"Publish or Perish" Unknown
Publish or Perish
The importance of research and publications cannot be overemphasized in the advancement of medicine and science. And so is in the career of a budding medico. Lots of us already know and are convinced with this fact and therefore want to publish “something”. However, very few would know how to write a good quality peer-reviewed publication. This section will give you an insight into the process of scientific publication and will help you familiarize yourselves with the different ‘Do's and ‘Don’ts’ of the game.
Absolutely. Right question. Why bother doing something that; first of all ‘I don’t know how to do’, second; ‘is so difficult’ and above all seems to be a ‘pretty boring and monotonous job’! Well, you might be right but consider the following points before jumping to the final conclusions.
A. Moral responsibility: The only way medical research advances is through publications. If nobody would have published his or her research before, we would have never been able to see the face of medicine that we see today. Almost every invention and discovery that benefits humankind today reflects the hard work and research of dedicated scientists. And the discovery came to you only when they published their findings! Don’t you think this is your turn to give something back? To add something to the treasure of knowledge everybody enjoys for granted? Or at least give it a try?
B. Part of your duty: Medical research and Audits are two of the main pillars of Clinical Governance and, as an NHS employee you are duty-bound to follow Clinical Governance and therefore to do medical research and publish. There is no escape if you’re working in NHS!
C. Hard work/ commitment/ goal-oriented approach/ teamwork: A publication is a result of hard work that is done by a team of teammates committed to their goal. There are no shortcuts. If you want to publish you will have to acquire these qualities somehow. So in other words, a publication is a testimonial that testifies automatically all these traits in you, without you saying a single word!
D. Career development: Taken an interview lately? Or planning to take one in future? Ask your colleagues and seniors the single most important point that can turn the table in your favour during the interview. They are right. Research and publications are the single most important aspects that shine through your CV in an interview. Wanna that job, baby?
What to publish?
Well, that’s a million-dollar question. But definitely, a second step when you’ve made up your mind that you wanna publish. I will answer your question for sure but let me ask a simple question first. How many types of publications do you know? Case reports, Clinical studies, Randomized Controlled Trials, Review of literature, Editorials. That’s it, one would say, ‘my list is about to exhaust now, that’s all people publish’! Think twice my friend and have a look at the table on your right. The different types of publications described by the National Institute of Health run in three figures (over 122 types of publications, to be more precise)! Oh dear, you never imagined that!! Don’t worry, neither did I, till I start observing.
The most common type of publication that comes to anyone’s mind is – A case report. That’s very sad, honestly. Case reports are literally destroying the soul of medical research. This is a common ‘trap’ that keeps people from publishing good papers. Well, what’s the problem with Case reports? Ok, let me explain it. There is a number of factors; first, in order to be publishable the case has to be unique and rare, which by definition will be rare to find! You may never find one (or not so easy, especially if it’s a ‘truly rare’ case warranting publication). Second, the rate of rejection of case reports is way too high, ranging in the order of 8090%. A number of prestigious journals don’t even consider case reports for submission! Third, case reports are considered to be the most basic types of publications (level 5 evidence).
Ok, so what are the other categories you can publish? It’s a good idea to be a part of a clinical study going on in your department or even better a multicentric randomized controlled trial. However, the problem with this approach is that you can’t start a multicentric trial or a big clinical study yourself until you are quite senior and by that time you already would have published enough papers not to worry about reading this document! Apart from that, you can give your contribution to these studies (which is mostly limited to data collection and digging out old medical charts!) in hope that your name would be somewhere on the authors’ list. That may not be the case, unfortunately, as there are predefined criteria by ICMJE (International Committee of Medical Journal Editors http://www.icmje.org/ethical_1author.html) to claim authorship of any publication. If your contribution is not enough to warrant authorship you will have to satisfy with your name in the acknowledgements section only. That can be quite depressing.
Believe me, most people commit that mistake and keep on waiting for ‘an odd case’ or hoping their names to be included in a big study based on their relatively ‘trivial’ contribution. Nevertheless, there are a number of avenues where you are not dependent on most of these factors mentioned above and hence can publish relatively easily. By having a close look at the categories of publications in the table you would have realized that the range of publications is much wider than you can imagine.
A review of literature is a comprehensive analysis of literature on a particular topic. This can be done by anyone without the need of having a ‘rare’ case in your bag. Good reviews are mostly done on a relevant topic where there is a lack of consensus for diagnosis or treatment or any other aspect of the problem. It’s always a good idea to analyse more recent literature rather than going back to centuries-old manuscripts. If you are feeling particularly motivated you can even review a book! Reviews are believed to be quite important and in fact, MetaAnalysis, a type of Review of literature where the ‘reviews are reviewed’, is considered as one of the highest levels of evidence in science. It should, however, be differentiated from a Historical Article that usually gives an account of past events or circumstances significant to the field of study, discovery, invention, etc. The only downside here could be that some of the journals don’t accept unsolicited (uninvited) reviews. However, lots of them do, so it's better to check the journals author’s guidelines section or even send a quick mail to the editor to check if they will accept a review on that particular topic, before deciding to write a review for that. Historical Article therefore could be another type of publication that you can write on your own. Overall; is a type of publication where the author describes a number of different articles on the same topic in a single publication.
Biography is a section where you can present works and accomplishments of a person's personal and professional life as well as the presentation of an obituary. Similarly, another interesting category not in the table above, is ‘Medicine in Stamps’, a section published regularly in Singapore Medical Journal (http://smj.sma.org.sg/smjcurrent.html). In this section, the journal publishes the short biographies of eminent physicians or medical researchers e.g. Noble Laureates, on whom a postal stamp has been published. Letters to editors are probably the easiest among all publication types to publish. They are not peerreviewed and hence quick to be accepted or rejected. However, there are reasonably good chances that you will get it accepted if you read an article published in the issues of the journal before thoroughly, and comment about the contents or scientific aspects. Whereas it’s a non peerreviewed article, still considered as a proper publication and can be a good starting point. Most of the journals welcome conference proceedings from their relevant areas of interest. If you have attended any conference recently, you can write a concise report and submit it to the relevant journal. You need to remember though; most of these journals have a time limit of mostly a couple of months after the conference to submit a report. However, if you’re looking for a sureshot quick publication nothing can beat an Abstract. When you present a paper at a conference it is automatically published in the official journal of that society. It is quite easy to get a poster accepted in any conference, as they want people to attend and pay for registration fees! Most of the systems don’t differentiate between an Abstract and a proper Publication including ERAS (Electronic Residency Application System, USA) and ST Training, UK. You can indeed write this as a ‘presentation’ in your CV as well, hitting two birds with one stone! Other categories that can yield a relatively easy publication are Translated Articles and the Reproduction of interesting articles with the author’s permission. But be careful, reproducing an article in full or part without prior permission of the author/ journal is considered plagiarism! Some of the journals even publish cartoons, humorous medical caricatures, drawings and interesting photographs of medical significance, personal diaries or even laboratory manuals or simply lecturenotes or patient information handouts!
How to publish?
One of the toughest parts of writing a paper in the beginning. Do most people struggle to find where to start? Well, the most important step is to decide what you gonna write and grab a pen and a notebook. And then stick your bums to a chair and table! Start writing your thoughts. Jot down whatever comes to your mind about that topic. It doesn’t necessarily need to follow a logical pattern. For the first 5 minutes, it might look like clutter but keep on writing continuously for 30 minutes and then stop. See what you’ve done. You will find that there are portions in that clutter that look very logical and make clear sense. The next step is to tidy it up and
try to put your thoughts in a coherent way.
Whereas this technique can give you a good start, it definitely takes much more to write a quality publication. In order to achieve that you need to familiarize yourself with the different components of a paper. Whereas the format of a paper may vary according to its specific type, most scientific publications follow a structure. The different components of a scientific publication are as follows:
1. Title: A good title reflects the purpose of the study and the core idea behind the research. It shouldn’t be too long, or containing complex words and shouldn’t reveal the vital findings of your study. Leave the best for the last!
2. Abstract: This is a summary of your paper. Whereas the abstract is mostly written, at last, this is the most important part of your paper as this is the first part read by a reader and a reviewer and usually determines if it's worth reading the whole article. Two types of abstracts are prevalent depending upon the journal you’re targeting; structured and unstructured abstracts. Structured Abstract where abstract is divided into different sections viz. Background and Objectives, Material and Methods, Results and Conclusions. Most journals also want you to include few Keywords. Unstructured Abstract no such division in sections is required and a continuous summary is given, though following a similar pattern.
3. Introduction: Introduction, essentially speaking, states the background and objectives of your paper. The purpose of the Introduction is to focus the reader’s attention on the message authors want to deliver in this manuscript but NOT to deliver it! This is done by introducing the topic authors are addressing in the current manuscript. Provide a background on the current state of the particular topic covered in the study. Give a focused review of literature highlighting the controversies, deficiencies and differences of opinion etc, in the current literature. Include carefully selected citations to support or refute these deficiencies/ controversies. The second part of the Introduction is stating clearly your Aims and Objectives. The first part of the Introduction should naturally lead to Aims and Objectives. You should state the clear purpose of your study. You should be able to define a unique aim, what are the unique questions this study is trying to address? And how this is distinguished from the previous studies or the new knowledge added to the literature by this paper? Remember, defining clear aims for your study is the single most important step in writing a good quality publication. A study without a clear aim won’t appeal to readers.
4. Materials and Methods: This is should be relatively straightforward. You simply need to present a summary of the stepbystep process what you have done to conduct the study or research. The common pitfalls here are; authors are so involved in the study that they start taking it for granted that the readers will be familiar with the specific technicalities. And therefore fail to sum up the technical details of their experiment comprehensively presented in a language that a relatively nonexpert reader can understand. Classically, in Materials and Methods, you should include detail about study design i.e. Retrospective or Prospective, Case-control or Randomized, Review of literature, Case report, Technical note etc. Give demographic information about your cohort i.e. age, sex, number of cases, time frame, followup information etc. Describe any inclusion or exclusion criteria for your study. The material and methods section is replaced by Clinical Details in a case report. Finally, never forget to mention the ethical approvals. You should not give any results here, as there is a separate section for that.
5. Results: This is the organized presentation of the collected data. Try to present the data systematically and follow a pattern. Haphazard information is difficult to understand for both, readers and reviewers. Be consistent; don’t present any unnecessary data that is not described in the Materials and Methods section. Similarly, don’t leave anything out that you have mentioned before that you gonna do. You can use different formats of presenting your data including; charts, bars, graphs, pie charts, pictures, tables, etc. Chooses what suits best to your manuscript. Don’t use figures or tables just for the sake of using them. They should present meaningful info rather than making readers feel being snowed under by the heaps of meaningless data!
6. Discussion: Authors have some degree of liberty here in structuring discussion. But, generally, you start by summarizing your results and important findings. Compare your findings with the results from the previously done studies on the same subject. Highlight similarities and differences and offer a scientific explanation for the discrepancies. These discrepancies and differences may be the important outcome of your study so you need to explain them in the context of your research. You are allowed to make reasonable assumptions here if there are no direct explanations available from the literature. Try to explain the clinical implications of your study, if any. However, don’t repeat the findings of the Results section in the Discussion and don’t present any new data for sure! Last but not least, recognize the limitations of your research. Remember, no study is perfect!
7. Conclusions: This section concludes the findings of your research. Don’t try to make any speculations or assumptions. The conclusions are derived from what you have observed not from what you would have observed!
8. References: These are the citations of the previous works and studies done. You need to know what reference system is followed by the journal you are targeting and be consistent with that. Two, the most commonly used reference systems ate either Harvard or Vancouver. Here, you don’t have to be puzzled, if these words sound alien to you. Simply open any published article in the same journal and see how the references are used there. Look for; first, are they appear in alphabetical or as it comes in sequence. Second, in the body of the paper, are they used in a bracket or parentheses in roman numbers or they are used in the author-year style. Now see the references section. There are very subtle differences in the way they are written but journals want you to stick the way they are used in that journal. This can be a pain in the neck, believe me, as you are supposed to be accurate by comma and full stop! What to do then? Thanks to technology. You can use computer power to format the references. The two most commonly used software for formatting references are viz. Reference Manager and EndNote. I use EndNote regularly and can recommend it with confidence. This is a very useful tool and you can format all your references according to the style of journals in seconds. You can directly import the references online from PubMed and can create your own library. The references can either be copied/ pasted to the word document or can be exported. A snapshot of an interphase of EndNote is given here. The only thing here to remember is that some of the functionalities cannot be used on Mac, as usual with any other software!
Remember, the single most important step in the whole game of publications is submission. If you can’t submit, don’t write at all. You’re not writing a manuscript to keep in your pocket! Lots of people do this; they postpone the submission until very late. Hoping to ‘improve’ their manuscript and making it ‘perfect’. You got to remember; there is no such thing as ‘perfect manuscript’ exists in the world! Even the manuscripts that won noble prizes had a number of mistakes when they were submitted. So the best piece of advice I can give you all is SUBMIT your manuscript it's ready for the first time. Don’t worry about the rejections. They are the inevitable part of the game! You can’s escape rejections unless you’re a medical Shakespeare! And even then it's not guaranteed. There are more than 10,000 medical journals (I suppose) and there would be a couple of hundreds that will suit your research for sure. Nobody had to submit an article that many times before it gets published!
Few points to remember for submission
Most of the submissions are online nowadays. Open an account on the website of the concerned journal.*
Read the instructions to the authors thoroughly. They contain important information and your manuscript
won’t even go for review if you don’t adhere to them! Most of the journals are pretty strict with that. Look carefully at the word limits. There are different word limits for different types of manuscripts. Case reports are usually more restricted in terms of word limits than original contributions. Also, see what is the word limit for abstracts and if the word limit is including or excluding references.
You can find templates for manuscripts on journals’ sites or even in EndNote. You can use these templates to format your manuscript.
Look for the types of files they accept for images or figures and also the guideline for creating artwork. Most journals want all files uploaded separately e.g. Manuscript (with no figures but tables can be pasted at the end of the manuscript), consent letters from the patients/ subjects, ethical approval letters, figures, a declaration about the contribution agreement form signed by all authors, appendices, if any, etc. Some journals want figures to be embedded in the manuscript, as they should appear.
Some journals accept submission by email as well but it’s very rare if they accept manuscript submission by post.
Post submission saga: don’t keep your fingers crossed!
Grab a phone rather and give them a call! Yeah, that’s 100% true. This is the most important secret in the game of publication no one will ever tell you. What have you heard about the timeline in publications? I mean, how much time do you expect from the submission of a paper and the final acceptance or rejection? It could easily be 6 – 8 months and sometimes may run into years! And do you know where most of this time is consumed? Well, you will be surprised that most of the time your manuscript sits on the editor’s desk just for a glance before he can send it for review. Or even in a clerk’s email waiting to be ‘marked for’ editor. Editors are busy people, mostly professors and clinical directors in their departments. They do the job of the editor as an additional responsibility, mostly without any extra remuneration. Seeing your manuscript probably lies on the bottom of the list of millions of things they have to do! So if you think that your job is over after submission and the ball is in their court, you’re wrong! The ball is in no one’s court really! It is just in the air or maybe lying outside the court!
The bottom line guys, if you want to publish 10 publications in a year’s time (I published 20 in a year and a half!), the only way to speed things up is CALL, CALL, CALL and CALL. Bombard them with calls and emails requesting to send you the manuscript for review ASAP. Believe me, this is the only thing that works in this world!
Dealing with rejections:
How to deal with rejection? Hip, hip hurray! Well done!! Three cheers!!! That’s the only way to deal with rejections, honestly. You might think that I have gone mad, but I am not.
What do you gain from a rejection, especially if it comes quickly? Well, lots of things. First, every rejection comes with the reviewers’ comments. These comments are an invaluable source of improving the mistakes in your manuscript. No one will give you such comprehensive feedback as the reviewers can give, who usually are the best in the field of your research. Second, time is money. If the manuscript comes back to you fairly quickly you can always resubmit it to any other journal with all corrections. This time you knew your weak points and rectified them as well so the chances of success are far higher. Third, once you have submitted a manuscript somewhere, it is already formatted and as lots of journals have almost the same formatting requirements, it only needs a little bit of reformatting before it can be resubmitted in any other journal. What do you lose by a rejection? Probably nothing. No one asks that how many times a paper was rejected before it finally got published! So, the true secret of the publication lies in submissions and resubmissions!
Pearls for Authors
Few basic points to help you out
Most journals want manuscripts prepared doublespaced and figures and other relevant materials uploaded as separate files.
Look for special issues that suit best to your research. The chances of acceptance are far higher in special issues as they really ‘hunt’ for good paper on that topic and mostly cannot publish anything else in that issue other than the topic covered!
Target the right journal. Few points to remember here are; choose the right audience, choose a journal with high acceptance rates. Acceptance and rejection rates are usually given in the journal’s info. Browse few issues of the journal you are thinking to submit and see what kind of papers they generally publish. If a journal has already published almost same kind of article recently, it’s better to search for another one!
Publish in online journals. These journals are independent journals and the rates of acceptance are quite higher. The downside however is the low impact factor.
Find newly started journals. Same as online journals, chances of acceptance will be higher but not as prestigious!
Include big names in your paper. Most of your consultants and professors have already published lots of papers and have a fair idea of the process of publication so can give you very good guidance, if they are involved as well. Apart from that, whereas the review process is supposed to be ‘blinded’, the reviewers can usually make a fair guess about the author group involved. The chances are that your consultant may be a schoolmate of one of the reviewers or maybe they are members of the same golf
KISS: ‘keep it short and succinct. Nobody wants to publish epics! The chances of acceptance are much higher where the topic is presented concisely in a comprehensive manner.
Write a good letter to the editor. A letter to the editor is a requirement for submission in most journals.
Write a good letter and communicate the merits of your study clearly to the editor in chief as well as the suitability to the given journal’s readership. Being polite is always helpful.
Form ‘Writers’ Club’. A writers’ club can be formed to help people who are looking to publish and they can help each other in a number of ways. Apart from motivating each other members can help in critically reviewing the manuscript before submission, which can be very helpful.
Grammar and syntax. Nothing is more irritating than reading an otherwise interesting paper that is written in poor English. Pay attention, it's not difficult and you don’t have to be a medical Shakespeare in order to write good understandable English. Take help from your colleagues, if you want.
Statistics. Last, but by no means least! In fact, I would consider statistics one of the top factors affecting the chances of acceptance. Always apply at least basic stat in your paper e.g. mean, mode, median, etc. Calculate the significance (pValue) and describe your stat methods in the Materials & Methods section, separately. You will see the real magic if you can apply few complex statistics. If you can prove your point by statistics and can represent it on fancy graphs, no one can reject your paper, which I can guarantee!