Manuscript Writing: Problems and Solutions

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Manuscript WritingProblems and Solutions

• Hashem B El-Serag, MD, MPH
• Associate Professor of Medicine
• Michael E. DeBakey VA Medical Center
• Baylor College of Medicine

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Outline

• Obstacles to Writing
• Manuscript Writing
• Paper Submission Process

Tips to Increase Productivity
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I have not foundwriting one bit easier today
than it was 30 years ago. I still have to work
at it very hard and make many revisions, with a
rare exception because the saying of Francis
Bacon has always been deeply impressed in my
mind..Writing maketh an exact man.Morton
Grossman (gt400 scientific papers, 134
editorials, 71 books or book chapters)
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• The more you write, the better writer you will
  become
• If I can write in ENGLISH, most of you can

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Why Writing Is Important?

• No publication, no project
• Make information available for others
• No publication, no promotion
• Yardstick of productivity
• No publication, no funding
• What have you done for me lately?

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I would urge you to write, not because it is a
good thing, not because it is nice to see your
name in print, but rather because you will
really get to know a field only if you contribute
to itMahoney MJ, Psychology of the Scientist
1979
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Disclaimer

• This talk will not help you if you have nothing
  to write about
• Ability to ask a good question
• Commitment to career development
• Experience in research
• Ability to protect your time

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What is the gestational period for a clinical
science publication?
START
PROTOCOL/IRB 2-4 months
STUDIES/ EXPERIMENTS
4-24 months
14-44 Months!
WRITE AND SUBMIT
2-4 months
REWRITE AND RESUBMIT
2-4 months
2-4 months
WAIT
2-4 months
PUBLISHED!
BEST GUESS
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Setting Goals

• First author papers in major journals
• First author papers in secondary journals
• Total papers
• Non-first author papers
• Secondary journals
• Book chapters or review papers (AVOID)

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Tracking Goals

• Every 3-6 months, tabulate
• Published papers in past year (Ppub)
• Number of papers under review (Prev)
• Number of papers in preparation (Pprep)

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Probable Annual Production (PAP)
Ppub Prev Pprep
PAPraw
3
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Barriers to Goals

• Extrinsic
• Major teaching responsibility (Tr)
• Major committee assignments VA (C)
• Personnel disputes (Pers)
• Grants (Gr)
• Intrinsic

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Adjusted Probable Annual Production (PAPadj1)
PAPadj1 PAPraw - 2(Grn Persn) (Tr C)
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Intrinsic Causes of Writing Problems

• Internal Censors
• Fears of Failure
• Perfectionism
• Procrastination

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Censors

• Watchers at the Gate
• Internal censors
• Internal critics
• Induce bad feelings about writing
• Undermine ability to generate ideas

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When you hear him, the internal critic speaks in
a shrill tone- rational, often pessimistic,
alerts only to the dangers of the world around
us, and therefore to the shortcomings in our
work.Assuming the voices of parents, teachers,
and other authority figures, he whispers and
sometimes shouts that our writing is badHe
edits words and thoughts before we have a chance
to put them on paper, and thus creates a blank
page panic.
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Intrinsic Blocks to Writing (I) Inability to
Start Writing

• First, there is the difficulty of writing at
  all
• D. Brande Becoming a Writer
• Perfectionism, self-consciousness,
  procrastination

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How To Increase and Sustain Productivity

• Time management
• Stimulus Control
• Contingency management
• Limit Setting

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How to Start

• Daily
• 30 minutes to one hour
• Do not pay attention to structure, grammar,
  spelling

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Spontaneous Writing

• You cant think and hit at the same time Yogi
  Berra
• Learn to write
• Without feeling ready
• Without feeling fully in control
• Without awaiting inspiration
• Learning to write at a gallop leaves ones
  internal critics behind. Virginia Woolf
• Once under way, writing builds its own momentum

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10
of typed-page equivalent
9
5
8
of hrs writing
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4
6
5
3
4
2
3
2
1
1
Scheduled Writing Days
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Best Time to Write

• Morning
• Afternoon
• Evening
• Night
• Pick a time and protect it

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Stimulus Control

• Few regular places to work
• Close the door
• Unplug the phone
• No e-mail
• Arrange the site
• But do not clean up the office

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Priority Principle

• Law of Delay
• That which can be delayed, will be
• Priority Principle
• That which can be delayed, need not be
• Decide which recurrent, daily activities you
  enjoy and make them contingent on doing a
  valuable but delayable activity
• Require the daily occurrence (of writing) before
  more recurrent activities such as eating, or
  taking a shower

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(II) Inability to Finish Writing

• Multiple revisions
• Multiple analyses
• Each time I think I am finished, I see there is
  a lot more to do
• Similar roots as inability to start
  (perfectionism)
• Different people
• Lack of insight

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Placed on top of that unfinished manuscript, The
Original Writer's Block can be effective against
the obsessive distractions that can plague a
person during a writing slump. A wonderful gift
that works wonders, it does so by providing the
kind of symbolic focus and psychological boost
that creative people so often require.
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How to Write a Manuscript

• Assemble the material
• Tables
• Graphs
• Protocols
• References
• Refman, Endpoint
• The analyses should precede the writing

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Authorship

• Decide on authors, and their order, as early as
  possible
• Preferably before starting the project
• Authors should only include those who made
  substantive intellectual contribution to the
  project reported, and can defend the data and
  conclusions publicly.

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Where To Send The Paper?

• Who is the audience?
• Apply the who-cares test
• Select the journal
• Check the requirements
• General Medicine vs. Specialty vs. Methodology
• Start high but realistic
• Consult with senior person
• Choose electronic submission when available
• Make sure you receive a notice of receipt
• Choose the target journal before writing the paper

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Map

• Develop an outline with major and minor points in
  each section
• Write first draft
• Give to coauthors
• Revise the prose style for fluency, clarity,
  accuracy, and grace
• Review references and citations
• Review format

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OR

• Start with finalizing the Results
• Shells for Tables and Figures
• Background
• it is easier if you know the results

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Never Throw Away a Good Sentence

• There is no good writingonly good re-writing
• Rationale We are better at editing than writing
• Methods of conserving sentences
• Write about the same thing
• Use similar methods
• Dictation

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Title

• Key elements that advertises the papers contents
• Informative and Specific
• Design
• Results (give it away if new or controversial)
• Inquisitive
• Remove empty phrases such as A study of..
• Subtitles
• Often helpful to choose the title when the paper
  is complete

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Abstract

• Conclusions should answer the Background/Aims
  
• Results should have meat in it (participants,
  follow up, findings, analyses)
• Check the numbers against the main text

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Introduction/Background

• Magnitude/importance of the problem
• Why this study has to be done
• Dont make it a review article
• Dont put down every all previous studies
• Dont explain pathophysiology irrelevant to your
  study

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Methods and ResultsKnow the Lingo

• Lang TA, Secic M. How to report Statistics in
  Medicine Annotated Guidelines for Authors,
  Editors, and Reviewers. Philadelphia (PA)
  American College of Physicians 1997.
• CONCERT guidelines for RCT

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Results

• The heart of the paper
• Provide only enough interpretation to lead the
  reader from one experiment to the other
• Avoid lengthy analysis and comparison to the work
  of others
• No need to follow chronology of study
• Rather, provide a logical progression and tell a
  story

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Results

• Stand alone tables
• Make sure totals add to 100
• Do not repeat the Tables and Figures in text
• Summarize eg, there were no significant
  associations
• Describe eg there was a three fold increase in
  the risk of ..
• Rate/proportion/frequency/ratio

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Do NOT

• Use big words that you do not really mean
• Attributable
• Causality
• Preferential
• Significant (without statistical evidence)
• Validity
• Mix incidence and prevalence
• Mix frequency, rate, proportion, ratio

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Discussion

• How the findings relate existing literature
• Support but using a different angle
• Extend
• Different conflicting, inconsistent,
  limited generalizability as possibilities for
  differences
• Avoid sweeping statements first, only, best,
  previous flawed studies
• If not a review article, dont make it one
• Unlikely reason for getting rejected
• Good place for deliberate omission

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Discussion Limitation and Acknowledgment

• Limitations (followed by strengths)
• Show yourself as a critical thinker
• Do not over do it otherwise why did you do the
  stupid study
• Complete the argument (think it through) many
  limitations may be true but they would not
  explain the results

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References

• Reviewers tend to read these first
• Be generous in acknowledging previous work
• Quote potential reviewers
• Spell my name right.. EL-SERAG
• Use software (Refman, End Note)

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Reviewers

• Anticipate reviewers
• Choose reviewers
• Choose non reviewers
• Schmooze potential reviewers
• Leave traps in the manuscript

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Dealing with the Journals Response

• Unconditional Acceptance
• Rejection

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Dealing with the Journals Response

• Absolute Rejection
• Dont take it personal
• Dont write or call the editors (unless you know
  them well !)
• Editorial rejection send it out the next day to
  another journal
• Reviewers comments
• Fix the easy ones
• Fix the glaring ones
• Unlikely to get much better sitting on your desk
• Send it out the next day

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Dealing with the Journals Response

• Conditional acceptance (rejection)
• It is yours to lose
• First cool down (24-48 hours)
• Within 1-2 weeks decide on responses
• Make real changes, say you have done great
  changes (describe, highlight,etc)
• Look for clues from the editor as to the extent
  of the revision needed.
• Avoid arguments
• Thank sincerely, but avoid being obsequious

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Learn to Enjoy the Road
El-Serag et al 1998. Number of citations
0 El-Serag et al 1999. Number of citations gt450
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WRITING TIPS

• Authorship
• Division of work
• Pick journal
• First draftGET IT OUT!

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COMMON CRITICISMS
I dont like this paper

• The manuscript is 30-50 too long
• Overall structure is out of order sequence!
• Paragraphs lack smooth transitions
• Discussion simply re-states the results
• So what does it mean? What are the implications
  of these findings?

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PICKING YOUR TEAM

• High PAP team members
• Make and meet deadlines
• Establish writing culture and rules of authorship
• Choose team members interested in your content or
  methods

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Submission Letter

• Identify the paper
• Describe the paper
• Repetitive publication and duplicate submission
• Conflict of interest
• Corresponding author
• Suggest reviewers

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Decide on the Message of the Paper

• What is the main point?
• Can you state it in one sentence?
• You may not be sure until you searched the
  literature
• Hint You should have done that already

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Critical Argument

• Why did you start? Question
• What did you do?
• What answer did you get?
• Your finding, evidence, counterevidence
• Assessment of conflicting evidence
• What does it mean anyway? Answer

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• Know how to read your own writing carefully and
  revise it thoroughly.
• Identify drafts in a logical way

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PUBLICATIONS ARE IMPORTANT
Criteria for academic promotions
Assistant Professor 1-4 papers Associate
Professor 20-40 papers, 7 years, grant
funding Professor 30-50 papers sustained
grant funding
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Life is Too Short

• Is the paper worth writing?
• Have similar findings been reported?
• Is there a need for another report?
• Are your findings more convincing?
• Is the paper important?
• Apply the so-what test

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Format

• Double space
• Each section on a separate page
• Use subheadings (in methods, results)
• Page numbers on the right (bottom..or top)
• Make sure font size and type consistent
• Format the documents 1 to 1.5 inch form the top,
  bottom, sides

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2 GET FORMAL TRAINING IN CLINICAL RESEARCH

• Study design
• Study analysis
• Ability to understand the results
• Training Curriculum in Patient-Oriented Research
  (TCPOR), an in-depth NIH-funded program at 58
  institutions
• Extra degree that has at least two letters in it