Concise Academic Writing

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Concise Academic Writing

• Mark I. Langdorf, MD, MHPE, FACEP, FAAEM,
  RDMSProfessor and ChairUniversity of
  California, IrvineEditor, Western Journal of
  Emergency Medicine

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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

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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

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EM Subspecialty Journals

• Pediatrics Pediatric Emergency Care Clinical
  Pediatric Emergency Medicine
• Disaster Medicine Disaster Medicine Disaster
  Management and Response (for nursing)
• Emergency Medical Services Journal of
  EMS Emergency Medical Services Prehospital
  Emergency Care
• ED Management ED Management Emergency Health
  Services Quarterly Emergency Health Services
  Review

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EM Subspecialty Journals

• Emergency Nursing Journal of Emergency
  Nursing Emergency Nurse
• Accident and Emergency Nursing
• Emergency Radiology
• Emergency Surgery Journal of Trauma Injury
  Infection and Critical Care Turkish Journal of
  Trauma and Emergency Surgery
• Reviews Topics in Emergency Medicine Emergency
  Medicine Clinics of North America
• Emergency psychiatry
• International Journal of Emergency Mental Health
• Injury prevention Traffic Injury Prevention

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Aims and Scope

• Go to website. Does it fit your paper?
• First/resident projects rarely make top tier
  journals
• Take advice from mentor
• Review process 2-4 months
• Very useful but painful review

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Throwaway Journals

• Sent without subscription or society membership
• Authors are paid to write
• Not considered academic
• Not or loosely peer-reviewed
• Not evaluated for accuracy or completeness
• Classic example Emergency Medicine (magazine)
• Looks like you could throw it away when youre
  done

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Writing Tips

• Write with a partner/collaborator
• Youll keep each other on track
• Three-hour blocks minimumstay in the zone
• Use the draft of the paper as a notepad
• When to start next time
• What new references you need
• What new statistical analysis you need
• Put brief citations at end of sentences
• Assemble final reference list at the end
• Use Endnote or similar
• Automatically reformats references to conform to
  new journal

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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

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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.

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The Structure of DNAWatson and Crick, Nature,
1953
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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?

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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

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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.

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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.

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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

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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
  doesnt belong in a research paper.

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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

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Sitting Down to Write the Paper

• Use template from UC San Diego Emergency Medicine
  Residency included in your syllabus

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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.

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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

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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 reviewers mind
• What else is wrong if they cant even get this
  right?

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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.

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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

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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.
  200545448-451 with 12 criteria for a proper
  methods section

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Worster and Bledsoe
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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
• Dont repeat results from a table in text
• Instead refer to general synopsis of the tabular
  results

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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

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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

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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.
1999123235-240
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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

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Fagan Nomogram
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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.

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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

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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

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Conclusions

• Dont 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.

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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

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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

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Responding to the First Critique

• Expect the paper to be rejected
• Only 5 of papers are accepted without revision
• You will get pissed
• The reviewer will ask you to do things you cant
  fix
• At first reading, you wont understand how the
  reviewer could possibly have misunderstood or
  been confused by your paper
• Put the paper down for three days to let your
  anger subside.

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Rewriting the Paper

• Editor must see you took the review seriously
• Even if rejected outright, respond to critiques
  completely before sending to new journal
• If first reviewers were confused
• Use constructive tone to respond to same journal.
  Dont be defensive.
• Respond within one month
• Familiarity with the paper will increase chances
  of acceptance
• Author to upload point by point response to
  review under supplemental content.

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Questions?