it. Label it clearly, treat preprints as provisional, and resist turning early findings and recommendations into policy and protocol. We already know how to do this at the bedside. When we consent a patient for a procedure, we discuss what we do and don’t know. By disclosing uncertainty, we can do the same thing with new evidence from preprint manuscripts and PAP articles before we let it shape our practice or our teaching. —Wesley D. Davis, DNP, ENP-C, FNP-C, AGACNP-BC, CEN, FAANP, FAEN, FAANFamily & Emergency Nurse Practitioner Program Coordinator & Associate Professor College of Nursing University of South Alabama, Mobile, Alabama
Wesley D. Davis (Thu,) studied this question.