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					Association of Academic
Dermatologic Surgeons
            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
       How to Write a Paper ?

  Disclaimer: My Perspective. Everyone is
different. These are just guidelines and pearls
            that I have found useful.
How to Write a Paper
               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
            The Evidence Pyramid
                                      Systematic Review
Randomized Controlled                  & Meta-Analysis
Trial (RCT) Double Blind

                           Cohort studies

                     Case Control studies

                            Case Series

                           Case Reports

                Ideas, Editorials, Expert Opinion

                   Animal research, Test tube
    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
Writing a Paper: Getting Started
“The only way to learn to write is to write”
  --Peggy Teeters

 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
Writing a Paper: Getting Started

 Find statistician BEFORE study
   Sample size
   Power analysis

   Appropiate statistical tests

 Select journal-review guidelines
             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
  Write Manuscript--Structure
Parts of a in What Order?

“Writing is a lot easier if you have something to say”
--Sholem Asch
                Methods I
For informed readers this is the most important
 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
             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
                        IRB !!
 Start by reading your local IRB website
 PEERRS certification: Program for Education and
 Evaluation in Responsible Research and Scholarship
   Fulfillsthe NIH requirement for human subjects
    training for PIs and "key personnel”
 Trials MUST be enrolled for publication in
  the best journals
                      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.
                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
               Results II
 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
Statistical vs. Clinical Significance
    Is it real? vs. Is it important?
   There are three
      kinds of lies:
lies, damned lies, and
   In God we trust
All others must bring
                                Mark Twain
             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)
             Discussion II
 First answer the question posed in the
 Summarize previous work-compare your
 Explain what is new without exaggerating,
  perspectives, implications
 What do your results mean? - clinical
  practice, management, policy
             Discussion III
 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
 Short (3 paragraphs)-1 typewritten page
   First   paragraph      What we know?
    Brief background-establish context, relevance,
     nature of the problem/question/purpose
   Second     paragraph What we don’t know?
    Importance of the problem and unresolved issues
   Last    paragraph Why we did the study?
    Rationale: state hypothesis/main objective/purpose
 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
   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
 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?
             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
              Style and Authorship
 Follow ICMJE* criteria:
    Uniform   Requirements for Manuscripts
      Submitted to Biomedical Journals
 Order:
    Firstauthor-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
        Accuracy, 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
              Accuracy, 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
 Avoid overusing there is, there are, it is, it was, etc.
Active: Scientists have conducted experiments to test the hypothesis
   There are treatment guidelines for Merkel cell
   carcinoma that been conducted by scientists to test the hypothesis
Passive: Experiments have were reported by Bichakjian, et al.

                          Active (more concise)
  Passive (more wordy) guidelines for Merkel cell
   Correction: Treatment
    carcinoma were reported by Bichakjian, et al.
          Accuracy, Clarity, Brevity
 All first drafts have too many words
 Next drafts: prune vigorously, avoid repetition,
  wordiness, long sentences, excessive
 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
   a majority of = most
   a considerable amount of = much
   a number of = several/some
   on account of = because
                               “Those who
   referred to as = called
                               have the most
   has the capacity to = can
                               to say usually
   it is clear that = clearly
                               say it with the
   at the present time = now
                               fewest words”
   give rise to = cause
   is defined as = is
   subsequent to = after
      Accuracy, Clarity, Brevity

 Abbreviations and Acronyms
 Liked by authors, disliked by readers
 Reading should not require a glossary
 Unwieldy word occurring > 10 times
 Avoid using colloquial language
        Troublesome Terms

 And/or: and or or alone usually suffices
 Diabetic as a noun may be condescending
  to some, patient with diabetes
 Significant means statistically significant
 “Firstness”-provide details if true, rarely
             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
   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
              “Deadly Sins”
           Publish and Perish
   Data manipulation, falsification
   Duplicate manuscripts
   Redundant publication
   Plagiarism
   Humans use concerns
   Animal use concerns
   Author conflicts of interest
   Failure to discose conflict of interest
 What is Redundant Publication?

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

 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
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!
        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
   What Happens Next?
The Review Process
 Acceptance    If at first
                 you don’t
 Revision        succeed,
                you’re about
 Rejection       average!
    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 is really, really hard, but it is really, really,
    really, really important
Responding to Reviewers-Revision
 Carefully prepare your responses
     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
          -disappointing at best

A journey of a thousand miles sometimes
ends very, very badly
   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
 May be nothing basically wrong
   More  confirmatory than original
   Insufficient priority, backlog inventory

 Wrong journal
        Why Papers are Rejected II
   Poorly written
    Your manuscript is both good
    Sweeping conclusions-unjustified by data
   and (IRB) approval not obtained
    Ethicsoriginal, but the part that
   is good is not original, and the
    Flawed or poor study design-methods
  Unrepresentative original is not good.
part that issample(s)

                       --Samuel Johnson
      Uncontrolled, poor controls, nonrandomized interventions
     Sample size too small

     Incorrect statistical analysis

     Hypothesis not adequately tested
 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!
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
           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
Introduction to Evidence Based Medicine: Critical
      Appraisal and Informed Medical practice
Introduction to Clinical Medicine - Professional Skills January 2005

Professor Trisha Greenhalgh (University College London)
"How to Read a Paper" Series
Getting your bearings (deciding what the paper is about). BMJ 1997;315:243-6.
Assessing the methodological quality of published papers. BMJ 1997;315:305-8.
Statistics for the non-statistician. II: "Significant" relations and their pitfalls. BMJ
   1997; 315: 422-425.
Statistics for the non-statistician. I: Different types of data need different statistical
   tests. BMJ 1997;315:364-6.
Papers that go beyond numbers (qualitative research). BMJ 1997;315:740-3.
Papers that summarise other papers (systematic reviews and meta-analyses). BMJ
Papers that tell you what things cost (economic analyses). BMJ. 1997;315:596-9.
Papers that report diagnostic or screening tests. BMJ 1997;315:540-3.
Papers that report drug trials. BMJ 1997;315:480-3.