How to get your research published

This presentation, which the BMJ’s research editors Domhnall Macauley, Elizabeth Loder and Trish Groves have given at conferences around the world, explains how to get your research published. It includes clear guidelines on how to write a paper, clinical trial registration, ethics, authorship, conflicts of interest and how to navigate the peer review process.

Electronic medical publishing: We’re not in Kansas anymore

Some day, we might say it all started at the BMJ.

Beginning with the first issue of 2010, clinical research articles in the BMJ print version are limited to structured 1-page summaries. The full text of these articles are available online and are accompanied by a host of additional features including tables and figures, commentaries, blogs, videos, rapid response tools, and podcasts.

For the readers, this is an abrupt shift, but Dr Fiona Godlee, BMJ Editor, says the change process was cautious and paced. “We have known for some time that the needs of authors and readers are different. Authors want length and lots of space, while print readers are likely to read only research abstracts.” Thus, the BMJ editorial staff concluded that original research belongs online, in an open-access format, with no word-limit restrictions, and alongside extensive backup content – a publication strategy that frees up more space in the print journal for educational content, columns, and reviews.

Is the BMJ approach an anomaly, or the start of a new trend in medical publishing? Albeit an unscientific sample, we interviewed several editors and publishers, who suggest that print versions of most journals, except perhaps for certain speciality journals, will remain intact for the foreseeable future. However, there was universal agreement among those interviewed that journals are substantially expanding the amount of content provided online. According to Dr David Hughes, Managing Director of Expert Reviews in Pharmacoeconomics and Outcomes Research, “There is an increasing need to augment articles in a more interactive way – to make the terrain less flat.” At the same time, he notes that a fixed role remains for print journals, for example in underdeveloped nations.

Dr Christine Laine, a member of the Secretariat of the International Committee of Medical Journal Editors (ICMJE) and Senior Deputy Editor of the Annals of Internal Medicine, notes that the publishing world is watching closely to see if the BMJ experiment takes off. Says Laine, “This change certainly fits with the realities of practising physicians, whose biggest pressures are related to limited time, including limited time to read medical journals.” The change also reflects current ‘green concerns’ related to paper, printing, and transportation (the reduction of which, serendipitously, translates into financial savings for journals likely to be deprived of print advert revenue). Although Laine and others have found that readers still want to ‘hold the paper’ when they perform in-depth reading, they also think that e-readers like the iPad will become the next norm. According to Laine, “People tend to use print when they are sitting down reading something in-depth, and electronic information when they are looking in a more hurried manner.” In other words, we have not yet found the e-technology that will force that final step away from the printed page.

However, Hughes believes that BMJ’s ‘hybrid’ content is well-suited to its new publication plan. That said, he indicated that format might be unfavourable for other publications or article types – such as the comprehensive reviews favoured by Dr Hughes’ publication, which would not translate well in abbreviated form.

Dr Gregory Curfman, Executive Editor of the New England Journal of Medicine (NEJM) believes that rapid turnaround is one absolute benefit that online publication offers to both researchers and journals. Says Curfman, “To keep information from the health care community simply because the printing press has not yet run does not make a lot of sense to me.” However, Curfman also believes that a ‘tipping point’ has not yet been reached where researchers will be satisfied with online publication only; authors still want the sensory experience of being able to see and hold their published work.

Christopher Carswell, Editor-in-Chief of PharmacoEconomics, offers a more cautious view of fast-track publication. He is concerned that it would be impossible for editors and peer reviewers to adequately review or revise a clinical study or health economics model under extremely tight timelines. Along similar lines, Laine warns of the need for increased editorial vigilance once online content grows and word limits disappear. If journals publish articles online without sufficient editorial input, says Laine, “this will do a disservice to the readers, who really need to understand the methodological details of the study.”

Laine cites the authorship burden imposed by space limitations when dealing with complex research methodologies such as meta-analyses or systematic reviews. Carswell agrees, and emphasizes that online access enables readers to more closely review and understand the design and content of health economics models. Says Carswell, “Whether it is a standard Markov decision tree or a regression, you just cannot include that level of detail in a printed paper. This is an effort to increase transparency.” Of interest to HOC readers, Carswell also mentioned that the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) has recently implemented a task force to develop standardised guidelines for health economics and outcomes research publication preparation and submission.

Excluding these caveats, however, publishing professionals agree that making more content easily available online is a positive step forward. Curfman and others note that online readership is swelling, even as print readership shrinks somewhat. The BMJ experiment is into its fourth month, and Godlee notes that, despite some concerns expressed during the transition period of the last couple of years, not a single complaint has been registered since the new format’s introduction.

What’s next for BMJ online? How about brief commentaries from authors, as well as full access to the peer reviewer-to-author communications? In addition, the BMJ editors hope to provide authors with the bandwidth required to publish all of their data online.

Although Hughes expresses some sadness that the increased computerisation of our medical literature might lead to the death of activities such as perusing the actual journals in an actual library, he is happy to acknowledge that the benefits of serendipitous browsing might extend to the online universe.

According to Laine, no matter what course is taken, the top priority for editors should remain the same. “We need to focus on publishing papers with the potential to effect change in how we care for patients, educate physicians, or set the agenda for future research.” At the same time, to hold onto and even encourage greater readership, it is imperative for publishers to try and anticipate how physicians will use information 5 to 10 years from now. Laine says, “We need to try to be more forward looking, as opposed to always playing catch-up.” If this is the case, the next few years in the medical publishing industry should definitely be interesting

The art of online networking

Think about all the people you know. And then about all the people they know. Now imagine being able to connect with all of them at the touch of a button. That’s the premise of social media sites like Facebook and LinkedIn. For savvy networkers, they can be a virtual goldmine.

Ready to start digging? A few pointers will set you on the right path — and help you avoid the biggest pitfalls.

Enduring truths

There’s more to making connections in person than shaking hands and handing out business cards. Not surprisingly, the same rules apply on-line.

Focus on developing relationships, not building the biggest possible contact list. Think about what you can give as well as what you can gain: offer advice, make referrals, and share useful resources.

And just like in real life, appearances count, so choose your photo or avatar with care. Likewise, watch what you say: nothing in cyberspace is truly private.

Social media savoir faire

While social media sites can be powerful networking tools, they also give rise to some sticky social dilemmas. Do you really want to add that annoying woman from last week’s conference to your circle of Facebook friends?

Others judge you by the company you keep, so it pays to be a little selective with your connections. Develop a few personal guidelines about what kind of contacts you want to cultivate.

If you do decline an invitation from someone you know, consider sending a polite note explaining your policies. (Complete strangers who contact you with a boilerplate ‘friend me’ request can simply be ignored.)

Extending an invitation to someone? Take a moment to personalize the boilerplate invitation that LinkedIn or Facebook supplies. Remind the recipient of how you’re acquainted or what you have in common. Explain what you hope to get out of the connection and what you hope to offer.

Facebook specifics

The biggest danger of Facebook — aside from consuming far too much time of your time — lies in blurring the line between your professional and personal lives, so invest some time in mastering the privacy settings.

Consider using the Friend Lists function to set up categories of contacts, such as Family, Close Friends, Coworkers, and Business Contacts. Once you have these in place, you can designate which groups can post to your wall, for example, and which can see the photos from last weekend’s wild party.

Be careful about disclosing personal information. Your profile will automatically display the year of your birth, for instance, unless you change the default settings.

Protect the privacy of others as well. A Facebook wall is public space, so while it’s the perfect venue to congratulate a co-worker on her promotion, save more personal comments for e-mail or a private Facebook message.

Want to promote your company, organization, book, or conference? Check out Facebook’s Pages feature.

LinkedIn specifics

LinkedIn is often described as Facebook for business, free of any distracting games, virtual gifts, or ‘What Sex in the City character are you?’ quizzes.

Start by creating a networking-friendly profile. For the Summary Section, think elevator pitch or cocktail party introduction: something that displays a bit of personality as well as summing up your professional strengths and interests. Filling in the Experience and Education sections will help people make connections with you.

Don’t post your email address on your profile, however. Because LinkedIn works by tapping the networks of people you know, encouraging strangers to contact you is a no-no.

Successfully worked on a project with a colleague? Ask him or her to write a brief recommendation that you can include with your profile. (When you receive it, don’t forget to send a note of thanks!)  And be open to writing endorsements for others — but only if you can genuinely recommend them.

Closing thoughts

Social media success boils down to two key principles: showing consideration for others, and following Roman rules when you spend time in Rome.

Respect other people’s time, privacy, and contacts. Social capital is valuable, so don’t turn off friends and colleagues with ‘me, me, me’ marketing. And whenever you join an online community, whether it’s Facebook, LinkedIn, or a dozen other lesser-known sites, tread carefully until you understand the accepted conventions.

Editor’s note:

The following LinkedIn groups may be of interest:

Making molehills out of mountains – of clinical data

By Mary Gabb (mgabb@rxcomms.com)

Writing a manuscript can be daunting, even for a seasoned researcher. How does one synthesise a coherent publication out of the mountain of accumulated data?

The most traditional approach is to start with the IMRaD principle: Introduction, Methods, Results, and Discussion. But how to summarise all of those results?

This is a common challenge, but it can be overcome with a straightforward approach and by being mindful of two key principles:

• Always keep in mind the original research question. All of the data you choose should be able to answer the original research question. Data that do not answer the primary question should not be included (although if secondary endpoints or hypotheses were tested, relevant data for those questions can be included, depending on your word count limits).

• Be as clear and transparent as possible. After reading your manuscript, the reader should be able to duplicate your study design and results. Regarding the data, be sure to include:

• All data related to the study sample (eg, race/ethnicity, education, socioeconomic status, etc)
• Statistical analyses
• Characteristics of diagnostic tests
• Study limitations (eg, sample size, type of data, low response rate).

It is also important to present your data clearly:
• Write in short, direct sentences
• Try to present as much data as possible, and in short tables and figures
• Report data comparisons clearly (for example, actual “raw” data as well as absolute or relative risk reduction, confidence intervals as well as P values).

Finally, consult checklists used by journal editors, such as the Consolidated Standards of Reporting Trials (CONSORT), the Quality of Reporting of Meta-analyses (QUOROM), the Meta-analysis of Observational Studies in Epidemiology (MOOSE), and the Standards for Reporting of Diagnostic Accuracy (STARD).

How to make the best use of graphics

The power of a graph lies in its ability to convey a variety of complex relationships in a way that is difficult to describe in words, but is easily comprehended from a picture. When designing a graph, consider these points:

• Avoid fussy, excessively complicated graph design;

• Don’t use 3D graphs. They are usually harder to interpret and more cluttered than 2D graphs (see Figure 1);

• Reduce clutter by removing key borders and gridlines (see Figure 1b);

• Avoid bold shading or cross hatching which can cause distracting visual effects (Figure 2);

• Use colour and shading sparingly as it distracts from the message;

• Avoid graph designs that use keys. Where keys are unavoidable, use the simplest key available (Figure 1b);

• When adding text, use plain English, and avoid jargon and repetition. In addition, use the same typeface as the graph (preferably a sans serif font), avoid fancy lettering and fonts, don’t mix upper and lower case lettering, and don’t box the text;

• Where several graphs are used for similar types of information use, where possible, the same scales on the x- and y-axes; and

• Where practicable avoid truncating the axes, unless it will inform rather than mislead the reader (Figure 3).

How to use visual images when explaining QALYs

Before lecturing on quality adjusted life years (QALYs) you should carefully consider the most appropriate way to educate an audience.

The most obvious visual image related to QALYs is the graph of health utility over time. However, health economists called upon to give one-shot lectures to clinical audiences should not limit the visual images they employ to these standard graphs. The use of visual images relevant to clinicians’ day-to-day professional lives can facilitate communication.

Imagine discussing a series of syringes, flasks, and vats to illustrate the aggregation health-related quality of life over time and among individuals.

To begin illustrating the concept of measuring health related quality of life, you could ask members of a clinical audience to imagine filling a 10mL syringe in proportion to their personal feeling about health-related quality of life on the day of the lecture. When comparing different individuals, syringes filled with more liquid represent a higher quality of life for that individual.

To characterise health-related quality of life over a year, you might ask members of your audience to imagine filling a syringe each day. At the end of the year, the contents of all 365 syringes are emptied into a single flask that measures 3.65L of liquid when full.

The number of QALYs experienced by the individual in a year would be the fraction of the flask that is full. Many different sequences of syringe levels (i.e. daily quality of life) can yield the same total amount of liquid after a year.

The calculation of QALYs cannot distinguish among these sequences. The fact that the sequence of health-related quality of life experiences during a year does not affect the QALYs that are calculated is the key insight regarding aggregation over time for an individual.

Then, imagine a population of 100 individuals, each of whom has filled some fraction of a 3.65L flask. The QALYs experienced by the population (an important component of a cost-effectiveness analysis) can be measured by emptying all 3.65L flasks into a 365L vat.

The fraction of the vat that is full measures the average QALYs experienced. The key insight for aggregation at this stage is that the distribution of QALYs among members of the population is not considered.

An economist who wants to facilitate understanding of cost-effectiveness and QALYs should take advantage of the opportunity to be creative, or even light-hearted, when choosing visual images to use in a lecture. The images must meet two primary criteria: being appreciated by the audience and being easily explained by the economist.

Watch your language

As Oliver Wendell Holmes, Sr., the famous American physician and writer, wrote in his essay titled Scholastic and Bedside Teaching: “I would never use a long word… where a short one would answer the purpose. I know there are professors in this country who ‘ligate’ arteries. Other surgeons only tie them, and it stops the bleeding just as well.”

Here are a few more words and phrases to avoid:

• multiple for many
• interface for talk
• time frame, or period of time, for time
• great majority for most
• ongoing for continuing
• demonstrated for showed
• enhances for increases
• minimises for decreases
• optimal for best
• prior to for before
• following for after
• quantify for measure
• input, impact and dialogue – used as verbs

From Edith Schwager’s book Medical English Usage and Abusage (Greenwood Publishing Group/Oryx Press).