The inside view on writing for medical journals Richard Smith Editor, BMJ

What I might talk about Why publish? What do editors want? The basics of writing a paper The rudiments of style Peer review processes Authorship/contributorship Conflict of interest Redundant publication Good practice in publishing

Why publish? Because you have something important to say To change practice To promote thought or debate To allow examination of your work “Fame and the love of beautiful women” Money Career advancement To entertain/divert/amuse To educate To console

What do editors want? Excitement/ “wow” Importance Originality Relevance to the audience True Clearly written Engagingly written

Utility of information Utility=relevance x validity x interactivity work to access

The basics of writing a paper 1. Before you begin What do I have to say? Is it worth saying? What is the right format for the message? What is the audience for the message? Where should I publish the message? How can I best use paper and the web?

The basics of writing a paper 2. The importance of structure Structure is everything.

The basics of writing a paper 3. Possible structures Beginning, middle, end ( A A beginning, a muddle, and an Philip Larkin) Tell people what you are going to say, say it, tell them what you = ve said Rudyard Kipling: ( A I keep six honest serving me, (They taught me all I knew), Their names are What and Why and When, And How and Where and Who?)

The basics of writing a paper 3. Possible structures continued News story: (Story in the title; story in the first line; expand slightly on the story in the first paragraph; give the evidence for the story; give the counter view) ImraD (Introduction, methods, results, and discussion) Stream of consciousness Chronology: diary, autobiography

The basics of writing a paper 3. Possible structures continued A list Something very formal: for example, sonnet, limerick, haiku Ulysses

The basics of writing a paper 4. Still structure Make sure that readers know where they are, where they are going, and why.

The basics of writing a paper 5. IMRaD Introduction--Why did I do it? Methods--What did I do? Results--What did I find? Discussion-- What might it mean? What is our overall finding? What are the strengths and weaknesses of the study in relation to other studies? Why might we have got different results? What might the study mean, particularly for clinicians or policy makers? What questions remain unanswered and what next?

The basics of writing a paper 5. IMRaD (Introduction) Why did we start? What has gone before - ? A systematic review Why was this study needed? Be sure that readers understand the importance of the study-but don = t overdo it short Don = t try to show readers that you have read everything Short, short, short

The basics of writing a paper 5. IMRaD (Methods) Like a recipe For informed readers this is the most important section Describe how subjects were selected and excluded Don = t describe standard methods in detail - use references Statistics Ethics Remember that you can put more detailed methods on the web--for example, questionnaire

The basics of writing a paper 5. IMRaD (Results) Stick to what is relevant Be sure to include basic descriptive data The text should tell the story The tables give the evidence The figures illustrate the highlights Don = t include just percentages or p values Include confidence intervals Think about absolute risk, number needed to treat, etc Avoid beginning to discuss the implications or strengths and weaknesses of your study

The basics of writing a paper 5. IMRaD (Discussion) Statement of principal findings Strengths and weaknesses of the study Strengths and weaknesses in relation to other studies, discussing particularly any differences in results Meaning of the study: possible mechanisms and implications for clinicians or policymakers Unanswered questions and future research Go easy on the last two

The basics of writing a paper 6. Topping and tailing Title: Include design; Don = t try to be clever Abstract: Must be structured; Include some numbers, not all References: Keep to the essentials Covering letter: Something very crisp Authorship, acknowledgements, competing interests

The rudiments of style George Orwell: A Good prose is like a window Somerset Maugham: A To write well is as hard as to be Jonathan Swift: A Proper words in proper places make the true definition of Matthew Arnold: A Have something to say and say it as clearly as you can. That is the essence of

The rudiments of style I Short words Short sentences Short paragraphs No jargon No abbreviations Prefer Anglo Saxon over the Latin Prefer nouns and verbs to adjectives and adverbs Cut all cliches

The rudiments of style II Avoid figures of speech and idioms Prefer active to passive Prefer the concrete to the abstract Avoid the A not unblack cat crossed the not unwide Don = t hector Be unstuffy

The rudiments of style III Don = t be too chatty Don = t be pleased with yourself Be careful with slang Use the scalpel not the sword A Too many notes, Add a dash of colour, just a dash

Peer review processes As many processes as journals or grant giving bodies No operational definition--usually implies “external review” Was largely unstudied Benefits come from improving what is published rather than sorting the wheat from the chaff

Problems with peer review A lottery A black box “Ineffective” Slow Expensive Biased Easily abused Can’t detect fraud

Peer review processes “Stand at the top of the stairs with a pile of papers and throw them down the stairs. Those that reach the bottom are published.” “Sort the papers into two piles: those to be published and those to be rejected. Then swap them over.”

BMJ peer review process I 6000 papers 1000 rejected by one editor: unoriginal, too specialist, “so what,” invalid, incomprehensible (standard rejection list) 2500 rejected by two editors 2500 sent to one reviewer, who is revealed to the authors Discussed at “minihang” 1000 rejected by reviewer and editors

BMJ peer review process II 200 accepted as short reports after approval by statistician 1500 to one of three “hanging committees” A hanging committee comprises two practitioners/researchers, one statistician, and one editor 300 accepted, almost always after revision

BMJ peer review process III Always willing to consider first appeals-- but must revise the paper, refute criticisms, not just say the subject is important Perhaps 20% accepted on appeal No second appeals; always ends in tears; plenty of other journals

Authorship/contributorship Who is an author? I A totally blind haphazard study of the effect of being a Mason on promotion within medicine A. Professor Sir Joshua Fulloftosh, president of the university. Raised the grant, got permission for the study from the Masons B. Professor Michael Halfpenny, British American Tobacco professor in the joint department of respiratory, Masonic, and imaginary studies. Suggested the idea for the trial before departing for a six month sabbatical in the Seychelles and handled the postpublication media coverage by satellite

Authorship/contributorship Who is an author? II C. Dr Alec Fedup, senior lecturer in the department of Masonic studies. Drew up the protocol, wrote the grant proposal, and then died in mysterious circumstances. D. Sir Bloated Corpulent, visiting consultant. Allowed his staff to be entered haphazardly into the study E. Dr Alice Holditalltogether, senior registrar. Ran the study, collected the data and sent them to the statistician, arranged for the writing up of the study, and negotiated with the editors

Authorship/contributorship Who is an author? III F. Polly Paired-T-Test, statistician. Did all the analysis, prepared the tables G. Pamela Poltergeist, editorial adviser to the Masons. Wrote the paper E. Professor Avaricious Loadsapesetas, director of the Acapulco Institute of International Masonic and Financial Studies. Allowed his name to be added to the paper in exchange for a lucrative consultancy. Unfortunately didn = t have time to read the paper.

Criteria for authorship of the International Committee of Medical Journal Editors Authorship should be based only on a substantial contribution to: i Conception and design or analysis and interpretation of data and ii Drafting the article or revising it critically for important intellectual content and iii Final approval of the version to be published.

Why does authorship matter? I Authorship is about credit and responsibility Academic life revolves around publication - credit comes from publishing, which implies being an author Publication brings A fame and the love of beautiful Research evaluation is based on publication Grants depend on/demand publication

Why does authorship matter? II In some parts of medicine you need publications to get a job You may have a disease named after you - for example, Crohn = s disease Authorship means you are accountable; who is the author of a fraudulent paper? Authors can be sued for libel

What are the problems with authorship? The two basic problems of credit and accountability Many authors on papers have done little - do not meet ICMJE criteria Gift authorship People don = t know about the criteria of authorship People think that the definition is unworkable People are left off papers

Options for responding to the problems of authorship Status quo Loosen up the criteria Enforce the ICMJE criteria more strictly Tweak the ICMJE criteria - for instance, allow statisticians to be included Other ideas--for example, limits on numbers of authors Abandon the idea of authorship - go for film credits, contributors with a guarantor

Competing interest What is conflict of interest? A person has a conflict of interest when he or she has an attribute that is invisible to the reader or editor but which may affect his or her judgement.

Competing interest Why does it matter? Because it may have a profound effect on somebody = s judgement. Because of the perception that a person = s judgement may be affected--whether it is or not

Competing interest: evidence that it matters

How should we manage conflict of interest? Ignore it--unaceptable Avoidance - hard Disclosure - to the editor, author, or reader?

Problems with conflict of interest Should it be just financial or personal, academic, political, religious, anything? People don = t declare it because a) it implies wickedness; b) they are confident that their judgement is not affected Might we avoid these problems by changing A conflict of to A or A interests?

The best policy on competing interest Always declare a conflict of interest, particularly one that would embarrass you if it came out afterwards

Redundant publication I Happens commonly--perhaps 20% of studies Negative studies are often not published; positive studies are more likely be published more than once Distorts what the evidence says

Redundant publication II There is lots of room for arguing over the degree of overlap and what’s legitimate Disclosure is the key Always send copies of overlapping papers and reference them The problem is not the publication but the lack of disclosure

Good publication practice Read “Guidelines on good publication practice” from the Committee on Publication Ethics (COPE) Available free at ethics.org.uk

COPE guidelines on good publication practice cover Study design and ethical approval Data analysis Authorship Conflicts of interest Peer review Redundant publication Plagiarism Duties of editors Media relations Advertising Dealing with misconduct, including sanctions

Last advice Disclosure is almost a panacea. John Bailar, professor of statistics, University of Chicago