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 (AA beginning, a muddle, and an
end.@ 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 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: AGood prose is like a window
pane.@
• Somerset Maugham: ATo write well is as hard as
to be good.@
• Jonathan Swift: AProper words in proper places
make the true definition of style.@
• Matthew Arnold: AHave something to say and
say it as clearly as you can. That is the essence of
style.@
 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 Anot unblack cat crossed the not
unwide road@
• 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, Mozart.@
• 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 Afame and the love of beautiful
women@
• 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
Views of authors with financial relationships with the
pharmaceutical industry on whether calcium-channel
antagonists are safe

Manufacturer Supportive Neutral Critical P value

N = 24 N=15 N=30 for trend
Calcium channel 96 60 37 <0.001
antagonist
Competing product 88 53 37 <0.001
Any 100 67 43 <0.001

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
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 Aconflict of

interest@ to Arelevant@ or Acompeting@ 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 www.publication

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