The inside view on writing for medical journals Richard Smith


The inside view on writing for medical journals Richard Smith
The inside view on
writing for medical
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
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”
Career advancement
To entertain/divert/amuse
To educate
To console
What do editors want?
Excitement/ “wow”
Relevance to the audience
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 (AA beginning, a
muddle, and an [email protected] Philip Larkin)
• Tell people what you are going to say, say it,
tell them what you=ve said
• Rudyard Kipling: (AI 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
• 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
• Describe how subjects were selected and
• Don=t describe standard methods in detail - use
• 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
• 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: AGood prose is like a
window [email protected]
• Somerset Maugham: ATo write well is as
hard as to be [email protected]
• Jonathan Swift: AProper words in proper
places make the true definition of [email protected]
• Matthew Arnold: AHave something to say
and say it as clearly as you can. That is the
essence of [email protected]
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
• 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 Anot unblack cat crossed
the not unwide [email protected]
• 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
AToo many notes, [email protected]
• 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
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
• “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
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
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
• D. Sir Bloated Corpulent, visiting consultant.
Allowed his staff to be entered haphazardly into the
• 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
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
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 Afame and the love of
beautiful [email protected]
• 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
• The two basic problems of credit and
• Many authors on papers have done little - do
not meet ICMJE criteria
• Gift authorship
• People don=t know about the criteria of
• 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
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
Views of authors with financial relationships with the
pharmaceutical industry on whether calcium-channel
antagonists are safe
N = 24
P value
for trend
Calcium channel
Competing product
Two thirds of authors contacted had a financial conflict of
interest, but the conflict was declared in only 2 of 70 articles.
How should we manage conflict of
• 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
Aconflict of [email protected] to [email protected] or
[email protected] interests?
The best policy on competing
• 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
COPE guidelines on good publication
practice cover
Study design and ethical approval
Data analysis
Conflicts of interest
Peer review
Redundant publication
Duties of editors
Media relations
Dealing with misconduct, including sanctions
Last advice
• Disclosure is almost a panacea.
John Bailar, professor of statistics,
University of Chicago