How to Write a Paper

1. Association of Academic Dermatologic Surgeons Content Review date: August 27, 2012 Originally Submitted: September 15, 2007 How to Write a Paper Timothy M. Johnson MD Lewis and Lillian Becker Professor University of Michigan I have No COI-no relevant relationships with industry

2. How to Write a Paper ? Disclaimer:My Perspective.Everyone is different. These are just guidelines and pearls that I have found useful.

3. How to Write a Paper

4. Why Write?“Duty vs. Passion” • To advance knowledge • Improvement in management of disease • To advance your institution • Academic accomplishment, prestige, funding • To advance yourself • Enhances clear thinking & scholarship ability • Promotion, career development, reputation Benefits often greater to author than reader

5. The Evidence Pyramid Systematic Review & Meta-Analysis Randomized Controlled Trial (RCT) Double Blind

6. EVIDENCE LADDER

7. Stages in a Research Study • Planning the study & writing the protocol • IRB approval • Funding/Infrastructure • Executing the study & collecting the data • Data analysis • Writing • Going through the editorial process

8. Writing a Paper: Getting Started • No single best way • Varies from paper to paper • Background reading--Literature search! • Identify mentors to understand what constitutes good versus bad papers • Decide on authorship “The only way to learn to write is to write”--Peggy Teeters

9. Writing a Paper: Getting Started • IRB • Find statistician BEFORE study • Sample size • Power analysis • Appropiate statistical tests • Select journal-review guidelines

10. Writing a Paper • Fix realistic schedule (Adherence) • Write by a biological clock • Need stretch of protected hours or days • Ideas come while writing • When time is short: prepare, revise • Location • Boring area, nothing to distract • Maintain momentum • Academicians rated by what they finish, not by what they attempt

11. Parts of a Manuscript--Structure Write in What Order? Title Abstract Introduction Methods Results Discussion References “Writing is a lot easier if you have something to say” --Sholem Asch

12. 1 Methods I WHAT DID YOU DO? For informed readers this is the most important section • Past tense • Precision-study design-like a recipe • Explicit inclusion/exclusion criteria, retrospective or prospective, etc. • Detailed enough so results can be repeated by others

13. 1 Methods II • Ethical approval (IRB) • Statistical methods • Subheadings only if necessary-duplicate in results • Remember that you can put detailed methods on the web-i.e., questionnaire WHAT DID YOU DO?

14. IRB !! • Start by reading your local IRB website http://www.med.umich.edu/irbmed/ • PEERRS certification:Program for Education and Evaluation in Responsible Research and Scholarship • Fulfills the NIH requirement for human subjects training for PIs and "key personnel” • Trials MUST be enrolled for publication in the best journals • http://clincaltrials.gov • http://prsinfo.clinicaltrials.gov

15. IRB !! • Almost every study worth publishing requires IRB approval • Determination of exempt status is made by the IRB • Exemption Categories 4. Research, involving the collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, if these sources are publicly available or if the information is recorded by the investigator in such a manner that subjects cannot be identified, directly or through identifiers linked to the subjects.

16. 2 Results I • Just the facts, in a logical sequence • Past tense • Importance of accuracy cannot be overstated-check, recheck data/numbers-must add up • Give numbers and percentages:1 (10%) of 10… • P values and confidence intervals • Avoid discussion of results in this section WHAT DID YOU FIND?

17. 2 Results II WHAT DID YOU FIND? • Tables & figures-straightforward, concise, not duplicative, should stand alone • Table(s) - short specific title at top of page, footnotes • Figure(s) - concise legends, QUALTY, avoid distracters, anonymity • You can put extra results on the web

18. Statistical vs. Clinical SignificanceIs it real? vs. Is it important? There are three kinds of lies: lies, damned lies, and statistics. In God we trust All others must bring data. Mark Twain

19. 3 Discussion I • Always focus on your results • Outline 2 or 5 main points that come from results • Build a paragraph or two for each point • Finally permitted latitude to elaborate and speculate (some) WHAT DOES IT MEAN?

20. 3 Discussion II WHAT DOES IT MEAN? • First answer the question posed in the Introduction • Summarize previous work-compare your results • Explain what is new without exaggerating, perspectives, implications • What do your results mean? - clinical practice, management, policy

21. 3 Discussion III WHAT DOES IT MEAN? • Strengths and weaknesses in relation to other studies, particularly any differences in results • Usually avoid ending with a conclusions-summary section if redundant • “further studies are required”- usually not necessary and implies to some you need to do before submitting

22. 4 Introduction WHAT IS THE QUESTION/OBJECTIVE? • Short (3 paragraphs)-1 typewritten page • First paragraph Brief background-establish context, relevance, nature of the problem/question/purpose • Second paragraph Importance of the problem and unresolved issues • Last paragraph Rationale: state hypothesis/main objective/purpose What we know? What we don’t know? Why we did the study?

23. Abstract • Critical part of paper • Determines if paper will be read • Is distributed freely in databases • Structured per format • Avoid acronyms and abbreviations • Write and rewrite until flawless • Clear and concise - stand alone

24. References • Errors reflect scholarship-check & recheck • Be selective-cite only those vital • Relevant and recent (or seminal) • Balance • Read the references • Do not misquote • Use correct style for journal

25. Title • Determines how paper gets indexed • Often determines whether paper gets read • Should describe and identify subject matter • Avoid long title-impossible to comprehend at a glance • Avoid abbreviations • Question: may be easier to understand, more impact?

26. First Draft What works for me? • Write as quickly as possible • Get everything down • Ignore spelling, grammar, style • Skip troublesome words • Correct and rewrite only when the whole text is on paper • Do not split the manuscript among the co-authors

27. Style and Authorship • Follow ICMJE* criteria: • Uniform Requirements for Manuscripts Submitted to Biomedical Journals http://www.icmje.org/index.html#top • Order: • First author-primarily responsible for collecting & analyzing data, and writing • Last author-usually an established investigator, assumes overall responsibility • Middle authors-list in order of contribution * International Committee of Medical Journal Editors

28. StyleAccuracy, Clarity, Brevity • Proper words in proper places make the true definition of style.--Jonathan Swift • Have something to say and say it as clearly as you can… the essence of style.--Matthew Arnold • If writing is unclear, meaning unintelligible readers and reviewers won’t understand • Use concrete over vague language • Multiple mistakes in spelling and syntax, suggests similar sloppiness in the project • Check and double check data

29. StyleAccuracy, Clarity, Brevity • Use active voice whenever possible Active voice: the subject is performing the verb Passive voice: the subject receives the action expressed in the verb Passive (more wordy) Active (more concise) • Avoid overusing there is, there are, it is, it was, etc.  • There aretreatment guidelines for Merkel cell carcinoma that werereportedby Bichakjian, et al. • Correction:Treatment guidelines for Merkel cell carcinoma werereported by Bichakjian, et al. • Better:Bichakjian, et al.reportedtreatment guidelines for Merkel cell carcinoma. (Active voice) Active:Scientists have conducted experiments to test the hypothesis Passive:Experiments have been conducted by scientists to test the hypothesis

30. StyleAccuracy, Clarity, Brevity • All first drafts have too many words • Next drafts: prune vigorously, avoid repetition, wordiness, long sentences, excessive adverbs/adjectives • Strip every sentence • Writing improves in proportion to deletion of unnecessary words • When you have the choice of two words, use the simpler one • The most valuable of all talents is that of never using two words when one will do.--Thomas Jefferson

31. Simplify • a majority of = most • a considerable amount of = much • a number of = several/some • on account of = because • referred to as = called • has the capacity to = can • it is clear that = clearly • at the present time = now • give rise to = cause • is defined as = is • subsequent to = after “Those who have the most to say usually say it with the fewest words”

32. StyleAccuracy, Clarity, Brevity • Liked by authors, disliked by readers • Reading should not require a glossary • Unwieldy word occurring > 10 times • Avoid using colloquial language Abbreviations and Acronyms

33. Troublesome Terms • And/or: and or oralone usually suffices • Diabetic as a noun may be condescending to some, patient with diabetes • Significant means statistically significant • “Firstness”-provide details if true, rarely needed

34. Getting Help • Get co-author and mentor help • Experts are good • Non-experts may also be good • “I got lost here” is more important than “oncololy is misspelled” • Learn from editing changes

35. Revise, Revise and Revise • You may not be a very good writer, but be an excellent rewriter • Always look from a distance--see your paper as the reviewer will see it • Polish the writing style • Double check spelling, look for typos • Double check references • Every fat paper has a thin one trying to get out

36. “Deadly Sins” • Data manipulation, falsification • Duplicate manuscripts • Redundant publication • Plagiarism • Humans use concerns • Animal use concerns • Author conflicts of interest • Failure to discose conflict of interest Publish and Perish

37. Happens more commonly than expected What is Redundant Publication? No Yes Maybe Data in conference abstract? Same data, different journal? Data on website? Data included in review article? Expansion of published data set? OK if later Probably

38. Redundant Publication • Problem is not the publication but the lack of disclosure--disclosure is key • Always send copies of overlapping papers and reference them • Negative studies are often not published; positive studies are more likely be published more than once-creates BIAS • Distorts what the evidence says

39. Submission • Read “Instructions for Authors” thoroughly • Conform to “Instructions” precisely • Write cover letter (suggest reviewers) • Know the journal, its editors, and why you submitted the paper there • Avoid careless mistakes

40. What Editors Like About Papers • Originality • Interesting to readers, important, messages that matter • Clear questions, correct methods • Brevity, clear presentation (style) • Good grammar and spelling Editors and reviewers spend hours reading manuscripts, and greatly appreciate receiving papers that are easy to read and edit!

41. What Editors Dislike • Very long papers (> 3,000 words) • Second-rate Style • Conclusions not justified by data, sweeping conclusions • Inability to follow “Instructions to Authors” • Splitting versus lumping

42. What Happens Next? • Acceptance • Revision • Rejection The Review Process If at first you don’t succeed, you’re about average!

43. The Post Review Phase-Revision Listen to your reviewers • Study reviews objectively and dispassionately • Read every criticism as something you could explain more clearly • Resist temptation to respond “you brainless person, I meant X”. Fix the paper so that X is apparent even to the most brainless reader. • Be open to criticism - do not get defensive -This isreally, reallyhard, but it isreally, really, really, reallyimportant

44. Responding to Reviewers-Revision • Carefully prepare your responses point-by-point: • Each comment should be addressed • Each change should be stated • Make your changes obvious • Reviewer may be wrong • Be tactful-next reviewer may be the same • Do not respond to reviewers while upset • Get help from co-authors

45. Rejection -disappointing at best A journey of a thousand miles sometimes ends very, very badly

46. Why Papers are Rejected I The best scientists get rejected and have to make major revisions • Number of journal pages available has not kept pace with number of articles and authors • May be nothing basically wrong • More confirmatory than original • Insufficient priority, backlog inventory • Wrong journal

47. Why Papers are Rejected II • Poorly written • Sweeping conclusions-unjustified by data • Ethics (IRB) approval not obtained • Flawed or poor study design-methods • Unrepresentative sample(s) • Uncontrolled, poor controls, nonrandomized interventions • Sample size too small • Incorrect statistical analysis • Hypothesis not adequately tested Your manuscript is both good and original, but the part that is good is not original, and the part that is original is not good. --Samuel Johnson

48. The Post Review Phase-Rejection Honest criticism is hard to take, particularly from a relative, a friend, an acquaintance, or a stranger. --Franklin Jones • Get over it • Do not get defensive • Study reviews as objectively & unemotionally as possible-for resubmission to another journal • Address all of the reviewers’ concerns • Next reviewer may be the same At least 50% of initially rejected articles are eventually published somewhere else!

49. The Post Review Phase-Rejection Appeal Option • Do not call the editor---usually • Willing to consider first appeals--but must revise the paper, refute criticisms, not just say the subject is important • Few accepted on appeal • No second appeals; ends in hostility or tears; plenty of other journals

50. Become a Reviewer Become a Better Writer • Approach the editors and editorial staff • The best reviewers are often the best writers and vice versa • Apply principles from today Professor Trisha Greenhalgh: "How to Read a Paper" Series--BMJ