Concise Academic Writing

1. Concise Academic Writing Mark I. Langdorf, MD, MHPE, FACEP, FAAEM, RDMSProfessor and ChairUniversity of California, IrvineEditor, Western Journal of Emergency Medicine

2. Choosing a target journal • 35 general and subspecialty journals in EM • 11 indexed in Medline (National Library of Medicine) • most established and prestigious • most discriminating • Rough order: most discriminating to least are: • Most: Annals, Academic • Middle tier: Journal of, American Journal of, Canadian Journal of, European Journal of, Journal of Accident and EM, EM Journal (formerly Journal of Accident and EM) • Lower tier: Internal and EM (Italy), EM Australasia (formerly EM), Journal of Trauma: Injury, Infection and Critical Care

3. 20 Non-Medline EM Journals • Author pays for publication: BMC Emergency Medicine ($1860 if accepted) World Journal of Emergency Surgery ($1665) • Brand new (2007-08): Western Journal of EM International Journal of EM • Electronic only: Internet Journal of EM

4. Emergency Medicine Conventions • Emergency physician (EP) • Emergency department (ED) • Emergency medicine (EM) • Not: emergency room physician, emergency room, emergency medicine physician, ER physician, EM physician or even ED physician • First time use: spell them out, and then, in parentheses, abbreviate • Then use abbreviation throughout paper • Except for tables and figures • Abstract stands alone

5. Rules of the Road • Be brief! • Journal editor wants as much content in as few pages as possible • Strunk and White, 1918, The Elements of Style: • “Vigorous writing is concise. A sentence should contain no unnecessary words, a paragraph no unnecessary sentences, for the same reason that a drawing should have no unnecessary lines and a machine no unnecessary parts. This requires not that the writer make all his sentences short, or that he avoid all detail and treat his subjects only in outline, but that every word tell.”

6. The Structure of DNAWatson and Crick, Nature, 1953

7. How to Get Your Paper Reviewed • Follow the instructions to authors completely. • Follow the instructions to authors completely. • Follow the instructions to authors completely. • Follow the instructions to authors completely. • Follow the instructions to authors completely. • Get the picture?

8. Other Tips and Requirements • Avoid complicated medical terms and jargon • Not, “juxtaposed,” but “adjacent” or even “next to.” • Use medical terms only when the appropriate lay term is not precise enough. • Expect active voice almost all the time. • Use the template to include all vital elements • Avoid using the same word twice in a sentence

9. Other Tips and Requirements • Avoid redundant hyperbole • “extremely arachnophobic, • “close proximity” • “summarize briefly” • “very deep” • “overcrowded” • “very precarious” • Vary sentence length • Avoid run-on sentences • Use no more than one parenthetical phrase per sentence • Alternate short sentences with long ones.

10. Rules of the Road • Paragraphs need to have at least three sentences: • a topic • an explanation • some sort of conclusion. • If there are only two, incorporate this thought into the paragraph before. • Paragraphs should not generally have more than six sentences.

11. Rules of the Road • Someone not in EM, or not even in medicine, should understand the paper. • A college graduate should be able to understand much of medical writing • If they would be lost, the paper needs more work • Goal is to NOT write in a language called “medicine,” but rather in English

12. Rules of the Road • Avoid politics in the paper • Little room for opinion in a scientific paper • Facts speak for themselves • Discussion section: Allow the author to opine a bit, for maybe 2-3 sentences, if at all • Assure such opinions, are clearly marked, such as, “we believe.” • If the concept is provocative, it probably doesn’t belong in a research paper.

13. Reviewing Papers • Helps gain experience in academic writing • Flips your perspective from author to consumer • Provides insight into common problems and mistakes • Time consuming; good review = two hours • Will dramatically improve the quality of the journal • Ultimate Medline indexing depends on this

14. The Title • Answer the question posed by the paper in the title • Type of study belongs in the title: retrospective, randomized controlled trial, cohort study, before and after, case report, case series • 120 character limit for WestJEM • Strike balance between brevity and accuracy • Spell out all abbreviations.

15. Structured Abstract • Introduction: two sentences max • Objective: one sentence • Methods: 2-3 sentences • Results: as many as you have, but major only • Conclusion: one sentence • Parallel the rest of the paper in content and order • Limit for WestJEM: 300 words • Normally, abstract written first, then paper • Must assure consistency with body of the paper

16. Internal Consistency • Sample size, numbers, results • Make sure these are the same in Abstract, Methods and Results • Nothing brands a paper as amateurish than inconsistencies • Casts doubt in the reviewer’s mind • What else is wrong if they can’t even get this right?

17. Introduction • Typically four paragraphs • Not a literature review • Cite references in the introduction that set stage for the problem or hypothesis • All other citations belong in the discussion (except methods description from previous work) • Last sentence: • We hypothesized…. • Our objective was…. • We sought to….

18. Methods • Describe setting • How inclusive was the sample • Specific inclusion/exclusion criteria • What was the intervention? • How were subjects identified? • How was data gathered and recorded? • How was it analyzed? • What tests? • Have statistician or senior mentor write or review • What computer program, version, manufacturer, corporate headquarters…. • Make and model of all equipment • Goal of methods is to enable replication

19. Methods: Retrospective Chart Review • Adhere to seven elements of methods described in Gilbert and Lowenstein, Annals Emerg Med, 1996, or • Worster and Bledsoe, Ann Emerg Med. 2005;45:448-451 with 12 criteria for a proper methods section:

20. Worster and Bledsoe

21. Results • Present primary outcome measure first, followed by secondary • Graphs easily visible in black and white, with different patterns, not colors • For more than 4-5 related results, use table • Tables are easier to digest • Don’t repeat results from a table in text • Instead refer to general synopsis of the tabular results

22. Results: Statistical and Reporting Conventions • All results in absolute not relative terms • “The absolute risk reduction from a mortality of 4% to 2% was 2%,” rather than, “The relative risk reduction was 50%.” • Relative changes inflate the magnitude of the effect artificially. • To compare two groups, use p values with 95% confidence intervals AND calculate NNT/NNH from the absolute difference in outcomes • Gives information to gauge clinical import

23. Results: Diagnostic Tests • Use likelihood ratios in addition to sensitivity, specificity, and positive/negative predictive values • Allows reader to change probability of a given condition after the diagnostic test • Pre-test probability modified by likelihood ratio = post-test probability by the Fagan nomogram

24. Pulmonary Embolism and d-Dimer Sensitivity = 91% Specificity = 42% LR Pos = (30/33) / (42/72) = 1.5 LR Neg = (3/33) / (30/72) = 0.22 Heit JA, et al. Arch Path Lab Med. 1999;123:235-240

25. Plain Language • A negative d-dimer is 0.22 times as likely to occur in patients with PE than in patients without PE • A negative d-Dimer is 4 ½ times less likely to occur in patients with PE than in patients without PE

26. Fagan Nomogram

27. Figures • Even if it seems obvious, annotate figures and pictures with arrows (point to the brain hemorrhage or appendicitis) • High resolution, at least 300 dpi • Low resolution images “pixel out.”

28. Legends for Tables and Figures • Tables and Figures with their legends are separate pages, not imbedded in text of paper • Must stand alone and be very descriptive • Must spell out all abbreviations used each time • Must be large and clear (little white space) • Make sure they are numbered in proper order

29. Discussion • Most important findings first • Same order as results section • Then secondary outcome measures • This is the place for opinion, though quite limited • How could or should this change clinical care? • Discussions should be limited to 5-6 items, each with one to two paragraphs

30. Conclusions • Don’t allow overstatement • Definitive study is almost impossible • Insist on words such as, “it appears,” or “from these data.” • Always call for further investigation • Retrospective studies cannot show causation, only association • Make conclusion specific enough to stand alone. Include, “in adults,” or “in emergency department patients with a chief complaint of chest pain.”

31. Limitations • Limit to 1-2 paragraphs • Should acknowledge: • Small sample size/underpowered study • Incomplete patient enrollment • Lost to follow up • Retrospective design • Lack of blinding • Lack of generalizability • Author should be honest about shortcomings and biases, or appears naïve

32. References • Consistent format, adherent to journal requirements • Citations go at end of sentence, unless sentence compound and citation applies only to first part • Need to be up to date: look at most recent reference • Lit review from two years ago is out of date • Suggest new references as your expertise dictates

33. Questions?