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Effective Clinical Practice

Preparing Manuscripts for Submission to Medical Journals: The Paper Trail

H. Gilbert Welch, MD, MPH
Editor, Effective Clinical Practice

Abstract

Context: Preparing a manuscript for publication in a medical journal is hard work.

Objective: To make it easier to prepare a readable manuscript.

Approach: Start early - a substantial portion of the manuscript can be written before the project is completed. Even though you will revise it later, starting early will help document the method and guide the analysis.

Focus on high visibility components - pay attention to what readers are most likely to look at: the title, abstract, tables and figures. Strive to develop a set of tables and figures that convey not only the major results, but also the basic method.

Develop a systematic approach to the body of the paper - a standard framework can make it easier to write the introduction, methods, results and discussion. An obvious organization with frequent subheadings and consistent labels makes them easier to read.

Finish strong - improve the paper by sharing it with others and by learning how to elicit and receive their feedback. Take the time to incorporate useful feedback by revising frequently.

Preparing a manuscript for publication in a medical journal is hard work. Authors must strike a balance between being comprehensive and being clear. They must engage the reader's interest and communicate results succinctly. And, to continue to have the time to do research, they must develop a systematic approach to manuscript preparation.

Without a systematic approach, the effort can easily become haphazard. This consumes more time and produces an inferior product, which frustrates authors, editors, and readers alike. Worse, good researchers can easily become discouraged—resulting in research that is not written or in papers that are not published.

Although others have provided useful guidance in the proper style and structure of scientific writing (1-3), this article offers guidance at a different level: how to develop a systematic approach to manuscript preparation. Although the emphasis is on writing original research, this guidance also applies to other kinds of papers. My goal is simple: to make it easier to prepare a manuscript and to make manuscripts easier to read.

Starting Early

Writing a good paper is a complex task. It requires both creative energy and quiet reflection. The road to the finished product is never straight, is often rough and may well involve a few dead-ends. In short, writing takes time. It is easier if it is not left to the last minute.

You can start writing three components of the paper before the work is completed. The introduction can be sketched out at the time the investigation is conceived (and generally has been, when external funding has been sought). Draft the methods while the research is ongoing, as a running account of what is being done as it is being done. Finally, develop skeleton forms of numeric data (often called "dummy tables") early on.

Putting something down on paper early is valuable even though you will revise itlater. Clarifying the motivation for the paper in the introduction helps you identify a context in which to place your work. Early documentation of the methods helps avoid having to reconstruct subtle details of the analysis long after they occurred. The structure of dummy tables helps focus your analytic effort. Most important, writing forces critical thought about your work.

In particular, invest some time thinking about the main message of your paper (4). Work to distill it down to a few succinct points that address the following: Why did do what you did?, What did you do?, What did you find?, and What might it mean?. Further crystallize these points by articulating them to your colleagues; you may want to try out a number of variations. Although only some journals will use them (e.g. Key Messages in BMJ, Take-Home Points in ecp), all papers should be guided by them.

Putting the Paper Together

High visibility components

Although the audience of a medical journal can be quite heterogeneous, one thing that professionals generally have in common is that they are busy. Physicians, managers and policymakers may only look at your work briefly, if at all. Although most authors know this, they may not consider it when they sit down to describe their own work. Most could do better by thinking more like a reader and by paying more attention to what readers are most likely to look at: the title, abstract, tables and figures.

Title/Abstract

Too many authors choose a title and tack on an abstract immediately prior to submission. Yet these are the first (and often, the only) parts of your paper that will be read. Furthermore, they are often the only parts of the paper accessible via electronic access (e.g. MEDLINE, websites etc.). Equally important, they are the components of the paper that the journal editors first review. They should, therefore, be composed early in the process and subjected to the same level of critique as the body of the paper.

Visual Elements

Visual elements are critical (5,6). If readers go beyond the abstract, they are likely to examine the tables and figures next. Tables are typically used to display precise numeric values - a tool to make a paper more readable by removing numeric data from text (7). Other ways to use tables are as a way to synthesize prior literature, to explain variables, or to present the wording of survey questions. A figure provides visual impact and thus is often the best way to communicate your primary finding. Figures are traditionally used to display trends and group results, but can be used effectively to meet other objectives: to communicate processes or to display detailed data simply. Clear informative figures are invaluable; think creatively about how to use them. Work to develop a coherent set of visual elements than can "stand alone" — that is, not only convey the major result, but also the basic method.

The Body of the Paper

There are a number of strategies to encourage readers to move into the text itself. Perhaps the most important is brevity. Sentences should be short, simple and direct. So should the paper. Do not equate complexity with sophistication. But be aware that such brevity does not come quickly or easily; instead it may require a great deal of time.

A readable paper also requires an obvious organization (1). Every paragraph needs a purpose. Describe it in the topic sentence and make sure every sentence is congruent with that purpose. Paragraphs must be linked and produce a sequence of thought which reflects the "argument" for the central message. An obvious organization is facilitated by the conventional framework used in medical journals: introduction, methods, results and discussion.

Introduction

The paramount job of the introduction is to motivate the audience to read the paper and care about the results. In addition, it may be useful to help reviewers and editors judge the paper's importance. Address why the work was done and, equally important, why the reader should care. To help get started, Table 1 outlines a general framework for a 3-paragraph introduction. The first paragraph describes the general problem or situation that motivated your work. The first sentence, in particular, must be strong and catch the reader's attention. The second paragraph focuses on the specific problem that the research will address. It may detail relevant issues with which readers are unfamiliar. Gaps in the existing literature may also be a focus of this paragraph. The third paragraph motivates the study itself. By the end of the introduction the reader should be 'hungry' to read the rest of the paper.

Methods

The methods section must give a clear overview of what was done. Recognize that there is an obvious tension between brevity (you cannot describe every technical issue) and completeness (you need to give adequate detail so that readers know what happened). Striking this balance is first the author's job, then ultimately the job of editors and reviewers. The methods section should also give the reader some information relevant to generalizability (e.g. how did subjects get included?, from what population were they sampled?).

Pay particular attention to what you name things (and ideas) which appear repeatedly in the text. Think hard about these labels. They should be brief, yet intuitive. What are you going to call the intervention? What is the one word that describes the outcome measure? Develop a list of frequently used terms to be sure that you use them consistently. Nothing is more confusing than having the same thing go by different names (with the possible exception of having different things go by the same name).

A rigid structure makes writing the methods fairly mechanical. This structure has been particularly well delineated for randomized trials (8). Use subheadings (e.g. overview, setting, exclusions, primary outcomes, secondary outcomes, analysis) frequently; think creatively about their names and tailor them to your research. Even if you delete them later, subheadings will help organize your writing by forcing a structure. Consider a figure as a way to depict processes (e.g. study design, patient selection, and computer algorithms), as shown in Figure 1. Use appendices to provide details of the analysis or specific data collection instruments (of interest to reviewers or researchers who wish to replicate your work).

Results

The results should be short and to the point. Be sure to distinguish primary from secondary results and report them first. Use tables and figures to reduce the amount of text. In addition to your primary finding, use figures to present multiple confidence intervals or individual data points (see Figure 2).

Discussion

As shown in Table 2, authors should use the discussion section to summarize their work and put it in perspective. First, this section is a good place to restate the major finding of the paper. The finding can then be put in the context of other work using a more complete literature review than is appropriate in the introduction. Second, potential limitations must be identified, particularly those that threaten the study's validity. Valid criticisms should simply be acknowledged and discussed. No paper is perfect; the key is helping the reader gauge what can be confidently learned and what is more speculative. Expected criticisms that are invalid should be introduced and rebutted. Third, the work should be put in perspective. Assess its generalizability and consider its clinical implications. Speculate a little, but not too much. Finally, consider the question "What next?".

Finishing Strong

Getting Help

Good papers are the product of multiple revisions, revisions made in response to the criticisms of others. To test how well your paper has communicated its case requires that others read it. To make it better requires that you respond to their feedback. Don't wait until the paper is done to get feedback; in fact, your colleagues may be more focused if given only discrete components (e.g. abstract, introduction, the set of tables and figures).

To get feedback, you need to develop a cadre of "internal reviewers" - colleagues who read and criticize the paper before it is submitted for publication. "Big names" may not have the time or inclination to do the job well. Younger, more junior faculty may be equally capable, have more time and be more highly motivated to do a good job (9). There are two broad categories of internal reviewers:

• "General reviewers" - whose primary job is to determine whether your writing can be understood. Anybody has the potential to be a good general reviewer. The primary quality is someone who will make the effort to read and think carefully. It is particularly useful if they are readers of your target journal, but not part of the particular "research culture" peculiar with your topic.
• "Expert reviewers" - whose primary job is to help prepare you for reviews by journal editors and peer reviewers. Here you will want a member of the "research culture" to look hard for flaws (what are the biggest threats to validity in this study?, are there alternative interpretations of these results?). The ideal is a "hostile friend"- people who meet two criteria. First, they must be supportive of or even a little invested in your work to make the effort required. Second, they must be (or be able to assume the stance of being) critical or even a little hostile to your ideas.

Good reviews take up valuable time(10,11). Once you have identified internal reviewers, it is prudent to consider how to use them efficiently. Figure 3 displays specific suggestions to maximize reviewers' contributions. These include tactics to both elicit and receive feedback.

Tactics for eliciting feedback

Having a cadre of good internal reviewers is extremely valuable to an author. Tactics that make their job easier and more rewarding are, therefore, very much in your own self-interest. The commitment of your internal reviewers can be maximized by clarifying expectations and by extending simple courtesies. First, get an explicit commitment. Ask, before you send a paper. Unannounced mail, electronic or conventional, is both poor form and is at high risk to go to the bottom of the pile. Establish a time (or at least a range) when feedback will occur. And recognize that good reviewers have many demands on their time. If you must have feedback quickly, say so. If the reviewer cannot accommodate your needs, move on.

Second, specify the purpose of asking for a review. This will make your reviewers more efficient. Take the time to consider what it is you really need. Is it a general review? If so, at what level of detail? It could be broad-based (does the argument flow?, do you understand the content?) or fine (e.g. stylistic concerns, typos). You may want to focus expert reviewers on any specific technical or theoretical questions you have (is this an adequate description of the logistic model?, is this a confounder or in the causal pathway?).

Three simple courtesies are also important. First, provide your paper in a format that is easy to review. Triple-spaced text (to provide room for comments) and page numbers (so you can each locate text) are particularly important. Second, avoid undermining the review by requesting a careful review of a "moving target". Nothing is more frustrating for a reviewer than spending a lot of time on a section only to learn later that is has been deleted. Finally, have a conversation to get feedback. This will help make your reviewer feel like a more useful part of the process.

Tactics for receiving feedback

But there is a much more important reason to have a conversation - your reviewer will be a more useful part of the process. You can learn much more from sitting down with the person than you will from scribbled notes alone. Encourage reviewers to mark up the paper, but go over these comments in a conversation. Without this interaction, not only are you at risk to miss certain points (scribbled-up drafts are difficult to read), you will also miss the motivation for their concerns.

There are other tactics important for obtaining feedback. Most important is your own demeanor. Don't be defensive. Leave your ego at home. At this point, you want the "best shots" and the "low blows". Such feedback only better prepares you for the journal's review process.

Focus on understanding problems. Assume that anytime a reviewer is motivated to mark on the draft, a legitimate problem exists. Make sure you understand the reason for concern. Explore the motivation behind each comment and work together to articulate what the problem is. This may take time, as the precise problem may not even be clear in the reviewer's mind. The conversation ought to go on until you understand what the reviewer had in mind, not until one of you has convinced the other. Without some limits, you may lose the opportunity to learn about other issues.

Finally, be critical - not of your reviewer, but of his or her suggestions. While we all appreciate guidance, many get bogged down with conflicting advice. Problems identified by reviewers generally have face validity; their proposed solutions, on the other hand, may be wrong. Separate issues of style from issues of substance. Take what are clearly good suggestions, but think of alternative solutions for those that seem less good. When you find yourself reverting to prior revisions, it's probably time to stop.

Getting Better

Becoming a good writer takes time. To give yourself the opportunity to become a better writer, make the time. As shown in Table 3, you will need time to improve the paper and time to improve your own skills.

To improve the paper, don't rush the writing process. Too many authors are impatient to get the paper off their desk and on to the editor's. First, get the general structure and message straight before fiddling with the fine detail. Then allow yourself the time to step back and read your work with a fresh perspective. This opportunity for "digestion" can be efficiently scheduled while your internal reviewers are doing their work.

You will then need to revise frequently. To do so, lower the barriers to revision. Do your own word processing. No technical advance has meant more to those of us for whom structure and prose does not immediately flow (12,13). Look at the big picture and scrutinize your structure again. While it may have been obvious when you first wrote it, it may now look garbled. Check to see if the paragraphs are well connected. Don't hesitate to move things around and revise transitions. Everyone says to begin with an outline; try writing one again when you think you're finished.

Now get into the detail. Two points are particularly important. First, check for consistency. Both data and the labels should be consistent across text, tables and figures. Second, eliminate clutter—unintended repetition and peripheral points. Sift through the words until each can produce a "proper account of itself" (14,15). There are also other sources of clutter to attend to: unnecessary precision (e.g. 97.89%), jargon and excessive abbreviations.

Ultimately you will have to revise the paper in response to the reviews by journal editors and peer reviewers. While this process is never enjoyable, it frequently produces a better paper. Don't fight it reflexively, but don't acquiesce to bad suggestions. Do make clear to the editor (in cover letter) what you changed, what you didn't and why.

To improve your skills, help others. Just as a single paper benefits from the cycle of review and revision, the author can benefit from the cycle of careful reading, critiquing others, and writing. By reading critically, you will grow comfortable with principles of organization and coherent argument. Serving as an internal reviewer for other authors will hone your skills. Identifying their mistakes will enhance your ability to find your own. Finally, take the opportunity to serve as a peer reviewer, particularly for journals you are interested in publishing in. Not only will you further develop your skills, you will also learn something about the review process, how others review, and the characteristics of papers you are competing with.

Take Home Points

• Start writing before your project is completed.
• Focus your attention on what readers are most likely to look at: the title, abstract, tables and figures.
• Develop a systematic approach to the introduction, methods, results and discussion.
• Improve the paper by learning how to get and incorporate useful feedback.

References

1. Day RA. How to Write and Publish a Scientific Paper. (2nd ed.) Philadelphia: ISI Press, 1983.
2. Huth EJ. How to Write and Publish Papers in the Medical Sciences. (2nd ed.) Baltimore: Williams & Wilkins, 1990.
3. Eger EI. A template for writing a scientific paper. Anesth Analg 1990;70:91-6.
4. Berk RN. Preparation of manuscripts for radiology journals: advice to first-time authors. AJR 1992;158:203-208.
5. Hill AB. The reasons for writing. BMJ 1965;2:870-871.
6. Tufte ER. The Visual Display of Quantitative Information.Cheshire, CT: Graphics Press, 1983.
7. The Standards of Reporting Trials Group. A proposal for structured reporting of randomized controlled trials. JAMA 1994;272:1926-31.
8. Huth EJ. The physician as author of medical information. Bull NY Acad Med 1985;61:275-282.
9. Evans AT, McNutt RA, Fletcher SW, Fletcher RH. The characteristics of peer reviewers who produce good-quality reviews. J Gen Intern Med 1993;8:422-428.
10. Lock S, Smith J. What do peer reviewers do? JAMA 1990;263:1341-1343.
11. Yankauer A. Who are the peer reviewers and how much do they review? JAMA 1990;263:1338-1340.
12. Fletcher SW, Fletcher RH. Responsibilities of medical journals to readers. J Intern Med 1992;232:223-228.
13. Dudley H. How to encourage a referee: use your word processor carefully. BMJ 1989;299:1614-6.
14. Godden JO. Notes on the composition of scientific papers. Can J Surg 1971;14:242-3.
15. Macphail A. Style in medical writing. 1911 [classical article]. Can Med Assoc J 1992;146:2197-8.

Acknowledgments

This paper relies on numerous ideas originally expressed in a paper by Greg Froehlich and myself (Welch HG, Froehlich GW. Strategies in writing for a physician audience. J Gen Intern Med 11:50-55, 1996). I would also like to acknowledge the assistance given me by the current associate editors of ecp.

Correspondence

Address Reprint requests to: Editor - Effective Clinical Practice, VA Outcomes Group (111ecp), Department of Veterans Affairs Medical Center, White River Junction, VT 05009.

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