HOW TO WRITE A PAPER FOR PUBLICATION

Communication of research results through publication in a scholarly journal is an essential and intrinsic component of science. As researchers and anaesthesiologists we need to communicate not only to peers but also to laypersons and media. Thus there arises a need to be more proficient in the field of communication. Written communication is more difficult to learn, more factual and archival. The ultimate proof that one has arrived in the field of science lies in ones success in written communication. Writing a paper may seem like a daunting process for the inexperienced researcher (and sometimes for those who are experienced!). However, this does not need to be the case if the approach is logical and systematic. 1 The quality of paper often depends on the planning that goes in before the paper is actually written.

HOW TO START? THINK AND PONDER FIRST!! Is the paper worth writing? What do I have to say? Is it worth saying? What is the audience for the message? What is the right format for the message? Where should I publish the message? What are the requirements so that my paper is published?

What do I have to say, Is it worth saying?

When planning to write any paper, the first question that must be asked is Is this study of sufficient interest to the profession, that it warrants writing a paper? Why am I writing? The honest answer may be that a paper is required for reasons to do with career advancement. The more usual responses are that you have interesting results to share with others and/or that research is original and 1

not reported as yet. These pertinent questions need to be addressed first, to enable the editor to establish four main following facts:2 Is the science accurate? Is the material new and will it have any impact on clinical practice or add substantially to current knowledge? Is the message appropriate for the readership of that journal? Has the manuscript been prepared carefully or will major revisions be required to bring it up to the standards required? Some research that is done out of necessity (i.e. student projects) can never be original and this question should be asked at the outset, before much time and effort is spent writing an article that is not likely to be accepted for publication.

What is the audience for the message?

Are you writing for your peers and fellow experts in a narrow specialty who will instantly recognize the problem you have looked at and understand the technical language, or for a less expert reader, who will need assistance? Not being clear about the audience is probably the most common error, and specialists regularly write for generalists in a way that is entirely inaccessible.

Where should I publish the message? Choice of journal

The next question to be asked is Where do I wish this paper to be published? In the current climate of research assessment exercise, ideally, the chosen journal should have the maximum impact factor and citation index. Tables of these can be obtained from most libraries and also on the Internet. However, it must also be considered whether the paper you intend to write is appropriate to the style of that journal. For example, is the paper clinical or basic science oriented, and which type of paper does that journal prefer? Once a decision has been made, obtain a copy of the guidelines for authors straight away so as to start writing the paper in the correct format and not waste time altering everything at the end. This can save a great deal of time and effort. Be careful to adhere to these guidelines, as your paper may not reach the referees at all.

What is the right format for the message?

The foremost element is to decide on the most crucial message of your paper. This crucial message forms the basis of the type of format. With an increased emphasis on randomized, controlled clinical trials, there has been a definite shift away from case reports and this is how I do it . . . publications. These types of

article are still welcomed by some journals, but it is advisable to check their policy on this first.

PREPARATION OF MANUSCRIPT
In the early 20th Century, Scientific papers were written in singular form & loosely structured. In 1950 - 1960s increased publication of papers lead to the need for uniformity & standardization. A small group of editors of general medical journals met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the National Library of Medicine, were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Uniform Requirements primarily to help authors and editors in their mutual task of creating and distributing accurate, clear, easily accessible reports of biomedical studies. The ICMJE gradually has broadened its concerns to include ethical principles related to publication in biomedical journals. The ICJME has produced multiple editions of the Uniform Requirements for Manuscripts submitted to biomedical journals.3 The most significant and successful attempt towards standardization and uniformity was made by Sir Bradford Hill, a British Statistician who introduced the IMRAD Format in 1965.3 It is a standard structured format for writing the text of original research, which enhances comprehension, and clarity of manuscript with no repetition. IMRAD format is accepted and recommended by ICMJE & most international scientific journals. Thus, the generally accepted structure of a scientific paper has the following four sections :

Introduction..Why did you start? Methods.What did you do? ResultsWhat did you find? Andand DiscussionWhat does it all mean?
This so-called IMRAD format though being the chief guide to structure papers, has a few limitations. For someone writing up research data for the first time, it is far from complete IMRAD does not say anything about a papers title, authorship, or summary. The conclusion, acknowledgments section, and references are neglected too. Another acronym TAS IMRAD CAR, though will never achieve IMRADs fame, but can guide a young writer into all the components of the paper. TAS IMRAD 3

CAR: T - title, A Authorship, S Summary/ Abstract, IMRAD, C Conclusion, A Acknowledgements, R References. Add a key i.e., Key words. As a supplement to IMRAD, research-workers could also bear in mind the six honest serving-men of the poet Rudyard Kipling. These writers servants are called What, Why, When, How, Where, and Who, and they can be applied to all parts of the paper from its title down to the tables.4

GENERAL PRINCIPLES
Writing style Each author will develop his or her own writing style, but the important issue is that it should be clear and easy to read. This means avoiding jargon and repetition of material in tables, figures and text. Beware of the pitfalls of plagiarism and never resort to salami submissions. Spelling and grammar There is no excuse for poor grammar or spelling with the advent of grammar and spell checks on most computers. The choice of English or American spelling will depend on where the journal is published. The use of abbreviations is accepted by some journals, but not by others and some specify that only internationally standardized abbreviations be used. If you are not certain, check through past copies of the journal to ensure what their policy is. When using abbreviations, always write out the word(s) in full on first mention, even if you think it is an established abbreviation. Abbreviations are acceptable for units of measurement and also in tables where space may be limited, in which case they should be explained underneath the table. Use of numbers Apart from those accompanying measurements, numbers under 10 should always be spelt out in full, while those of 10 and above can be presented as figures. When both occur in a single sentence, they should both be expressed in figures.5 It is also worth remembering that a sentence should never be started with numbers. Duplicate submission Authors need to refrain from submitting a manuscript simultaneously to many journals. Any manuscript can be submitted only to one journal at any given time. This is a form of serious author misconduct and call for punitive action from the editor. Remember to follow ethical principles in writing scientific papers.

A SYSTEMATIC APPROACH ALWAYS HELPS! Structure & uniformity is everything (Remember I M R A D)

First List the Components of the paper in the order of submission to the journal Title Authors Abstract Key words Introduction (usually concluding with Aims of the study) Materials and methods Results Discussion Conclusions Acknowledgements References Tables / Graphs / Illustrations It is important to pay special attention to what readers are most likely to look at, e.g. the title, abstract, tables and figures. The title and abstract are often the only part that is accessible electronically, therefore should be subject to the same level of critique as the rest of the paper.6It is usually worth leaving the abstract and title until the main body of the paper has been written, as it is then easier to write.

Title
Read the journal and familiarise yourself with its approach to titles. Authors should include all information in the title that will make electronic retrieval of the article both sensitive and specific. It is sensible to ensure that keywords are in the title. Some journals will ask you to provide keywords on the title page of your paper. Avoid attempts at clever or witty titles, and do not use abbreviations in titles.

Authorship

This has become a serious question, especially in medical journals. According to the International Committee of Medical Journal Editors (ICMJE) 3 all persons designated as authors should have participated sufficiently in the work and should be able to own public & intellectual responsibility for its contents. All authors should have seen and approved the final version as submitted for publication. Deciding on authorship before the study begins is a good idea though in a study that takes years to complete, the research team may change significantly. It should be decided at the outset, which roles qualify as author, corresponding author or qualify as acknowledgments.

Abstract
It is best to write the abstract after completing a draft of your scientific paper. The abstract should provide the context or background for the study and should state the study's purposes, basic procedures (selection of study subjects or laboratory animals, observational and analytical methods), main findings, and principal conclusions. It should emphasize new and important aspects of the study or observations. Remember that abstract contains no references. Many journals now request that the abstract be structured. Even if the journal does not specify this, it is a useful way of writing an abstract, as it is easy for the reader to see your findings. Because abstracts are the only substantive portion of the article indexed in many electronic databases, and the only portion many readers read, authors need to be careful that abstracts reflect the content of the article accurately.

Key Words
Use only 3 to 10 key words or short phrases that capture the main topics of the article. These will assist indexers in cross-indexing the article and may be published with the abstract. Terms from the Medical Subject Headings (MeSH) list of Index Medicus should be used; if suitable MeSH terms are not yet available for recently introduced terms, present terms may be used.

Introduction (Why did you start?)

Introductions should be short and arresting, and they should tell the reader why you have undertaken the study. The introduction is what motivates the audience to read a paper and the first sentence is particularly important. The introduction should be concise and include the key papers in that field of research.

Introduction should provide a context or background for the study (i.e., the nature of the problem and its significance). State the specific purpose or research objective, or hypothesis tested by the study. The research objective is often more sharply focused when stated as a question. Immediately prior to submitting the paper, do a last minute literature search just to ensure there are no very recent publications that warrant inclusion. Failure to include the most up-to-date publication that happens to be by the person refereeing your paper is certain to put them in a bad mood. Avoid the mistake of including the conclusion of the article in the introduction. End this section of your paper with a clear statement of the hypothesis your study set out to test.

Material and Methods

The methodology is Kiplings How? Or what did you do? This section should be written in great detail of what was done giving a sufficiently clear overview, so that others could reproduce the study. The guiding principle should be clarity about how and why a study was done in a particular way. Strike a balance between brevity and completeness, but the reader must be able to assess the following:7

What type of study was performed? (i.e. was it a randomized controlled clinical trial or was it a . . . ? How was randomization done etc?) How many subjects (or samples) were included? Who were the subjects? Where did the subjects come from? What were the inclusion and exclusion criteria? What intervention (if any) was offered? How long was the follow-up (if relevant)? What was the response rate (for surveys/questionnaires)? What outcomes were measured and how? What statistical tests were used?

Always start this section stating that ethical approval was granted by the ethics and scientific review committee of the institution and informed patient consent was taken adequately.8 Ethical issues are of vital importance in todays research climate and it is important to acknowledge that this has been treated seriously. If the method is complex it may be worth considering the use of a figure or flow diagram to clarify a situation. Appendices may be used if necessary, for example, to provide details of a particular analysis. It is also important to avoid confusing the reader by having the same thing called by several different names, so pay attention to how you name things that appear repeatedly in the text. Included within this section is the statistical analysis. A separate section for statistical methods is common nowadays. It is of paramount importance to obtain statistical advice before the research begins rather than after the data has been collected. Sample size and power are important issues, with journals increasingly expecting evidence that a sample size calculation was undertaken using, for

example, Altmans nomogram9 or one of the computerized packages. The other area that has become important in recent years is the use of Confidence Intervals, with many journals preferring these to the use of the standard deviation.

Results

The fool collects facts, the wise selects them

What did you find? Results are the Core of the paper. The results should be presented in a clear, accurate and concise format. There should be no redundancy so stick to what is relevant. Be sure to include basic descriptive data. The text should tell the story and the tables give the evidence while the figures illustrate the highlights. Present your results in logical sequence in the text, tables, and illustrations, giving the main or most important findings first. Do not repeat in the text all the data given in the tables or illustrations; emphasize or summarize only important observations. A question that is often asked is whether data should be put in tables or presented in the text. In general, if there are only a few factors to be considered they may be better presented in the text. Otherwise, try to present data in tables or figures for clarity. However, one point worth stressing is to avoid including tables with large amounts of data, as readers will find it very difficult to read. It is worthwhile considering presenting data as a graph, rather than a table, as graphical representation is often easier to follow. All tables and figures should be comprehensible without the need to refer to the text, the titles should be selfexplanatory i.e., each table should have the ability to stand-alone. They should always be referred to at the appropriate point in the text. Give a brief title and a footnote at the bottom of the table containing explanatory matter & explain all nonstandard abbreviations An illustration especially photographs, line drawings and cephalometric tracings, should be of good quality, professionally drawn & photographed or photographic quality digital prints. Electronic files of figures are preferably formatted in JPEG/GIF. Pathology specimens, X-rays, scan, radiology material should be in sharp, glossy, colored or black and white prints (5x7 inches or as per specifications of the particular journal). Tables and figures are visual elements and are the best way to communicate your findings, as readers frequently focus on these aspects of the publication. If photographs of patients are used written permission for publication should always be obtained as per the Helsinki Declaration.8 Avoid non-technical uses of technical terms in statistics, such as "random" (which implies a randomizing device), "normal," "significant," "correlations," and "sample." Do not interpret your results in this section. That comes next!

Discussion (What does it all mean?)

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The key questions here are a What and a How and a Where though you may not be able to answer them in only three paragraphs. What were the strengths and weaknesses of your own study? Then how do your findings fit in with work published by others? Finally, Where is this line of research going next? 1 This is when you face the challenge of deciding whether your original hypothesis is still standing. The discussion aims to summarize your work and put it into perspective. In the era of evidence-based medicine, this section should include the interpretation of results within the available body of systematically collected & evaluated knowledge. It is important to acknowledge potential limitations of the study no article is perfect, but equally these limitations should not be ignored. Always remember to comment on the clinical significance of your findings.

Do not repeat in detail data or other material given in the Introduction or the Results section. Common mistakes include citing as first study in the world (Megalomania), emphasizing the strengths of the study more than its weaknesses, reiterating & inflating selected results, going beyond the evidence & drawing unjustified conclusions.

Conclusions
The concluding paragraphs of 2-3 lines mentioning the principal findings & their relevance makes up the conclusion of the study. Link it with the aims of the study. It is useful to present these as bullet points as this provides maximum impact. Unjustified conclusions not supported by the data should never be made

Acknowledgments
Who should be thanked? As a general rule those who are paid, need not be acknowledged. Authors should follow ICMJE guidelines in deciding whom to acknowledge.3 All those who have helped in the work at some stage, but have not qualified for authorship may be included here; a) Support from Chief of the department. b) Financial and material help c) Intellectual help, scientific advice, data collection, participation in trial, review of draft, and d) Relationship that might pose a conflict of interest.

References
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The accuracy of the references is the authors responsibility; therefore, check them carefully. Many referees select one or two references at random and check them. If there are inaccuracies in the references, it tends to reflect badly on the paper as a whole. It is also important to make sure that the correct reference style for that journal is used both within the text and the reference list. There are two main types of reference system: Vancouver system: this system uses superscript numerals in the text and the references are in the order in which they appear in the text. Harvard system: this system uses the name of the first author and the date of the paper and the references are then in alphabetical order.

The uniform requirements style (Vancouver System) is based largely on an ANSI standard style adapted by the National Library of Medicine (NLM) for its databases. For samples of reference citation formats, authors should consult (http://www.nlm.nih.gov/sd/uniformrequirements.html/)3

References should be numbered consecutively in the order in which they are first mentioned in the text. Identify references in text, tables, and legends by Arabic numerals in parentheses. References cited only in tables or figure legends should be numbered in accordance with the sequence established by the first identification in the text of the particular table or figure. The titles of journals should be abbreviated according to the style used in Index Medicus. Consult the List of journals Indexed in Index Medicus, published annually as a separate publication by the library and as a list in the January issue of Index Medicus. The list can also be obtained through the library's web site (http://www.nlm.nih.gov/). Journals vary on whether they ask authors to cite electronic references within parentheses in the text or in numbered references following the text. Authors should consult with the journal that they plan to submit their work to. Avoid citing a "personal communication" or cross-referencing from other articles without having read the original paper, remember that you may be committing inaccurate interpretations of previous work to print with your name implicated!

FINAL CHECKS BEFORE AND AFTER SUBMITTING

Useful feedback It is helpful at this stage to ask a colleague(s) to read the paper in order to ensure

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that it reads well and is understandable. In addition, ask someone to look hard for flaws and be constructively critical in the same way that the referees will be. Then, incorporate useful feedback into the next draft of the paper before it is sent off. Always make sure you keep previous drafts of the manuscript on your computer in case you need them later.

The finished product and final checks When the paper is finished, it is very useful to put it aside for a few days and then re-read it a surprising number of errors may be found! Additional comments can also be added at that stage when you return to the paper refreshed. Always check for consistency, particularly with respect to data and headings, which should be consistent across the text, tables and figures. Also eliminate any clutter, for example, repetitions and jargon. Check carefully for any aspects that may appear ambiguous and amend them accordingly. Prior to sending the manuscript, double check that it is in accordance with the journals instructions. Always send an electronic version (CD/floppy) along with hard copies. The title page should contain all information as per the requirements of that journal. Also, ensure that, if you have used previously published material, you have written permission to reproduce it. If there is any way that individual patients can be identified, then either ensure that you have that individuals written permission or the content of the paper should be modified to protect the patients identity.

Revisions If the paper is returned to you requesting revisions, make sure these are done as quickly as possible. Think very carefully about all aspects that have been raised and discuss the appropriate way to proceed with your coauthors. When the revised manuscript is returned, always include a covering letter detailing your responses to each of the points raised by the referees. It makes it much easier for the editor to assess whether the issues raised have been addressed appropriately.

Checking the proofs When proofs are sent to the authors, they frequently have to be returned very quickly in order to fit in with the publishers schedule. However, even with these time constraints, always check the proofs carefully as this is your responsibility. Areas where errors can frequently occur are data tables and references, so check these carefully. Always keep a copy of the proofs for your own records.

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Rejection If the paper is rejected, it may be that the study had a fundamental flaw (i.e. the sample size was too small or the methodology inappropriate) or it may just be that the paper is inappropriate for that journal. The editors letter will usually give some indication of what applies and whether it is worth submitting elsewhere. Above all, do not be despondent at this stage, act on the referees reports and consider trying again. Making the simple complicated is commonplace; making the complicated simple, awesomely simple, thats creativity. To conclude, it is not enough to do the work, prove your hypothesis, and sit back. For your efforts to be worthwhile, they must be read and evaluated by others, so your skill in communicating your findings is as important as the original work. Writing a paper is an art, acquired by a keen, clear, patient and incisive mind. A well-written paper with the message being conveyed in crisp and brief way can certainly help a good paper find ready acceptance by peers.

REFERENCES:
1. Cunningham SJ. How to write a paper. Journal of Orthodontics, March 2004; 31(1): 47-51. 2. Garfunkel JM, Merrill RE. How to write a scientific paper and get it published. Adolesc Med 1994; 5: 40518 3. Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication. Updated November 2003 Available at www.icmje.org/index.html. 4. Sharp David. Kiplings guide to writing a scientific paper. Croatian Medical Journal 2002; 43(3): 262-67. 5. Nicolaides A, Thornton E. The process of writing a scientific paper. Int Angiol 2000; 19: 18490. 6. International Committee of Medical Journal Editors Welch HG. Preparing manuscripts for submission to medical journals: the paper trail. Effect Clin Pract 1999; 2: 1317.

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7. Greenhalgh T. How to Read a Paper. The Basics of Evidence Based Medicine. London: BMJ Publishing Group, 1997.

8. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2000 Dec 20; 284(23):3043-5. 9. Altman DG. Practical Statistics for Medical Research. London: Chapman Hall/CRC, 1991.

Author: Dr. ANJU GREWAL

Associate Professor and Associate Editor(JOACP), Department of Anaesthesiology and Resuscitation, Dayanand Medical College and Hospital, Ludhiana. E Mail : anjugrewal@yahoo.co.in / dranjugrewal@gmail.com

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