Robert B. Taylor (auth.)-Medical Writing_ A Guide for Clinicians, Educators, and Researchers-Springer-Verlag New York (2011)

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Medical Writing
Medical Writing
A Guide for Clinicians,
Educators, and Researchers
Second Edition
Robert B. Taylor, M.D.
Robert B. Taylor, M.D.
Department of Family Medicine
Mail Code FM
Oregon Health & Science University School of Medicine
Portland, Oregon 97239-3098, USA
ISBN 978-1-4419-8233-9
e-ISBN 978-1-4419-8234-6
DOI 10.1007/978-1-4419-8234-6
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2011931891
© Springer Science+Business Media, LLC 2005, 2011
All rights reserved. This work may not be translated or copied in whole or in part
without the written permission of the publisher (Springer Science+Business
Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief
excerpts in connection with reviews or scholarly analysis. Use in connection
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The use in this publication of trade names, trademarks, service marks, and
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expression of opinion as to whether or not they are subject to
While the advice and information in this book are believed to be true and
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Printed on acid-free paper
Springer is part of Springer Science+Business Media (
For Francesca, Masha, Jack and Annie
This book is intended to make you a better medical writer.
This is true whether you are a clinician in a busy practice,
an educator teaching students in the health professions, or
a researcher who conducts and reports randomized clinical
trials. It is for the physician, physician assistant, or nurse
practitioner who sees patients and who also wants to contrib-
ute to the medical literature. It is for the medical educator
writing articles and book chapters to share new information
and, incidentally, to attain promotion and tenure. And it is
for the investigator whose career success depends, in large
measure, on critical skills in developing research protocols,
preparing grant applications and writing articles describing
the eventual research findings.
If you are new to medical writing or even if you have
been the author of some articles or book chapters and seek
to improve your abilities, this book can help you. Who am
I that I can make this assertion and write this book, both
fairly presumptuous acts? Here’s my reasoning. As a prac-
ticing physician and medical educator, writing has been my
avocation. Over 14 years in private practice and 32 years in
academic medicine, I have written using all the major models
described in this book: review articles, case reports, editori-
als, letters to the editor, book reviews, book chapters, edited
books, authored books, research protocols, applications for
grant support, and reports of clinical research studies. Most
items submitted for publication have been published. Not
all. Perhaps my most noteworthy qualification is not that I
have managed to produce a lengthy curriculum vitae. In my
opinion, what is more important for you, the reader, is that
I have made all the errors. That’s right, the mistakes. Over
the years, I have jumbled spelling, mixed metaphors, tangled
syntax, gotten lost in my own outline, written on unimportant
topics, submitted grant requests that seemed to befuddle
reviewers, and offered articles to the wrong journals. But
along the way, I have published 25 medical books and added
several hundred papers and book chapters to the literature.
This book is written to share what I have learned—what
works and what doesn’t in medical writing.
This book aims to help clinicians, educators and research-
ers translate their practice observations, pedagogical innova-
tions, wise thoughts, and investigational data into written
form and eventually into print. In striving to achieve this
purpose, I have written the book with four objectives in mind.
Upon completion of this book, the reader should:
understand more about the art of medical writing, includ-
ing motivation, conceptualization, composition, and frus-
know how use the different models of medical writing,
such as review articles, report of clinical research, and
recognize how to get a manuscript published; and
realize that writing can be fun.
Compared to the first edition, which targeted the cli
nician as reader, this second edition of the book has an
expanded scope, with added material to help the educator
and the clinical investigator—especially the relatively new
academician who has encountered the infamous “Publish
or perish” imperative. I have added two important, and
somewhat technical, new chapters:
How to Write a Research
How to Write a Grant Proposal
. Also, through
out the book, I have updated content and added new con
cepts and examples, including technical advice on creating
tables and figures, and tips on electronic submission of
manuscripts. In Chap. 12 there is a new section about the
future of medical writing and publishing. The
Glossary of
Medical Writing Words and Phrases
has been expanded to
include some occasionally encountered items such as doi,
RBG color mode, and grey literature. In keeping with the
scholarly tilt of this second edition, I have added a focused
dictionary of
Methodological and Statistical Terms Used in
Research Studies
The book’s content is a blend of personal experience and
research on the Web and in printed sources. Throughout all
chapters, I have attempted to follow the time-honored prin-
ciple of supporting theory with examples, some from actual
published materials and some created to help illustrate the
ideas presented. Most of the examples presented are “good
examples;” a few are illustrations of what not to do.
In Chap. 1, I challenge authors to consider three ques
tions before beginning work on an article or book:
So what?
Who cares? Where will it be published?
As the author, I
believe that I should answer the three questions in regard
to this book. The “So what?” question asks what is new and
different, and I think that the answer lies in the fact that
I address medical writing knowledge and skills from the
viewpoint of the clinician and medical educator, not that
of the journal editor or professor of English literature. The
“Who cares?” issue concerns the potential reader; for this
book, that is the reader who aspires to write for publica
tion in the medical literature. This is, in fact, a surprisingly
large number of persons—all competing for limited space in
print. In regard to the “Where will it be published?” ques
tion, I am pleased that this book is published by Springer
Publishers, the world’s leading publisher of scientific books
and journals, with whom I have had an author–publisher
relationship since 1976.
As a clinician and/or perhaps a medical educator or clinical
investigator, you have a tremendous source for writing ideas—
the patients, students, or research subjects you see each day.
Think about the possible significance of a cluster of uncommon
problems you have observed recently, the unlikely manifesta
tion of a common disease, a curricular innovation that oth
ers could implement, or the extraordinary courage displayed
by one of your patients or study participants. Perhaps you
have found a new way to use an old remedy, have your own
thoughts about a recently published study, or even have a pile
of data from a clinical investigation you recently
This book is about helping you recognize the reportable idea,
organize your information, and
write it up
Happy writing!
Portland, Oregon
Robert B. Taylor, M.D.
Table of
About This Book
Getting Started in Medical Writing
Basic Writing Skills
From Page One to the End
Technical Issues in Medical Writing
What’s Special About Medical Writing?
How to Write a Review Article
Case Reports, Editorials, Letters to the
Editor, Book Reviews, and Other
Publication Models
Writing Book Chapters and Books
How to Write a Research Protocol
How to Write a Grant Proposal
How to Write a Report of a Clinical Study
Getting Your Writing Published
Appendix 1
Glossary of Medical Writing Words
and Phrases
Appendix 2
Proofreader’s Marks
Appendix 3
Commonly Used Medical Abbreviations
Appendix 4
Laboratory Reference Values for Adults
Appendix 5

Methodological and Statistical Terms
Used in Research Studies
True ease in writing comes from art, not chance,
As those move easiest who have learn’d to dance.
English Poet
Alexander Pope (1688-1744)
After reading this book, you will have a better understanding
of the art of writing, both of writing in general and, specifi-
cally, of medical writing, with all its idiosyncrasies. This short
introduction tells a little about the book’s organization and
its own peculiarities, including word use, reference styles,
and the examples and allusions you will encounter. In the
end, our common goal is to find some true ease in writing,
through consideration of both current theory and samples
from the literature, and by looking at what constitutes excel-
lent and not-so-good writing.
The book progresses from the theoretical to the practical.
It begins with basic writing topics and skills. Next comes
a consideration of the various models for medical writing,
from the review article to the report of a research study. The
final chapter discusses how to get your work into print. The
appendix has some handy tools that may help you along the
way, including a glossary of medical writing terms, proof-
readers’ marks, definitions of commonly used methodologi-
cal and statistical terms used in research reports, and some
tables of commonly used abbreviations and laboratory refer-
ence values that you may use in your own writing.
In the early chapters on basic writing skills, I use the
, even though later in the book the principles of
authorship described will also apply to editorials, letters to
the editor, research protocols, grant proposals and research
bout This
reports. I am a medical logophile, and in using words, I will
often go to the Greek or Latin roots; doing so helps me use
words more precisely.
Within chapters, you will also note some shorthand refer-
ence citations, presented in parentheses. These are used for
articles and books used as examples to illustrate good and
bad titles, organizational structure, and prose. Although I
believe it unlikely that any reader would actually want to
consult these writings, I have provided abbreviated citations,
just in case. With the information provided, you could find
most of the articles on the Web.
At the end of each chapter are references to sources impor-
tant to ideas described. These are presented in the style of
the “Uniform Requirements for Manuscripts Submitted to
Biomedical Journals,” a very useful guide that will be dis-
cussed in later chapters. Using this reference style for the
book models the way you will generally prepare citations for
your medical articles.
I have done my best to make this book a pleasure to read.
This includes using short, strong words, and, at times, colorful
images. I have included allusions to medical history, classical
writing, mystery novels, opera, sports figures, comics, and a
few very odd creatures. We will visit Hippocrates and Frau
Roentgen, Shakespeare and Hemingway, Princess Turandot
and Pogo, zombies and clones. As you read along you will
also learn some medical information, such as whether or not
the use of probiotics can reduce crying episodes in infant
colic and the relationship between the exposure to aircraft
noise and cardiovascular mortality. All the examples in the
book help illustrate points about medical writing that I con-
sider important.
I hope that what follows will help you master the art of
writing, to “move easiest” by learning—not really new dance
steps—but some guidance on how to walk the path from idea
to print. I wish that I could promise that, having read this
book, your next writing effort will be so inspired and luminous
that everything else in print will seem drab by
In fact, this is unlikely to occur. But I do earnestly believe
that, as stated in the Preface, using the principles and tips
presented here will make you a better medical writer.
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_1,
© Springer Science+Business Media, LLC 2011
Writing for the medical literature has its own special
considerations. Writing vibrant prose is not usually the key
issue, and at times may appear to be disadvantageous. By
that I
mean that editors of scientific journals tend to favor
densely written articles that put specificity ahead of clarity.
Rew <
> has written, “A fog has settled on scientific English.
Well-written English effortlessly communicates the writer’s
intent to the reader. Unfortunately, far too often, science is
written in a form that renders the content hard to under-
stand, and which makes unreasonable demands on the
reader.” It seems that many medical articles, notably reports
of clinical research studies, are written to be published and
cited, but not to be read. I hope that you and I can aspire to a
higher level of writing skill, and that editors and readers will
appreciate the enhanced readability of our work.
The ability to endure rejection is a must. I began medical
writing in the early 1970s while in small-town private practice.
I had some early success in conducting clinical studies and
seeing the results in print in respected journals. I also wrote
some articles for controlled circulation, advertiser-
journals, such as
Medical Economics
. Not everything I wrote
was published. I also began writing health books for non-
medical people, what the editors call the “lay audience.”
Here I collected so many rejection letters that I could have
wallpapered a room with them. Only when I began writing
and editing medical books did my acceptance rate become
favorable. However, after 40
years of medical writing experi-
ence, I still receive rejections for clinical papers, editorials,
and book proposals. And, yes, it still hurts.
If you aspire to be a medical writer you will need determi
nation. Being a writer takes a lot of effort and you really need
to want to see your work in print. But if you develop the itch
to write, it can only be relieved by the scratch of the pen—or
today by the click of the computer keyboard. If you begin to see
yourself as a writer working on a project, as I
am working on
this book today, then you will think about the project whenever
you have a spare moment, and as ideas occur, you will capture
them on a scrap of paper, index card, or smart-phone. You will
record the concept or phrase when and where you can, just so
it doesn’t get away, because that is what writers do.
For years I have periodically conducted writing workshops
for clinicians and medical educators. Conducting writing
workshops, of course, guarantees an audience that is self-
selected to be more interested in writing than those in com-
peting workshops on how to perform a no-scalpel vasectomy
or how to code office visits to receive maximum reimburse-
ment. Generally, most of the participants are previously
published medical authors, at least to some degree. Each
of these workshops begins with the same question: Why do
we write? The answers, while diverse, tend to be the same
in each workshop, and are listed in Table
. I am going to
discuss a few of these.
First, let’s consider and dismiss the final entry on the list—
earn income. Medical writing is not lucrative. Advertiser-
supported publications (more about them later) often pay a
few hundred dollars for an article. Book royalties are gener-
ally meager compared to what I earn in my “day job.” Book
chapters, editorial, and research reports pay little or nothing
and are written for reasons other than financial gain. If your
goal is wealth, you should add more clinical hours to your
schedule or buy stocks that go up—something other than
medical writing.
What about the other reasons we write? For those in aca-
demic medicine, promotion and tenure are very important,
easons why we write
Gain intellectual stimulation
Share ideas
eport research
xpress an opinion
Generate discussion
dvance one’s discipline
ssert “ownership” of a topic
ttain promotion/tenure
eport a case
nhance one’s personal reputation
chieve some small measure of immortality by publishing our ideas
arn income
and publications are the key to success. As medical schools
become increasingly dependent on clinicians seeing patients
for economic survival, it would seem that this clinical effort
would be rewarded with the carrots of career achievement—
promotion to the next rank and, where applicable, tenured
faculty positions. This, however, is not the case. In 1988, a
study at Johns Hopkins Medical School reported, “Those
who were promoted had had about twice as many articles
published in peer-reviewed journals as those who were not
promoted.” <
> I have not seen a recent similar study, but
don’t believe that anything has changed, and an academic
faculty member who bets his or her career on advancement
without publications is taking a dangerous path.
I tell young faculty that, as a broad generalization, it takes
at least two publications a year to be considered as “satisfac-
tory” in scholarly activity when it comes time for promotion.
Some can be clinical reviews or case reports, but others must
be research reports published in refereed journals. Also, you
must be the first author on your share of the papers, not
always second or third author. Faculty members who chiefly
see patients often do not get this message. Beasley and Wright
> surveyed faculty in 80 medical schools in 35 states. They
differentiated between clinician investigators (the research
faculty) and clinician educators (the patient care faculty)
and concluded, “Clinician educators are less familiar with
promotion guidelines, meet less often with superiors for per-
formance review, and have less protected time than clinician
investigator colleagues.”
Another benefit of medical writing is the in-depth knowl-
edge it brings. Think of it as a self-education program. If you
or I plan to conduct research (which requires various phases
of writing such as the research protocol, grant application,
and ultimately the research report), or develop a clinical
review or book chapter on a topic such as hyperthyroidism or
ovarian cancer, then we will necessarily learn a lot about the
topic during the process. In academic medicine, the way to
really get to know a field is to contribute to it, and those who
contribute by means of publication need current, evidence-
based knowledge if their writing is to be credible.
In my opinion the most enduring reason to be a medical
writer is the intellectual stimulation. Medical writers have
a lot of fun learning about their topics, rummaging in their
imaginations for the best way to present material, and find-
ing just the right words to say what is important. The writing
itself can stimulate discussion. For example, I published an
article on leadership with the premise that leadership skills
can be learned. A reader disagreed, stating that my article
had “missed the mark” and that the top leaders have inher-
ited abilities and character traits. I had an enjoyable time
composing my reply.
There is also the pleasant side effect of getting known. As
an editor of a number of medical reference books, I have
had the heart-warming experience of visiting clinics in Asia,
Europe, and South America, and having young doctors
exclaim, “Doctor Taylor, I have read your book.” On a practi-
cal level, if you are a referral physician who specializes in, for
example, refractive surgery of the eye or the management of
Parkinson’s disease, publishing articles on these topics helps
assure referrals.
In the end, however, when the going gets tough, and your
paper has been rejected again, what will sustain you is not
the discussion with readers, the recognition, or the referrals.
It is the simple joy of writing.
If writing is such a joy, why don’t we write? And for those in
academic medicine and whose career advancement depends
on publications, isn’t it curious that so many resist writing?
In my workshops on medical writing, the second discus-
sion question is “Why don’t we write?” Table
lists some of
the answers received over the years.
What about the resource issues cited in the list? Time to
write is always mentioned early in the discussion. No one
in private practice has revenue-generating time that is allo-
cated to writing. Those in academic practice soon find that
they don’t either. For academicians, time to do research and
to write must be “bought” by obtaining funding (which is
why grant application writing is important). For the rest of
us, writing time is going to be carved out of personal time.
When I was in private solo practice, my writing time was in
the early morning, before breakfast and when my family was
asleep. For others, the time will be weekend mornings or
late at night. In workshops, sometimes I have encountered
vocal—sometimes even angry—disagreement with my “writ-
ing on your own time” beliefs, but most experienced medical
writers and editors will tell you this is the way it is.
Whatever time you designate as writing time must be vig-
orously protected. In practice, patients will get sick and call;
this is the virtue of writing in the early morning or late-night
hours when the telephone is quiet. In academic medicine,
you may need to close the door while writing or go to the
library, to prevent colleagues from coming to discuss prob-
lem residents, curriculum changes, or patient referrals—
anything but writing.
How about the lack of ideas, lack of secretarial support,
lack of like-minded colleagues, and so forth? Any clinician
seeing 15–25 patients a day encounters a wide variety of clini
cal phenomena that could present the idea for an article: com
mon causes of pelvic pain, ways to manage the patient with a
low back strain, an unusual manifestation of lupus erythema
tosus, herbal therapy in the treatment of depression, and
much more. The variety you see depends on your specialty.
Your writing ideas will come from your clinical experience.
This is as it should be, because it brings
immediacy to your
writing and provides the credibility you need to write on the
topic. Later in the book, we will discuss how to develop clini
cal observations into writing topics, outlines, and articles.
easons given for not writing
ot enough time
othing to write about
o one to work with in writing
In my opinion, laments about lack of secretarial help,
collegial support, and research access are not as valid as they
once were. Why? Because of the computer and the Internet.
Not too many years ago, I was highly dependent on secre-
tarial support; I dictated my articles and made corrections
by hand to be changed on computer by my typist. Today I
the Microsoft Word program on my computer, doing the typ-
ing myself; the computer’s efficiency has led me to change
my writing methods. With e-mail, coauthors are also readily
available. In fact, I can pass documents back and forth with
colleagues across the country by e-mail just as readily as with
those down the hall.
The World Wide Web has revolutionized research, making
information needed for writing readily available to anyone
with a computer and Internet access. Because knowing how
to use the available resources is so important to medical
writers, we will shortly spend time learning about what is
online and how to use it. Basically, you can learn just about
anything you need to know while sitting at your desk, if only
you learn how to do it.
The lack of self-confidence is quickly overcome after a few
publications, which may also help to spark motivation.
Regarding the last entry on Table
, I can’t do much for
those who really hate to write.
Writing as History
In 1912 the citizens of the village of Caledonia, New York,
placed a large boulder as a monument commemorating the
historic treaty between Chief Ganaiodia, representing the
Native Americans in the area, and the local villagers and
farmers. As a civic leader, my grandmother had an idea. She
dispatched my mother, then age nine, to the grocery store
to buy a tin of cookies. Yes, those were the days that cookies
came in tin boxes and one could safely send a 9-year-old
child alone to the grocery store. When my mother returned,
grandmother removed the cookies, which I am sure were put
to good use. What she wanted was the box, into which she
placed several items, including a copy of the village’s weekly
newspaper. The box was then buried beneath the boulder
as a time capsule. I believe that it is still there beneath the
Your writing is a time capsule. It shows what you and your
colleagues think today about important issues such as diag
nosis, treatment, prevention, prognosis, clinical correlations,
health policy, practice management, and much more. As read
ers, we use medical writing to take looks back in history.
Let us look at the historic figures in medicine. Who comes to
mind? Hippocrates, Galen, Maimonides, Paracelsus, Vesalius,
Harvey, Osler, and more. (I am sure that, in choosing just a
few to discuss briefly, I have omitted many favorites, but
am going to try to make a point). Three centuries before the
Common Era (CE), the words of Hippocrates were recorded
On Hemorrhoids
On Fractures
On Ulcers
On the Surgery
On the Sacred Disease
, and the
Book of Aphorisms.
writing in Rome during the second century CE, compiled
the medical knowledge of the day into an encyclopedic work
that endured as an authoritative reference for centuries.
Maimonides wrote on diet, reptile poisoning, and asthma
during the twelfth century CE. Later, during the Renaissance,
Paracelsus described miner’s disease and the treatment of
syphilis with mercurials; he gave us the guiding principle
of toxicology: “The dose makes the poison.” We know this
because Paracelsus
it. Vesalius produced drawings of
the body that greatly advanced the study of anatomy. Harvey,
in the 1600s, wrote describing the circulation of blood in
the body and later William Osler’s book
The Principles and
Practice of Medicine
defined the practice of medicine in the
late nineteenth century <
Do you notice the common theme above? Is my point
becoming clear? While all were undoubtedly outstanding
physicians of their day, they are remembered because they
They recorded their observations and their thoughts.
In doing so, they literally helped shape the history of healing.
And by writing, they created the building blocks upon which
today’s house of medicine stands.
You and I can do a little of this, too. At this time, none of us
is likely to become the “father of medicine” or the “father of
anatomy.” Hippocrates and Vesalius hold those titles. But we
can add small twenty-first century contributions to the house of
medicine, while metaphorically tucking some our work away
in today’s time capsule for someone in the future to ponder.
Writing and Reading
Reading goes with writing like ice cream goes with apple
pie—one just makes the other better. All writers must read if
they are to be any good at medical writing, and you should
read diverse items and for various reasons: for information,
for ideas, for structure, for style, and for a sense of history.
All clinicians need to read the medical literature regularly
to stay up to date in their specialties; this is part of being
a good healer. (Later, in Chap. 3, I will describe how clini
cians read the literature). Educators and researchers must
read constantly to know the latest advances in their areas of
interest. Your journal reading will help build bridges to your
own experience.
Writers also read to seek information. For example,
when writing the section above, I needed to read parts of
Sebastian’s <
> excellent reference book
A Dictionary of the
History of Medicine
to learn about Hippocrates, Galen, and
Harvey. No, I did not have all the information in my head.
Right now I have promised to write an editorial for a journal
within the next 2
months, and I am searching for information
on the topic I have chosen.
In addition, writers read seeking general knowledge and,
perhaps, trolling for ideas. As I write this, some clinical-
interest topics I have encountered include the merits of vita
D, atypical fractures with bisphosphonate therapy, the
place of herbal remedies in medicine, and how best to treat
attention deficit/hyperactivity disorder in children and adults.
There is also reading for structure. By this I mean consid-
ering articles analytically. When you read an article that you
like—because of the writing, not the topic or statistics—go
back and reread the article looking at how the author put it
together. How was the title composed? How was the abstract
constructed? How did the writer organize the information so
that it was clearly presented? What tables and illustrations
were used, were they effective, and why were they effective?
How many references were included, and what publications
were cited? Reread this part of the book before going on to
Chap. 2 and think about the questions I just asked as they
apply to the Chap. 1 you are now reading. What are the good
points and what could I have done better? In short, look at
the craftsmanship of the article or book chapter, as well as
the message.
Read also for style. Study examples of well-written medical
literature. This may be a little hard to find, as refereed jour-
nals have increasingly become the repository for published,
citable, but barely readable reports of research data. The
writing in the
British Medical Journal
is better than most, and
some of the best writing in U.S. medical journals is found in
editorials and opinion pieces, as described in Chap. 7.
Reading for style includes reading nonmedical books,
vitally important to those who aspire to be serious writers.
Here you can gain a sense of language, grammar and syntax,
and the rhythm of words in good literature. I believe that a
medical writer should always be reading a nonmedical book.
Read some of the classics, such as the grand metaphoric
prose of Herman Melville’s
Moby Dick
, the powerful, yet
spare journalistic style of Ernest Hemingway’s
The Old Man
and the Sea
, the subtle and complex style of Jane Austen’s
Pride and Prejudice
, and the symbolism of Thomas Mann’s
The Magic Mountain
. You might also include a Tom Clancy
thriller or Patricia Cornwell medical mystery, or a James
Michener epic.
You and I can gain a sense of perspective by reading
about our heroes and our language. To read a collection of
time-capsule items, try to find a copy of R.H. Major’s
Descriptions of Disease
>. To learn about the words we
use, there is no more scholarly book than J.H. Dirckx’s
Language of Medicine
>. And one should include a book
on the history of our profession such as Roy Porter’s
Greatest Benefit to Mankind
Writing and You
Who Writes?
Is there a profile of the medical writer? There is no single
“typical” person who chooses to write. However, there are
degrees of “fit” between a person’s preferences and charac
teristics desirable for writing. It goes beyond mere technical
skills. Writing may be an opportunity for you to use your
talents and may give you great satisfaction while others
will describe writing as “frustrating” and “stressful.” Most
importantly, you need to be aware of your own preferences,
strengths, and priorities. Psychological inventories, such as
the Myers-Briggs Type Indicator (MBTI), have described
personality types that tend to be most attracted to writing
as being creative, adaptable, and eager to take on new chal
lenges (INFP, ENFP, INTP, ENTP, in MBTI terminology) <
If you are writing to a deadline, as for books or magazines,
your organizational and time management skills are also
factors in your potential success.
Medical Writing as Storytelling
Who hears more stories than patient-care clinicians? The
patient relating a medical history is really telling his or her
story. It is a narrative, and often one that is rich in color,
emotion, and drama. In fact, there is an appealing metaphor
that characterizes the patient and the clinical narrative.
It begins with the concept that the job of the healer is to
help the patient manage his or her “story.” And—here is the
metaphor—the patient comes to the clinician with the plea:
“My story is broken and I hope that you can help fix it.” <
Certainly among all these stories—broken and fixed, with
the clinician as both actor and observer—there are
topics for medical writing. Abraham Verghese states, “It
may take years of practice for a physician to appreciate and
accept his or her role as storymaker and storyteller.” <
> One
good example of such narrative writing is Howard Brody’s
Stories of Sickness
, 2nd edition <
Writing as Creativity
Whether what you are writing is a compilation of data in a
research report, an editorial about a topic that flames your
passions, or a new look at how to treat your favorite disease,
your writing involves creativity. This means that you are pro-
ducing something that comes from you, personally, and that
did not exist before you made it. I find this both humbling
and energizing. In writing this paragraph, I am putting 89
English words together in a way that no one ever did before.
This is exciting.
This creativity is what can get the juices flowing. It helps
focus your sense of purpose—that writing is important,
especially what you are writing
. The creative process is
more important than committees, television, the crabgrass
in the lawn, and even football. Your rewards come when
you have finished something and you can say, “This is great,
and I created it,” and from others reading the results of your
literary effort, and sometimes responding—even when they
Of course, creativity is also a solitary process. Note that of
the great medical writers in history that we discussed earlier,
none had a Boswell to record his thoughts. (From your college
courses, perhaps you recall James Boswell, the eighteenth
century writer best known for recording the words of Samuel
Johnson). Nor do we find coauthors listed. And none had a
team of administrative assistants, research assistants, or fact-
checkers. Each did it alone with parchment and quill, paper
and pen.
Be aware that your medical writing will require hours
spent staring into the computer screen and rummaging in
books and web sites—lonely endeavors, to be sure. American
author Truman Capote once wrote, “Writers, at least those
who take genuine risks, who are willing to bite the bullet and
walk the plank, have a lot in common with another breed of
lonely men—the guys who make a living shooting pool and
dealing cards.” <
> The solitude of writing will mean over-
coming the tendency to wander down the hall to yak with
colleagues, go for coffee, chat on the telephone—anything
to maintain contact with other humans. So be prepared for
quiet time alone with your ideas. However, you may find that
your ideas and your creativity are very good company.
Writing Topics and Your Career
If you are in private practice with no aspirations to an aca-
demic career or research grant funding, then you might skip
this short section. However, if you are a faculty member
seeking academic advancement (promotion and tenure) or
a future in research, the following can be important advice.
Here it is: Find your “career topic” early and stick with it as
long as your can. The “career topic” will be what you write
about. It will also be the subject of your research, and perhaps
why you receive patient referrals. For example, for years
I have written on migraine headaches. Clearly because of my
writing review articles and book chapters on this topic, I—as
a family physician—became a leading headache referral
physician in our academic medical center. In fact, I received
more headache patient referrals than I really wanted, all
because of writing on the topic.
Some topics I have seen young academicians developing
recently include: a national scorecard on women’s health
services, health literacy of patients, the impact of high pro-
fessional liability rates on physician retention, changes in the
quality of health services when patients are forced to change
doctors, the integration of complementary/alternative prac-
tices into allopathic medicine, the cost efficiency of various
health screening methods, racial or gender disparities in
health care, and a wide variety of clinical diagnoses. The list
of potential topics is endless. Take ear infection, example,
which most would describe as a mundane topic. Yet in 2011
a team from Finland published an article in the New England
Journal of Medicine (NEJM) describing a placebo-controlled
trial of antimicrobial treatment of otitis media (T½htinen PA
al. N Engl J Med. 2011:364:116).
What is important is to identify a topic that energizes you
and that has the potential to endure. For example, one could
write on a topic of, for example, treatment of Bartholin cyst or
infant crib safety, but would soon run out of things to say and
articles to write. It is much better to write on a topic of general
interest, with evolving research and, if possible, high social
relevance. Then, as you write on various facets of the topic in
journals and books, you establish your national position as an
authority in the field, which is a requirement for promotion to
the rank of professor in academic medical centers.
What should you
write about? First of all, don’t write
on topics outside your area of clinical expertise. To use
somewhat exaggerated examples, the psychiatrist probably
shouldn’t be writing about knee injuries, and the orthopedic
surgeon should find a topic other than pancreatitis. Also,
do not write on a clinical area in which you do not wish to
receive referrals and become recognized locally as an expert.
I once knew a general internist who wrote a few articles on
alcoholism. He was interested in the topic because his father
was an alcoholic. Before long his practice was dominated by
alcoholic patients, both through referrals by colleagues and
then by patients seeking out the local expert on the topic and
by attorneys requesting expert testimony. This shift in prac-
tice emphasis was not at all what he had planned.
Because the topic of resources is so important, I am going to
cover it early in the book. You must not try to write without
assembling what you need to write. Without designating a
writing area, acquiring books and computer resources, and
learning to use key web sites, a premature foray into writing
is likely to cause frustration.
Your Writing Area
What are your logistic requirements for writing? First of all,
you will need a comfortable chair and desk surface. The chair
must support your back, and ideally will have a height adjust-
ment that can change if your shoulders start to ache after a
few hours of typing. The surface may be the kitchen table,
as long as it is well lit and is large enough to accommodate
papers, books, computer, and all the rest.
You will need a computer with high-speed Internet access.
The days of submitting manuscripts on paper are almost gone.
All my latest article submissions have been online, and paper
was needed only for author attestations and signatures. My
last four books were submitted on compact disks or on line; I
mailed some illustrations that would print better from the orig
inal documents than had I scanned and sent them by e-mail.
The point of the story is that you will need a computer for
composition, revision, and submission. At home and work,
use both desktop and notebook computers. I find the desk-
top computer easier to use for long sessions of typing, chiefly
because I have two large side-by-side screens. The notebook
is more convenient when moving work from place to place,
and definitely if the computer must be taken into the shop
for repair.
Other items to have handy are a telephone, notepad, pen
or pencils, and a cup of your favorite beverage. Add your
books, computer programs, and Web sites, and you are good
to go.
If I were advising you a decade ago, this section would be
much longer. However, the Internet and the availability of
useful Web sites have changed how I search for information.
With awareness that this list is rather spare, here are some
basic books for the medical writer (and reader):
Do not underestimate the value of a good dictionary. For
example, I find the dictionary often the best place to look
up a newly encountered syndrome or eponymic disease
name. There are good dictionary computer programs, dis-
cussed below, but sometimes you just need to look it up in
a book that can be held in your hand. Two good ones are
Dorland’s Medical Dictionary
, published by W.B. Saunders,
Stedman’s Medical Dictionary
, published by Lippincott
Williams & Wilkins (LWW). Each has the Greek, Latin,
and other derivations of words, a feature that I value. I use
Dorland’s for two reasons: First of all, I have used various
editions of this dictionary since I was an intern and feel
comfortable with it, just like being with an old friend. The
second and more practical reason is that on my computer
is the
Stedman’s Electronic Medical Dictionary
, described
below. Thus, I have access to two medical dictionaries that
are not duplicates.
Also have available a general dictionary of the English
language. In the first edition of this book, I recommended
Random House Webster’s College Dictionary
(published by
Random House) and the
American Heritage Dictionary of the
English Language
(published by Houghton Mifflin). Today,
use the Google Dictionary on my computer desktop.
Basic Specialty-Specific Medical Reference Book
Every medical writer needs a basic reference book in his or
her specialty. Each specialty has at least two such books. In
internal medicine, for example, the basic reference books
are Harrison’s
Principles of Internal Medicine
by McGraw-Hill) or Cecil
Essentials of Medicine
by W.B. Saunders). This gives you a chance to check your
clinical data and recommendations against what’s generally
accepted in the field. Of course, a textbook begins to go out
of date as soon as the ink on the pages is dry, and you should
make a commitment to buy each new edition as it is released.
Still, you will find your omnibus specialty reference book
very important to have at hand when needed. Most major
specialty reference books are also available on line.
Inter-Specialty Reference Books
5-Minute Clinical Consult
, published by Lippincott
Williams & Wilkins, is a very useful reference for a wide
variety of clinical conditions. Using an outline format, this
“cookbook” tells what the busy clinician needs to know about
a wide variety of diseases, with an emphasis on the outpatient
setting. There is a version that can be loaded onto your smart-
phone or tablet personal computer.
2uick Look Drug Book
is one of my favorites. Like sev-
eral of the items noted above, Lippincott Williams & Wilkins
publishes it. It is a paperback book, published annually, that
is useful for checking drug generic names, brand names, and
doses. The latter is vitally important for accuracy in medical
writing (see Chap. 3). A computer program, described below,
is available.
A little-known but very useful book is Neil Davis’
Abbreviations: 32,000 Conveniences at the Expense of
Communications and Safety
. All too often in medical writ-
ing, I encounter abbreviations for which I cannot find the
explanation. Here are two randomly selected examples. What
are the meanings of TDS and BEGA? Give up? TDS stands
for traveler’s diarrhea syndrome and BEGA stands for best
estimate of gestational age. TEMP can mean temperature,
temporary, or temporal. This little book can help clear up
the confusion in ways I seldom could achieve looking in
the indexes of my big reference books. I buy mine on line at
If you are taken with using classical medical quotations
to augment your own prose, a good source is Maurice
B. Strauss’s
Familiar Medical 2uotations
(Little, Brown
Publishers). It is out of print, but is available from on-line
booksellers: Search Google for Maurice Strauss AND famil-
iar medical quotations.
Computer Programs
There is no need to buy a printed thesaurus. Your Microsoft
Word program has an excellent one; just highlight the word
and press shift/F7 on your PC.
Electronic Medical Dictionary
I own
Stedman’s Electronic Medical Dictionary
and keep
it running whenever I am doing a writing task. Lippincott
Williams & Wilkins reports that Version 7.0 defines more
than 107,000 terms, including 5,000 new terms. LWW
also tells that you can read the definition of a term, hear
it pronounced, see it illustrated, and watch it in motion.
don’t really value the audio pronunciations (after all, I am
writing—not giving a lecture) and spare me the anatomic
animations. That said, this is a very useful program to have
loaded on your hard drive.
Nevertheless, when my
Stedman’s Medical Dictionary
finally out of date, I probably will not renew because I think
I have found something almost as good—and for free. Since
the first edition of this book was published, I have begun
The Free Dictionary
by Farlex. This online web site is
a one-stop source for both medical and nonmedical word
definitions, with the advantage of supplying the etymology of
each word. As a field test, I looked up the word
I learned that the word describes “an abnormal mass of tis-
sue arising from the conjunctiva of the inner corner of the
eye that obstructs vision by growing over the cornea.” I also
discovered that the word is derived from an old Greek word
meaning “wing.”
You can access The Free Dictionary at:
With this and other sites available, you
may not need a print medical dictionary at all.
Spell Checker
I am a huge fan of
Stedman’s Plus Medical/Pharmaceutical
produced by LWW. This amazing program
integrates with your Microsoft Word spell checker. Then it
works while you type to verify spellings of medical and phar-
maceutical words plus the everyday words on the MS spell
checker. The latest version has the most recently released
drug names, including brand names, and virtually all medical
words you will ever use. It even has a feature that allows you
to add words to its base. For example,
(the medi-
cal dictionary described above) was not in its vocabulary, so
I added the word so that it will not be underlined in red next
time I use it.
Drug Reference Program
As an alternative or in addition to owning the
2uick Look
Drug Book
, the
2uick Look Electric Drug Reference
again) can be purchased and loaded on your hard drive.
Web Sites
Web sites are where today’s professionals look for infor-
mation. In fact, the list of books and programs above may
be wholly unnecessary a decade from now. I am going to
discuss my favorite sites; I think it is best to become really
familiar with just a few and learn to use them well. This is
better than cruising a large number of sites but doing
inefficiently. Also, some of the best Web sites charge a
subscription fee, which will put economic limits on your
surfing. For example, my medical school has subscriptions
(described below), as long as
I access them from a university computer. However, I must
pay a fee if I
wish to use them at home. No matter which Web
sites you choose as your personal favorites, you must learn to
use them yourself. You cannot be dependent on the expertise
of a medical librarian. And to be an effective Web searcher, it
helps to understand Boolean searching.
Boolean Searching
Boolean logic, named for British-born Irish mathematician
George Boole, refers to relationships between search terms.
Fundamentally, it allows you and me to search the Web for
the commonality, or maybe the lack thereof, of two possibly
related items. It lets you limit or widen your search. It’s not
difficult. In a Boolean search, you will use one of three words
to link two (or more) items. The words are AND, NOT, and
OR. As an example, let’s assume that I want to look up cur-
rent information about the treatment of migraine headaches.
I would first enter the terms migraine AND treatment. This
will give me only articles about migraine therapy, and not
information about the aura of migraine or the treatment of
peptic ulcer disease. If I request migraine OR treatment,
I should get a much longer list, including the treatment of
migraine, but also possibly including the treatment of hyper-
tension and chronic hepatitis. The mnemonic in Boolean
searching is: OR is mORe.
You can link more than two terms. The more terms you
combine with AND, the shorter the list of articles created.
The more terms linked with OR, the more articles on the list
Many, but not all, Web sites allow Boolean searching.
Don’t laugh. Google, at
, is an outstand
ing search engine. If you want a quick link to a phrase, book
title, author’s name, or an unfamiliar Web site, try Google
first. I have made it my Internet home page. The more you
use Google the better you will like it. According to a report
published in 2006, Google provided 56.4 of referrals from
search engines to medical articles <
If you have ever had an article published in an indexed
journal, search your name on Google to see what you find. Or
type in your home telephone number (all 10 digits, no punc-
tuation), and then after seeing your street address appear, go
to Yahoo! Maps to find a map to your home.
Google allows Boolean searching; its default is AND.
Sometimes in a Google search you may want to search for a
specific phrase, which is done using double quotes. Google
describes it this way: What is the difference between typing
pink monkey and “pink monkey”? Because of the default
Boolean AND, the pink monkey search will result in finding
all documents in which both the individual words pink and
monkey are present. The “pink monkey” search will only
locate the documents in which the phrase
pink monkey
Google Scholar
Google Scholar, first made available in 2004, is an especially
useful site when searching for a clinical citation. It seems to
let me focus my query better than PubMed, and will some-
times even let me have access to a full paper, rather than just
an abstract. When data were collected showing that Google
provided more than half of all referrals to scientific articles
(described above), Google Scholar was very new, and not
known to many academicians. In that study it accounted
for only 3.7 of referrals <
>. Although I can find no more
recent study, I am sure things have changed today. The
Google searching strategies described above apply.
MEDLINE (Medical Literature, Analysis, and Retrieval
System Online) is a service of the United States National
Library of Medicine (NLM). It allows you to search up to
12 million references to life-science journal articles, chiefly
those in the biomedical sciences. I prefer to search using
PubMed, a service of the NLM that includes over 14 million
citations from MEDLINE and other sources. Your search can
go back to the 1950s.
You can access MEDLINE on the Internet by going to the
NLM home page at
. There is no fee
for use of this service and no requirement to register. You
might also access MEDLINE through your medical library,
public library, or a commercial Web site. An example of
the latter is
), a web site for
physicians that offers email accounts and specialty-specific
current medical information, as well as MEDLINE/PubMed
access. Registration for
is required, but there is
no charge. The easiest access is to go directly to PubMed via
In PubMed you have choices: You can search by title word,
phrase, text word, author name, journal name or any com-
bination of these. PubMed allows Boolean searches. Your
search will yield a list of citations to relevant journal articles,
including the authors, title, publication source, and generally
an abstract. PubMed will search published scientific articles,
but not books.
You can also search by using the NLM controlled vocabu-
lary, MeSH, which stands for Medical Subject Headings.
MESH is used to index articles from 5,400 of the world’s
leading biomedical journals for the MEDLINE/PubMED
database. The NLM fact sheet describes MeSH as follows:
“MeSH is the National Library of Medicine’s controlled
vocabulary thesaurus. It consists of sets of terms naming
descriptors in a hierarchical structure that permits searching
at various levels of specificity.”
MeSH descriptors are arranged in both an alphabetic and
a hierarchical structure. At the most basic level of the hierar-
chical structure are very broad headings such as “Anatomy”
or “Mental Disorders.” More specific headings are found at
more narrow levels of the eleven-level hierarchy, such as
“Ankle” and “Conduct Disorder.” There are 25,588 descrip-
tors in 2010 MeSH <
Are you confused yet? I am. I have always considered
MeSH headings to be the medical librarians’ full employ-
ment act. I don’t use it. If you really want to learn more, go
PubMed also offers “Loansome Doc,” a feature that lets
you place an electronic order for the full-text copy of an
article found on MEDLINE/PubMed. The source is the
National Network of Libraries of Medicine (NN/LM). You will
need to register. You might also be able to link to the journal
publisher’s Web site and may be able to view a full text of an
article. You may need to pay a fee.
I find using PubMed a frustrating way to search for articles.
PubMed simply gives me too much “dead-wood” in its lists.
Instead I suggest that you check out, avail-
able at
. This free web site offers a much
more focused response to your query than PubMed, includ-
ing bar graphs showing the relevance of the each article to
the query term. As field test, try searching a disease, such as
“pancreatitis,” in both and to
see the difference.
is a subscription-based (yes, this means a fee) web
site that allows you to access several dozen medical reference
books, more than 50 clinically-oriented medical journals,
. It also contains an excellent reference base
on drug information and updates, more than 1,000 peer-
reviewed clinical practice guidelines, and useful patient edu
cation handouts that can be customized.
Boolean searches. You can learn more about
I find
user-friendly and I like it. Its good
point is that it combines medical reference book access with
journals, and it has an excellent drug reference, with prices.
When am working in the clinic with residents, I keep the web
site open and refer to it often.
I also like
, but for different reasons than I like
, also sub-
scription based, is a comprehensive clinical information
source. What makes it different is that it offers state-of-the-art
reviews of clinical subjects. The
web site states,
community includes our faculty of over 4,400
leading physicians, peer reviewers and editors and over
400,000 users. Our faculty writes topic reviews that include
a synthesis of the literature, the latest evidence, and specific
recommendations for patient care.”
Of course this means that
is composed of
“review articles,” and is not really taking you to primary
sources, although articles contain lists of reference cita
tions. This site is very useful for the busy clinician seeing
patients, and I use it in teaching residents.
designed to initially search a single subject, such as “head
ache.” Then you will be offered a menu of modifiers such
as: migraine, cluster, tension type, and so forth. You cannot
do a Boolean search on
. For the medical writer,
it is helpful to check current thinking on a topic. For pri
mary sources of clinical evidence, I would look elsewhere.
For further information about
, go to
Uniform Requirements for Manuscripts
Submitted to Biomedical Journals
The “Uniform Requirements” is the Bible for the serious
medical researcher, writer, and editor. I urge you to go to
the Web site—
—and review what is
there. You will use this information often to answer ques-
tions, especially when writing reports of clinical trials. What
is it?
The Uniform Requirements for Manuscripts Submitted
to Biomedical Journals
> tells medical writers how to pre-
pare their manuscripts. The section “Preparing a Manuscript
for Submission” has excellent discussions of authorship, the
various components of a research report (more on this in
11), and how to cite references that you will find very
valuable when working on your manuscripts. See Table
Who writes the Uniform Requirements? The Uniform
Requirements were first written in 1978, by a small group
of editors of general medical journals who met informally in
Vancouver, British Columbia. This group has evolved into the
International Committee of Medical Journal Editors (ICMJE).
The group meets yearly and updates the document as needed.
Some topics discussed in the uniform
requirements for manuscripts
uthorship and contributorship
Peer review
onflicts of interest
Privacy and confidentiality
Protection of human subjects and animals in research
bligation to register clinical trials
Preparing for submission
Sending the submission
Print references
The Medical Writer’s Three 2uestions
In Puccini’s opera
, the Princess Turandot asks
Prince Calef three questions, framed as riddles. If the love-
struck prince answers the three queries correctly, he gets the
princess’s hand in marriage. If he fails, well, it’s off with his
head. For medical writers, also, there are the three key ques-
tions, mentioned in the Preface to this book, that must be
answered when considering a project: So what? Who cares?
Where will my article be published?
For the medical writer—whether neophyte or seasoned—
these questions are vital. If you answer the three questions
clearly, you have the best chance of success. On the other
hand, if you fail to provide a convincing answer to one or
more of the questions, you won’t exactly lose your head, but
the success of your paper is definitely in jeopardy.
So What?
The medical landscape is littered with published papers, like
discarded fast food wrappers along a scenic country lane,
that have accomplished little more than adding a few lines
to the authors’ curriculum vitae. If you aspire to add to the
medical literature (or “
-ature”), I urge you to be honest
in considering the “So what?” question.
This question aims to determine the significance of your
work. After all, undertaking a writing project is going to take
you away from your patients, your family, your hobbies, or
whatever else you might otherwise be doing with your time.
And you are asking your audience also to commit time to
reading it. So be sure the effort is worthwhile.
The “So what?” questions asks: Is what I am writing about
something that hasn’t been said already, and perhaps said
better than I will say it? Am I saying anything new? Let’s
assume that you are a surgeon writing for a surgical jour-
nal. If you are writing an article titled
Surgical Treatment of
Acute Appendicitis: A Report of 100 Cases
, my first thought
is that this topic may be important, but what can you say
that hasn’t already been said? But if your topic is
A New
Surgical Technique for Appendectomy in the Patient with Acute
, then you have my attention.
Here is another example. One could study and report the
diagnoses of the next 1,000 patients seen in your office. But
so what? On the other hand, if you studied the next 1,000
patients seen with a presenting complaint of pelvic pain and
followed them to the definitive diagnoses, then most general-
ists and gynecologists would be interested.
Who Cares?
This question has to do with relevance to the potential reader
and to the universe of patients who might benefit. Let us
think about a paper describing how I treat sore throats
empirically with saline gargles and garlic, where I found that
that the treated group actually fared significantly better than
the control group. Although the topic seems unlikely, with
good statistics this paper might be relevant to generalists who
see many patients with sore throats. I recently read about
pickle juice being useful in preventing leg cramps, and being
touted by the Philadelphia Eagles as their secret weapon
their cramp-free win over the Dallas Cowboys in a game
played in over-one-hundred-degrees Texas heat. (Pickle juice:
food fad or fool-proof fix. Available at:
) Is pickle juice truly useful
in preventing exercise-induced cramps? Now here is a study
many would care about a great deal.
On the other hand, when I was in private practice four
decades ago, we often recommended that patients with
peptic ulcer disease drink plenty of whole milk. Yes, things
have changed. Nevertheless, at that time it seemed that,
more often than I expected, many patients with peptic ulcer
disease reported not liking milk. I thought of doing a study
and writing it up. I asked my colleagues about this idea, and
learned, to my dismay, that they really didn’t care. I never
did the study.
Where Will My Article Be Published?
Getting an article published requires two consenting adults—
an author and an editor. Of course, for refereed publications
there are peer reviewers who must also nod approval. Even
book publishers today have all proposals reviewed by experts
in the field.
When you write an innovative, relevant article, you must
seek the right audience. That means finding the best journal
for your work. Ideally you begin with a specific publication
in mind, your “target journal,” and then drop back to your
second and third choices only if you are not successful with
your first choice.
Be careful with your target journal. Some journals have
such a low acceptance rate that rejection is almost guar-
anteed. On the other end of the spectrum, the advertiser-
sponsored publications (discussed below), while lacking the
cachet of the
New England Journal of Medicine
, need a steady
supply of innovative articles and offer good opportunities for
the neophyte author. Some articles, by the nature of their
content, are best suited for refereed journals that publish
research reports; others—such as “how-to” and “five-ways-
to” articles—are inappropriate for such journals and sending
them in is a waste of time. There is also the “grey literature,”
describing works presented at scientific meetings or as con-
ference posters, and thus being “published” as abstracts of
the scientific congresses.
Some Early Steps
Writing Models for Beginners
As a beginning author, it would be quite difficult to write a
publishable report of original research on your first or sec-
ond attempt. First, you need research data, which you are
unlikely to have. Second, the report of original research is
the most demanding of all publication models and faces the
greatest competition in the publication sweepstakes. There is,
however, one way that you, the relative neophyte, can actu-
ally succeed in having your name on a research report. That
occurs when you are the junior member of a research team,
and you participate in all phases of the project, including
writing the report. This approach works even better if the
team includes a senior mentor, who can guide you through
the process.
In the absence of a research team, research mentor, and a
pile of research data, what is the aspiring author to do? Plan
to start with a writing model that offers the best chance of
getting in print with the least need for expertise and the least
effort. No, such a publication won’t get you tenure or assure
a lifelong career, but it will get you going. Also, it just might
help you settle on a topic area that you can pursue in future
The leading models appropriate for neophyte writers are
review articles, case reports, editorials, letters, and book
reviews. All are covered in depth in later chapters in the
book. The review article is appealing because advertiser-sup-
ported publications, sometimes called “throw-aways,” have a
constant appetite for content. Examples of such publications
Postgraduate Medicine
, and
Hospital Practice
All have Web sites for those who want to learn more.
Case reports are tempting, and are sometimes a good way
to get started as a writer. Be sure of two things: One is that
you have a point to make about the case—the “So what?”
question again. The second is to be sure that your target
journal(s) actually publishes case reports; not all journals do
so. That is the “Where will my article be published?” question
once more.
Editorials allow you to express opinions, and you may be
an especially appropriate author for an editorial if you hold a
position that gives you some expertise in the topic. For exam-
ple, if you direct a pain clinic, you are qualified to write about
narcotic abuse or regarding analgesic under-prescribing for
patients with pain.
Letters to the editor are a quick and easy way to get in
print. Generally a letter to the editor comments on a pub-
lished paper. What you have to say must offer new insights
and it must connect with the readers. Often such letters disa-
gree with conclusions of the paper, and that is okay. Letters
to the editor should be short and to the point.
Book reviews are another opportunity for publication.
Never send in an unsolicited book review. On the other hand,
you can write to your favorite journal and volunteer to be a
book reviewer. If added to the reviewer list, you will receive
a book to review. Your job will be to write the review, as
described in Chap. 7. You keep the book as payment.
Book chapters are almost always invited, and book editors
choose prospective authors from those writing on the topic
needed for the book. You may be invited to write a book chap-
ter after publishing a few articles on your new focus area,
book chapters are usually not where a new writer begins.
The same holds for writing a book. A few will succeed, but for
most this is not where to start.
Mistakes We Make When Getting Started
Trying to do it alone: If at all possible, work with someone
more experienced. Your colleague may be a coauthor, or
someone who reads your work and offers comments.
Trying to run before you can walk: Do not attempt to
write the definitive work on a topic or the grand epic in
your specialty. Aim early to learn the writing and publica-
tion process by getting something written and in print,
however humble your early pieces may seem. In my early
days, I wrote for
Medical Economics
on topics such as “Having Regular Meetings
with Your Office Staff” and “How to See Patients More
Efficiently in Your Office.” I don’t write on practice man-
agement subjects any more, but these articles helped me
learn how to write and get published.
Starting to write without preparation: It is a big mistake
to begin writing until you have selected and refined your
topic, figured out how you will structure your article,
done your research, and assembled your writing tools.
Without being prepared, inspiration won’t carry you very
far beyond page one. Starting off unprepared will almost
surely lead to an uneven product, and you will spend a lot
of time doing remedial work. It is much better to be ready
when you start, and know where you are going.
The Value of Early Success
Do not underestimate the value of early success in medical
writing. I urge you to strive for something in print early,
for your own contribution to the twenty-first century time
capsule. Seeing your work in print is an exciting affirmation
of your self-worth. A few early publications will carry you
through the effort of more writing and the rejections that
are sure to come as you aim higher and higher. Also, try very
hard to avoid a succession of early failures.
The next four chapters deal with basic writing skills that
can help you win the publication race. The later chapters
in the book describe the specific writing models, including
“how-to” advice and problems to avoid. The last chapter has
tips that can help you get your work published.
Rew DA. Writing for readers. Eur J Surg Oncol. 2003;29:
Batshaw ML, Plotnick LP, Petty BG, Woolf PK, Mellits ED.
Academic promotion at a medical school: experience at
Johns Hopkins University School of Medicine. N Engl J Med.
Beasley BW, Wright SM. Looking forward to promotion: char-
acteristics of participants in the Prospective Study of Promotion
in Academia. J Gen Intern Med. 2003;18:705–710.
Sebastian A. A dictionary of the history of medicine. New York:
Parthenon; 1995.
Major RH. Classic descriptions of disease. Springfield, IL:
Charles C Thomas; 1932.
Dirckx JH. The language of medicine. 2nd ed. New York:
Praeger; 1983.
Porter R. A dictionary of the history of medicine. New York:
Parthenon; 1999.
Hammer AL. Introduction to type and careers. Palo Alto, CA:
Consulting Psychologists Press; 1995.
Taylor RB. Medical wisdom and doctoring: the art of 21st cen-
tury medicine. New York: Springer; 2010:53–55.
Verghese A. The physician as storyteller. Ann Intern Med.
Brody H. Stories of Sickness, 2nd Ed. New York: Oxford
University Press; 2003.
Capote T. Preface. Music for chameleons. New York: Vintage;
Steinbrook R. Searching for the right search—reaching the
medical literature. N Engl J Med. 2006;354(1):4–6.
Medical Subject Headings (MESH) Fact Sheet. Available at:
International Committee of Medical Journal Editors. Uniform
requirements for manuscripts submitted to biomedical journals.
Available at:
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_2,
© Springer Science+Business Media, LLC 2011
Basic Writing Skills
Imagine practicing medicine without being versed in the
language of medicine, including all its formal terminology and
informal jargon. Without access to this specialized linguistic
domain, physicians couldn’t understand normal physiology
or pathophysiology. They would be incapable of synthesizing
findings from the history and physical, lab work, and imaging
studies to make a diagnosis. Words like
marasmus, fistula,
would make no sense. Communication in any kind of
meaningful way with peers or patients would be unworkable.
Couba C. The Language of Leadership <
Do not skip this chapter. Yes, there will be the temptation to
go directly to the chapter describing the article or research
report you want to write, but that would be a mistake. It
would be like attempting to build a house without a blueprint
and tools. In writing an article or a book chapter, the topic
is what you want to “build.” The structure is your blueprint,
and the paragraphs, sentences, and words are the contents of
your toolbox. So learn your craft and how to use your tools
before starting to construct your masterpiece.
Much of this chapter is fundamental English 101—just
adapted to medical writing. However, it is not a compre-
hensive course in composition and grammar. In fact, if my
English teachers from high school and college ever read this,
they might say, “Bob, is this all you remember of everything
I taught you?” It is not really all I recall, but it represents
the “cliff notes”—the bare bones of what the medical writer
needs to know.
The Great Idea
A good idea is the most important thing a medical writer can
have. It can come to you in a variety of ways. One might be as
a result of a discussion with colleagues, as happened to me a
few years ago. At that time, there had been a sudden drop in
students matching in my specialty. Yet, in trying to place an
unmatched student in a residency program using phone con
tacts, I encountered inefficiency and almost
from residency directors who had vacancies and whom
assumed really needed to recruit graduating medical stu
dents into their programs. I described this phenomenon at
our department’s weekly faculty meeting and reported briefly
what I thought the residency directors needed to know. In my
remarks to the faculty, I listed five things that residency direc
tors should do to be receptive to unmatched students attempt
ing to “scramble.” And then I thought: Why not write it up?
I returned to my office and finished the short piece by noon.
It was published as an editorial a few months later <
A second source of ideas should be your area of interest
and expertise. For example, I was once asked by a medical
journal to write an editorial; almost any topic would be okay.
I considered the significance of a current whooping cough
scare, the health risks to travelers in the holiday season, and
even the changing demographics of medical school classes.
In the end, I decided to do what I should do, and that is to
write about what I know. I did some research and wrote
a nice, short editorial, “How Physicians Read the Medical
Literature.” <
> The journal editor liked the topic and how
I handled it, and no readers wrote to say that I was unin-
formed or misguided. Also, some of what I learned was useful
in planning Chap. 5 of this book.
A third possibility is looking at clinical implications of cur-
rent public issues. Here is an example: From time to time,
I have taught a course in medical writing for faculty mem-
bers at our medical school. This course involves 90-min ses-
sions held once a month over 6 or 8
months. The course is for
beginning medical writers, and one objective is to have each
participant write a review paper and have it on its way into
publication before the last session ends. In our most recent
course, one faculty member with a certificate of added quali-
fications in geriatrics announced her plan to write an article
titled “Assessing Older Persons for Their Ability to Operate a
Motor Vehicle Safely.” She had a very good idea, timely and
clinically relevant. (I will discuss below how she developed
the idea). As a course assignment, she called a review journal
editor to discuss the article; the response was encouraging,
with a discussion of holding a spot for the article in a future
issue. A few months later, the article was in print.
The points I have tried to make in the anecdotes above
When something excites you and you have, you believe, an
answer to a current problem—such as residency directors
needing to learn to “scramble”—think about writing it up.
Then do it now, before the idea gets cold.
Write on what you know about and what excites you. This
helps maintain your interest and also helps focus your
writing on the topic that will move your career along.
Write on clinical topics in your area of expertise. In general,
medical publications need articles about practical aspects
of disease diagnosis and management. And, of course,
research journals need reports of original research studies.
Allowing the Idea to Incubate
For major projects—in contrast to the short editorial about
the residency “scramble” described above—you should let
your idea germinate for a while. I like to think of this activity
as “free-range” accumulation of odd facts, phrases, and con
nections. Thoughts will come into your head while you are in
the shower or driving your car. Sometimes they occur in the
middle of a meeting, when a comment creates a synapse in the
writing center of your brain. Thoughts about your writing may
appear in that shadow land between wakefulness and deep
sleep, when all the aspiring notions, some inspired and others
fanciful, in various parts of your brain, embryonic ideas gen
erally held in check by the oppressive distractions of the day,
can emerge and express themselves. Do not lose these prod
ucts of your subconscious! (Parenthetically, this is exactly why
I hate alarm clocks; you are jarred from sleep to wakefulness,
and lose the creative time of twilight sleep.) In these evanes
cent thoughts, you may have been blessed with a gift that can
be the basis of a great article, or that may make your article
better. Write it down. Enter it in your portable computer. Put it
in your journal. Scribble it on an old envelope. Whatever you
do, hang on to it, and don’t let it get away. Many times I have
left a shower or a warm bed to jot down a writing idea that
knew would escape if not captured at that moment.
For example, the metaphor of the “free-range” accumula
tion of items to flesh out an idea occurred to me during a
long airplane ride; it was Thanksgiving time and I had read
about “free-range” turkeys that sought their food in a more
or less natural way. I jotted the phrase on the blank sheet of
paper I always carry for this purpose. (Today I would record
the thought on my new smart-phone.) Now here it is in print,
courtesy of United Airlines, some handy notepaper, and then
my notebook computer. It may not be the brightest idea I ever
had, but at least it didn’t get away. A better example may be the
analogy, described in Chap. 1, of the three questions asked by
Princess Turandot of the prince and the three questions writ
ers must answer about their current work; this occurred to me
while listening to a very long aria at a performance of Puccini’s
opera, and I scribbled the idea on the printed program.
In preparing to write this book, I created a file of ideas
for each chapter. Under each chapter I record miscellane-
ous notes, brilliant thoughts, literary allusions, and short
paragraphs that seem witty. Then I go to this “Notes” file as
begin to write each chapter.
Focusing the Topic
Most article ideas are too broad, and an early task is generally
to limit the focus. Here is an example: Let’s say that I
want to
write an article about the diagnosis of headache. This topic
is much too broad, and so I might limit it first by focusing on
the diagnosis of a type of headache, such as migraine, ten-
sion type, or even cluster headache. But these topics are still
too broad. Let’s choose migraine headache, and limit it some
more. We might discuss diagnosis of migraine headache in
women, in adolescents, or in the elderly; the implications
are clinically different in each. Another way to approach the
diagnosis of migraine is to consider when diagnostic imaging
(computed tomography or magnetic resonance imaging) is
needed. Now we are getting more specific. In the end, a good
topic and title might be: “Red Flags in the Headache History:
Five Reasons to Obtain Diagnostic Imaging.”
The astute writer avoids telling too much. This helps pre-
vent “overwriting”—producing an article much too long for
any journal and thus in need of ruthless pruning. By this
mean that if your article is about when to seek diagnostic
imaging in a headache patient, you should make it clear to
your reader (and to yourself
) that you will not discuss what
blood tests to order, drugs and doses, or special diets. You
will plan ahead and stick to your topic.
Jotting notes and focusing the topic help move you to the
next step—planning the concept and structure of your article.
Your article or chapter is intended to provide information or
answer questions for your readers. To achieve this goal, you
must present your information in the best possible format.
Possibilities include the review article, editorial, case report,
letter to the editor, book chapter, or report of original research.
Each has its own rules for structure, and will be covered in
chapters to come. At this time, I will use the review article
format to discuss article structure. I choose this format since
the review article allows the writer the greatest opportunity
to express creativity in how to handle material.
Sometimes the focused topic yields the concept. In the
instance of “Red Flags in the Headache History: Five Reasons
to Obtain Diagnostic Imaging,” the article structure is self-
evident: The article will begin with an introduction stating
the epidemiology and background for the problem. Next will
come a five-part section on the red flags, which would include
migraine associated with a neurologic abnormality on physi-
cal examination (such as unexplained unilateral deafness
or weakness in an extremity), a seizure, or a trajectory of
increasing pain and frequency of headaches. Last will come
the summary/discussion section that pulls it all together. With
this framework, the article practically writes itself.
The secret of structuring an article is finding the topic’s
component parts. An article on treating back pain may have
four components: medications, physical therapy, determi-
nation of appropriate activity levels, and preventing future
recurrences. If writing a piece on diagnosing depression in
teenagers, I might cover the stresses teens face in life each
day, symptoms of depression that teens may exhibit, and
how to confirm a diagnostic hunch. I might even include a
table, “High Pay-Off 2uestions to Help Spot the Depressed
Teenager.” Such a list might prove especially useful to
In the end, the focused topic and presentation concept
should evolve into an outline. Yes, an outline. The outline
allows us to bring order to what would otherwise be an
unstructured and perhaps even a messy process. In planning
this book, I developed a 12-page expanded outline that gave
the topics for each chapter down to the third level of topic
heading. Of course, as I write each chapter, I may rearrange
things a little, but the overall outline tells me where I am going
and what will be presented in each chapter and under which
heading. It also, I hope, helps me avoid too much repetition.
In planning the article cited above on assessing driving
skills in the elderly, our faculty member decided on the fol-
lowing preliminary outline:
Background, including statistics
Legal aspects of the problem
Areas to assess
Mental competence and dementia
Physical competence and handicaps
Special senses
Making decisions
Dealing with the patient
State laws
Family issues
In general there are some time-tested ways to structure arti
cles. Of course, if you are writing a report of original research,
you must, repeat
, use the IMRAD model, which describes
Introduction, Methods, Results, and Discussion; this will be
described in detail in Chap. 11. If writing a book chapter or
review article on a disease such as gastroesophageal reflux
disease (GERD), the headings are likely to be Background,
Clinical History, Physical Examination, Laboratory Tests and
Imaging, Treatment Options, and Prevention.
For other articles, general approaches might be:
The List
This is a straightforward, time-tested way to organize a
review article or an
editorial. Examples might be:
Three exercises that may prevent back pain
Four herbal remedies for chronic joint pain
Five ways to improve collections in your office practice
Six questions that can help diagnose panic disorder.
What’s New?
A new procedure for ventral hernia repair
A new federal regulation that will affect your practice
A review of current treatment regimens for AIDS
New drugs to treat fungal infections of the skin.
2uestions and Answers
What are safe antibiotics to use in pregnancy?
Who should perform head and neck surgery?
What vaccines should be given to the international traveler?
What are the early signs of pancreatic cancer?
Current Controversies

Dementia and the statins: Do the drugs prevent or cause
Who should or should not receive pneumococcal vaccine?
Who should receive outpatient laparoscopic cholecystectomy?
The ethical issues in boutique medical practice.
Mistakes We Make in Article Structure
Beginning writers often make the following mistakes in
defining the concept and structure of their articles:
Starting to compose without a concept. Having a good
idea is wonderful, but you must also decide how you will
handle the idea.
Attempting to write without an outline. Maybe some crea
tive and experienced writers can do so, but for the begin
ning medical writer, an outline is a must. A study by Kellogg
found that preparing a written outline, compared with not
doing so, led to higher quality documents as indexed by
ratings of judges <
>. As I work on this chapter today, my
outline is located to my left on my desk.
Having an outline with too many major headings and not
enough development of each. More than five main head-
ings in the outline is almost certainly too many for a medi-
cal article. Please notice that this chapter, which is about
twice the length of a medical article, has only five main
headings plus a reference list.
Trying to cover too much ground. Focus, limit, and then
narrow some more.
Failing to introduce the purpose of the article very early in
the writing.
Developing a good concept and structure, and then failing
to follow the blueprint. Editors—and astute readers—will
quickly spot when you have left the main highway and
strayed off on a side path.
Beginning to write the manuscript without thinking the project
through. This will only lead to much painful rewriting later.
Clear writing comes from clear thinking. See the completed
project in your mind before starting the first paragraph.
A paragraph is a collection of sentences that all relate to a
common theme. In a sense, each paragraph is a small essay.
This means that you should follow the basic rules for writing
an essay: tell your reader what you are trying to say early,
develop the theme using some concrete examples, then con-
clude in a thoughtful way. In an essay, sometimes it is good to
reprise the opening sentence at the end in some way, and this
can also work well in a paragraph. An alternative conclusion
to a paragraph may be a transition to the next paragraph.
Choose your ending, and then move on.
The first sentence in a paragraph is classically the “topic
sentence.” The topic sentence states what the paragraph is
about and is thus probably going to be somewhat general in
nature. Let’s look at the paragraph just before this one: The
topic sentence is “A paragraph is a collection of sentences that
all relate to a common theme.” Then the paragraph goes on
to give three steps in developing the paragraph: (1) state the
topic early; (2) use examples; and (3) conclude in a meaning
ful way, perhaps with a hint of transition to the next topic. To
use a sample from the literature, in a 2011 article describing
innovative curricula for addressing medical students’ career
development, the authors’ first paragraph begins: “The unfor
tunate combination of increasing medical school class size and
stagnant numbers of residency slots has created a competitive,
stressful environment in which students are often forced to
make premature, uninformed decisions about medical special
ties and career choice.” (Navarro et
al. Acad Med. 2011;86:72.)
This is a classic topic sentence for both a paragraph and an
essay. It sets the stage and offers hints of what comes next.
There are occasional exceptions to the classic format, such
as when the example is stated first to get the reader’s atten-
tion, followed by a general statement telling what the exam-
ple means. Here is a demonstration of what I mean:
Over-the-counter drug availability and unintended
Initial example to get the reader’s attention:
Since H2-blockers became available over the counter (OTC) in
drugstores, Mary Smith, a public assistance patient with persis
tent upper gastrointestinal distress, has ceased her use of these
medications and is experiencing recurrences of symptoms.
General statement explaining the significance of the
Sometimes regulations that are intended to make drugs more
available to patients have a paradoxical effect of reducing
their use. W
welfare patients could previously get the H2-blocker drugs
no personal cost by prescription, but now that the drugs
are available OTC, they are no longer eligible for prescription
Organizing the Paragraph
Thoughts in a paragraph must be presented in an orderly
not jumbled like a bag of toys. Sentences can be arranged in a
chronology of what happens. I used this in the preceding para
graphs: moving from topic sentence, to examples, to conclusion.
Or you may decide to order sentences by rank of importance. In
describing causes of a low back pain, you might mention lum
bosacral strain (the most common cause) first, then herniated
lumbar disc (less common, but very important), followed by less
common causes such as spinal abscess, metastatic cancer, and
so forth. An alternative method of ordering sentences within a
paragraph might be a reverse ranking order: In this setting you
might describe the medications currently used to treat peptic
ulcer disease, briefly describing the least expensive or the least
effective ones first, and then spending most of the space on
today’s popular remedy, the protein pump inhibitors. Or some
times the rational order is nothing more than a simple list. In
this paragraph I told you about four ways to organize sentences
in a paragraph, presented in no particular order.
When you have finished writing a paper, try this test to
see whether you have organized your paragraphs well. Begin
with a paper copy of your manuscript and some colored
highlight markers. Then first highlight in yellow (or another
favorite color) the key sentence in each paragraph; the sen-
tences highlighted in yellow should, in most instances, be at
the beginning of each paragraph.
Next, use another color (let’s say blue) to highlight the
examples that support the key general statement. Most or all
paragraphs should have supporting facts, and they should
generally follow the yellow-highlighted topic sentence. The
exception, as noted above, will be when the example is used
as the lead item—the attention-grabber—in the paragraph. In
the next section, we will spend some more time considering
supporting examples.
Using Concrete Examples
At times you will read an article and think, “This is dull.”
When this happens, ask yourself why. Often the answer is
that the writer has written in broad general statements, and
failed to provide examples to illustrate theory. This happens
especially in philosophy and sometimes in the psychological
literature. Medical writers are often spared this transgression
because we present specific data such as laboratory tests,
drugs, and doses. In other instances, and perhaps ideally,
we describe cases. In all writing, we must be vigilant about
unsupported general assertions.
Why do we see writing without examples? Here is one rea-
son: Writing general statements is easy. We all like to share
our great ideas. But thinking up examples to support our
favorite philosophical thoughts is often a struggle. Finding
specific examples can be difficult, but concrete facts are what
make writing come alive.
To illustrate the use of examples to clarify general state-
ments, let us look at three examples:
Role of the primary care physician
General statement:
The primary care physician must be the expert in the care of com
The general internist or family physician should be skilled in
the management of degenerative joint disease, and be able
to differentiate it from rheumatoid arthritis, intra-articular
Changing our minds about the use of drugs
General statement:
Sometimes we ênd that drugs once avoided in certain diseases
It was once axiomatic that one did not prescribe beta-blocker
drugs for patients with congestive heart failure, but now we
have discovered that the drugs are useful in treating some
Use of multivitamins by healthy individuals
General statement:
In this age of evidence-based medicine, some clinical advice
seems to be based on intuition or tradition, rather than
results of scientiêc studies, and sometimes in the face of
Many of our patients take multivitamins daily, despite a paucity
of evidence that vitamin supplements have any favorable effect
on cardiovascular disease, common cancers, or overall mor
tality. In fact, a 2010 study conducted in Sweden, suggests that
multivitamin use might be associated with an increased risk of
breast cancer. (Larsson et
al. Am J Clin Nutr. 2010;91:1268.)
Being Considerate of Your Reader
Be considerate of your reader by making your paragraphs
not too long, not too short, and not too dense. In medical
writing, paragraphs often seem to go on for pages and pages;
that may be a little exaggerated, but when the prose is unnec-
essarily burdened with long medical words and phrases, and
when there is sentence after sentence without a break, the
resulting paragraph becomes just too long. Whenever you
find a paragraph that continues for more than eight or ten
sentences, look and see whether there is a logical break in
the middle, even if you need to add a transition phrase or
sentence. If a paragraph covers two or more topics, it almost
certainly needs to be divided into two.
Don’t make your paragraphs too short. I generally like
short paragraphs. They allow more pleasing “white space”
on the page, and they give the reader time to breathe. That
said, we must remember that a paragraph is, as noted above,
a collection of sentences that relate to a common topic. One
or two silver dollars do not make a collection, and most
paragraphs need more than one or two sentences. Are there
exceptions? Yes, the exception is when a one-sentence para
graph is used for emphasis. But, like a person who sends
e-mail messages laden with exclamation points or shouts
while talking, using more than the occasional
paragraph will irritate the reader.
How you construct your paragraphs affects the density of
the page. We like some journals and books in part because of
the information contained and part because of their pleasant
appearance. The computer screen has not yet equaled the
pleasure of holding and reading something with printed pages.
Part of the pleasure of the printed page is what is
there. By
that I mean, there must be a balance of printed word and, as
mentioned briefly above, “white space”—the area of the page
that has no ink. On any page there is probably an amount of
white space that is just right. This is achieved by alternating
paragraph length, avoiding an article with all very long para
graphs (tiresome) or all very short paragraphs (annoying), and
perhaps by using tables or figures (discussed in Chap. 4).
The density of the printed page is also managed by the
use of headings. I have made liberal use of headings in this
book. This allows the presentation of white space to frame
the paragraphs, and does so in a way that I hope you find
aesthetically appealing. After all, the pleasant appearance of
the pages is part of the joy of reading.
Active Versus Passive Voice
Here is a single answer quiz. Which is better? Pick one.
We found thatd
It was found thatd
About two decades ago, several colleagues and I submit-
ted a paper to a prestigious academic journal. It described
an innovative medical school clerkship for students. Our
paper read something like this: “We identified a need in the
curriculum. We developed and presented a 6-week clerkship
for the students. At the end of the year, we evaluated the out-
come of the program.” Following appropriate peer review,
the journal editor wrote to us, accepting the paper contingent
on certain modifications. One of these modifications was that
we authors change all statements to passive voice. And so, we
laboriously revised our prose to read: “A need was identified
for an addition to the curriculum. A clerkship was developed
and presented. The outcomes were evaluated at the end of
the year.” The changes continued throughout the rest of the
article. In due time, the paper was published, but what was
presented in print lacked the punch of what we originally
submitted, and actually took more words to express the same
If active voice has more vigor than passive, why do we
use the latter? Somehow, it may seem easier to express our
thoughts in passive voice, and perhaps we thereby take a lit-
tle less responsibility for them when “I” or “we” is not stated.
wonder if we are more likely to use active voice when we
feel confident about positive results in research and passive
voice when our confidence is lacking or the results are equiv-
ocal. Another theory is proposed by Day <
>: “Perhaps this
bad habit is the result of the erroneous
idea that it somehow impolite to use first-person pronouns.”
In fact, I
submit that, in contrast to being impolite, using the
active, first person voice, we respectfully take ownership for
our words.
We are definitely moving toward using more active voice
in medical writing, especially in reporting original research.
Here are some representative phrases from medical journals
that have crossed my desk recently:
The Lancet Infectious Diseases
“We aimed to assess the efêcacy and safety of triple antiret
roviral compared with zidovudine and single-dose nevirap
ine prophylaxis in pregnant women infected with HIV. ”
From the
New England Journal of Medicine
From JAMA (2010;304(17):1912–1918.)
“We used a stratiêed, cluster randomization designd”
There are, of course, times when the use of passive voice
is best. The classical example is when who does something
is less important than the recipient of the action. In this
instance it may be better to say that “the patient was injected
with the test drug” rather than “we injected the test drug into
the patient.” Or perhaps it doesn’t matter who performed the
action, just that it occurred. For example, in the statement
“The patient was transported to the hospital by ambulance,”
it does not matter who drove the vehicle.
Construct Sentences with Care
Words per Sentence
We medical writers often write jumbled and tortuous sen-
tences. We try to put too much into them and we forget that
the best sentences contain one thought. When a sentence is
too long it may become barely intelligible. As an example of an
unfriendly sentence, I am going to rewrite the last paragraph
in the section above on
Being Considerate of Your Reader,

the one on page 43 just before the heading SENTENCES.
Here goes:
The density of the printed page is managed by how we use
headings, and you will note that I have made liberal use of
headings in the book, which allows the presentation of white
space to frame my usually well-written paragraphs, doing so
in a way that is aesthetically pleasing, which is, after all, part
This 63-word stinker of a sentence did not even trigger my
Microsoft Word grammar and spell checker to tell me that it
is too long—but it is, even with the relatively small words it
contains. Imagine how bad it could be if weighed down with
long scientific terms or unfamiliar abbreviations.
If you have more than about 25 or 30 words or more than
two commas in a sentence, consider breaking it into two sen-
tences, and you will usually find that it will read better. As an
example, I wrote the previous sentence—on purpose—using
34 words and combining two thoughts. Now let’s rewrite it
as two sentences:
If you have more than about 25 or 30 words in a sentence,
consider breaking it into two sentences. You will usually ênd
that it will read better.
Do you agree that the rewrite is an improvement?
Words per Verb
If a sentence seems weak, count the words per verb. Verbs, the
action words, are your strong words in a sentence. More
20 words per verb tend to create a weak sentence. Here are the
thoughts in the previous three sentences,
considerably rewrit
ten into one with 37 words and only one verb (“makes”):
The use of an excessive number of words in conjunction with
a single verb makes for a weak sentence, deêcient in strong
words, often complex in structure, and very likely complicated
Using Variety in Your Sentences
To make your writing vibrant, be sure to vary your sentence
beginnings, type, and length. Avoid using the same word
repeatedly, especially at the beginning of the sentence. Also,
try to have some simple declarative sentences, some a lit-
tle complex, and some that even begin with prepositional
We have already discussed excessive sentence length,
which can be tiresome to the reader. On the other hand, using
too many short sentences is also poor writing. The following,
not atypical for a clinical record entry, is intended to illustrate
all three points—sentence beginnings, type, and length:
The elderly patient fell on a scatter rug at home. The patient
struck his shoulder when he landed. The patient sustained a
The three sentences all begin alike, are all simple and
declarative, and are all quite short. No one of the sentences is
improper in any way, but taken together, the writing is unskill
ful. A much better way to express the three facts would be:
The elderly patient fell on a scatter rug at home, striking his
Sentence Density
Single sentences, like paragraphs, can be too dense for
comprehension by mere mortals. Consider the following
sentence from a published report with the very clear title
“Effect of Improving Depression Care on Pain and Functional
Outcomes Among Older Adults with Arthritis.” This is a topic
of interest to all of us who treat elderly patients. And so I read
with great interest the first of two sentences in the Results
section of the Abstract:
In addition to reduction in depressive symptoms, the interven-
tion group compared with the usual care group at 12
had lower mean (SE) scores for pain intensity (5.63 <0.16> vs.
6.15 <0.16>; between-group difference, –0.53; 95 conêdence
interval (CI), –0.92 to ø0.14;
 .009), interference with daily
activities due to arthritis (4.40 <0.18> vs. 4.99 <0.17>; between-
group difference, –0.59; 95 CI, –1.00 to ø0.19;
and interference with daily activities due to pain (2.92 <0.07>
vs. 3.17 <0.07>; between-group difference, –0.26; 95 CI, –0.41
. 2003;290:2428
As a practicing physician and a medical writer, what are
my issues with this sentence and how could it have been
improved? First, it is much too long and convoluted.
believe that it could have been divided into three or four
shorter sentences to enhance clarity. Second, the abbre
viation CI (for confidence interval) is explained, but SE
remains a mystery and is not explained elsewhere in the
Abstract. Finally, the sentence is, in my opinion, much too
stuffed with data. Do I really need all of these numbers in
the abstract? What has been saved for the Results section of
the article?
Fortunately, the authors translate the difficult sentence
for us mere mortals, and do so in very clear English: “In a
large and diverse population of older adults with arthritis
(mostly osteoarthritis) and co-morbid depression, benefits of
improved depression care extended beyond reduced depres-
sive symptoms and included decreased pain as well as
improved functional status and quality of life.” Okay, even
this sentence is a little long and complicated, but I
can read
it without difficulty. And I like that the author used simple
words such as “mostly” instead of “predominantly” and “oste-
oarthritis” rather than “degenerative joint disease.” I will
present more on words in the next section.
Sentences have a cadence that the reader can sense, much
like the rhythm in a song. You can best sense the cadence by
reading the sentence aloud. If a sentence is convoluted by too
many clauses or if it is burdened by too many unnecessary
long words, the pleasant rhythm is lost. For example, take the
first sentence in this paragraph, beginning, “Sentences have
a cadenced” It’s not Haiku poetry, but I think the sentence
has a nice rhythm. It has several short words, then a long
word, and only one word with more than two syllables. Could
the sentence be worse? Yes, it could. Here’s how:
Very analogous to the rhythm that may be found in a song,
we are readily able to discern pleasing cadences in sentences
Ugh! The sentence is syntactically correct, but not enjoyable to
read. Make your reading a joy for the reader, if you can. If you
wonder about the cadence of your sentences, read them aloud.
Punctuation: Commas, Periods, and More
Commas, semicolons, periods, and question marks are called
stops. They improve sentence cadence and clarity, and thus
make reading easier. According to Jordan and Shepard <
“the stops should fit with the rhythm of respiration as well as
with the sense of what is said.”
Commas, like all stops, break up the flow of words. In a series
of items, a comma is correct if it could be replaced by
In her charming book
Eats, Shoots and Leaves
, Truss describes
commas as “separators,” likening the comma to a grammatical
sheepdog that “tears about on the hillside of language, end
lessly organizing words into sensible groups and making them
stay put: sorting and dividing; circling and herding; and of
course darting off with a preemptory “woof” to round up any
wayward subordinate clause that makes a futile bolt for seman
tic freedom.” <
> Consider the sentence at the beginning of this
paragraph and how it would read without commas:
I suspect that you would need to read it twice to discern my
meaning, and then would mentally insert the commas.
The placement of commas can actually change meaning.
For example:
The presence or absence of commas changes who seemed ill.
Bernstein <
> has reported how the state of Michigan
discovered that its state constitution inadvertently legalized
slavery. Section
8, Article 2 read:
Neither slavery nor involuntary servitude, unless for the pun-
Upon consideration, it was sagely decided to delete the
comma after servitude and place it after slavery.
The semicolon is used when you almost need a period; yet, a
period would break up linked thoughts. If I used a period to
divide the previous sentence, I would have created two short
sentences in sequence. It might be acceptable, but joining the
two thoughts with a semicolon seems right to me. In the set-
ting of related thoughts and phrases, the use of semicolons is
often a matter of individual style.
Semicolons are very useful in a series of items when the
comma is needed within items. Truss describes this role as
performing “the duties of a kind of Special Policeman in the
event of comma fights.” <
> For example:
Musculoskeletal injuries may be treated with rest; analgesics
or muscle relaxant medication; and physical therapy including
heat, ice, and stretching exercises.
Periods and 2uestion Marks
The period is the “full stop” that ends a sentence. Period. Oh,
yes, there are some technical uses, such as in abbreviations
(e.g., Mr., Ph.D., or Dr.), but these do not affect sentence
The question mark is an interrogatory symbol that appears
after a direct question. A period is used with an indirect ques-
tion. For example:
The direct question:
The physician asked the patient, “Where is the pain located?”
The indirect question:
The physician asked the patient where the pain was located.
Sentences with Misplaced Phrases
Do you remember the old song titled, “Throw Momma from
the Train a Kiss?” Jumbled sentences with goofy phrases can
find their way into the medical literature. The classic “Throw
Mommad” sentence mixes up phrases within the sen
tence, together with a single verb that could apply to either
phrase—albeit with potentially hazardous consequences in
one of the two possibilities. In this example, the object of
the verb “kiss” should follow the verb “throw” directly, with
the less important prepositional phrase “from the train”
relegated to the end of the sentence. Rewriting the sentence
then gives us:
Sentences with Verbose Phrases
Verbosity is a disease that afflicts many sentences in medical
writing. Verbosity is simply using a long phrase to express a
thought when fewer words will do nicely. A classical example
is saying “fewer in number” instead of “less” or even simply
“fewer.” Or a careless author might write, “has the capability
to” when meaning to say “can.”
presents a list of verbose phrases.
Of course, it is not just phrases that are afflicted with word
iness. Sometimes entire sentences are involved. Here is one:
The thesis is herein offered that woman (like man) is a biological,
social and cultural creature, and as such is dependent for health
on the acceptance, approval, support, and encouragement of
signiêcant individual members of the social group to which she
What the author means to say, I believe, is that a woman’s
health can be influenced by her peer relationships.
You can usually spot a verbose sentence before you are
halfway through. How? Because it often begins with a phrase
We are reminded of the necessity for the consideration
Although certainly not a new finding, it is pertinent to
remind the reader thatd
At this time, it is appropriate to emphasize thatd
It is a well-recognized fact thatd
Let me make clear thatd
It is interesting to note thatd
Of course, all this verbosity is really an excess of words,
and often large words. So let’s next consider our most basic
erbose phrases: why use one word when more will do?
erbose phrase
What you mean to say
t this time
t the conclusion of
With the exception of
n only a small number of cases
n many instances
n light of the fact that
ore often than not
n the absence of
n a daily basis
n close proximity to
he great majority of
With regard to
n the event that
n the not too distant future
onsensus of opinion
Words are the most basic tools we use to write. Winston
Churchill once wrote: “Short words are best and old words,
when short, are best of all.” Sir Winston’s sentence has a
pleasing cadence. It uses the active voice. It is not long and
convoluted. Most important, it uses only short words; in
fact, the sentence contains only words of one syllable. They
are old-fashioned English-language words, even though,
like most words, they can be traced to some language in
antiquity. Also, the sentence does not contain the complex
scientific words we often must use in medical writing. In lit-
erature, using short, strong words make for stronger prose.
As William Faulkner once wrote—perhaps derisively—of
Earnest Hemingway: “He has never been known to use a
word that may send the reader to a dictionary.”
One of the inescapable difficulties in medical writing is our
dependence on scientific words derived from the classical
languages. Their specificity is a benefit, but their complexity
can become a curse in medical writing. Let’s look at a few
medical words.
Understanding Medical Words
I have always been fascinated by medical words, and I try
hard to know the origins of those I use. I advise medical
students and residents to keep a “medical word journal” to
help them learn the classical roots, and various other origins,
of words we use in clinical care. I believe that knowing the
etymologic derivation of words such as
the Greek word for “vinegar cup”) and
Norwalk virus
the small town in Ohio where the microorganism was first
isolated) might make me a better writer. Even if this theory is
flawed, knowing how these words arose enriches my life.
According to Sobel, the newly minted physician has
learned 55,000 new words <
>. Most of these come from
Latin and Latinized Greek. The Latinization of Greek began
when the Romans conquered the Greeks, and they appro
priated everything, including their language. Later, in the
post-Renaissance era, scholars and scientists turned to
these languages as new words were needed to describe their
discoveries. Also, as theorized by Dirckx <
>: “But there
was a second and no less cogent reason: Latin was a dead
language. No longer anyone’s mother tongue, it was hardly
more subject to alteration or corruption through use than the
alphabet or multiplication table.” Examples of words coming
from Latin and Latinized Greek are
(to be mad),
(a flat cake),
(to scratch),
(diminutive of red), and
(from digit, meaning
finger or toe, and used because the drug came from foxglove,
also called “ladies’ fingers”).
Later, the Anglo-Saxon tongues gave us
, and
(The latter is now the name of a prestigious journal.) Middle
English gave us some medical words such as
and Italian
(meaning beautiful lady). Others that
are borrowed from foreign languages include
the Singhalese word
meaning weak; the doubling indi
cates extreme weakness) and
from the Egyptian
word for Jupiter (the rest of the story is that Jupiter was called
Jupiter Ammon, and many persons came riding camels to
worship the god at a shrine near the Libyan city of Ammonia;
from the accumulated camel dung came a substance that was
named ammonia).
came from a Persian word meaning
antidote, and
arose from the Spanish spelling of the
Peruvian word
, meaning bark (of a tree).
Some medical words come from literature or mythology.
These include
pickwickian syndrome
Munchausen syndrome
, and
Achilles tendon
. Some more
recent medical neologisms involve places: the disease name
comes from Tulare county in California, where the
disease was first described. Even universities and patients
get in the game: Warfarin, first marketed as a rat poison,
is named after the
plus the last four letters of its chemical name; and the name
comes from “baci” for bacteria and “tracin” for
Margaret Tracey, whose wound drainage permitted identifi-
cation of the antibiotic.
lists some of my favorite medical words and their
origins. I hope that this section and the table inspire you to
seek the sources, as well as the definitions, of unfamiliar
words as you encounter them.
he origins of selected medical words
edical word
rigin of the word
, meaning “sausage.”
n the
Some Thoughts About the Types of Words We Use
We use many types of words, which include nouns and
pronouns, verbs, modifiers such as adjectives and adverbs,
metaphors and similes, onomatopoeic words and alliteration,
literary allusions and eponyms.
Nouns and Pronouns
Nouns are generally strong words, and short nouns make
for easier reading than longer ones, but, as noted, this is
sometimes not possible in medical writing, as we sacrifice
readability to precision. We seldom get in trouble with
Pronouns are another story. We sometimes confuse the
pronoun and its antecedent, the word the pronoun replaces,
as in the following:
A new vaccine is available to prevent the flu, and to get it you
should see your doctor now.
This disease stands unique as the first truly American
and the guiding spirit that made this accomplishment possible
The resident anesthetized the patient as the attending
waited; he then made the incision in the abdomen.
Over the past few years we have discovered another
way to introduce complexity with pronouns, namely the
use of clumsy neologisms to avoid the perception of sexist
language. Newly created unisex pronouns have included
“shim” and “s/he.” Or, in the quest for gender-neutral writ
ing, we have also begun to accept annoying constructions
such as, “The physician should treat their patient with
respect.” Probably the best of the compromises is the use
of plural pronouns (“they”) or using both genders (“he or
she,” “her or him”). In this book you will not find “their”
used with a single noun as an antecedent. I have tried to
minimize the use of wordy phrases such as “he or she” or
“him or her,” but found that I could not avoid their use
Verbs, the action words, are the strongest we have:
. Every sentence needs a verb, which
should be close to the subject noun in the sentence. Verbs can
be expressed in active voice (“We found thatd”) or passive
(“It was found thatd”).
Verbs also have tense—past, present, future, and variations
thereof. There are two conventions in medical writing worth
Within a scientific article, we use past tense to describe
We found that one-third of the rats survived, one-third died,
and the third rat got away.
In describing a published work, present tense is used:
In their groundbreaking work, Smith and Jones report a
33 survival rate in the test population.
The infinitive is a verb form and in high school we were
warned to never split an infinitive. Today’s custom allows a split
infinitive if it will make the sentence clearer. For example:
Splitting an infinitive might greatly serve to clarify a sentence.
Better with a split infinitive:
Splitting an infinitive might serve to greatly clarify a sentence.
Adjectives modify nouns and adverbs modify verbs, adjectives,
and other adverbs. Although judicious use can enrich your
writing, beware the tendency to overuse modifiers, which
can produce wimpy writing. They creep into our writing eas
ily, and beginning writers tend to overuse them. In
economy in our words, we use abundant modifiers in writing
clinical notes (“well-developed, well-nourished, male factory
worker in no acute distress”) and sometimes we carry this
over into our scientific writing. Here are two examples of
sentences that string several modifiers together; the
contain all the necessary information, but lack vigor. In the
sentences below, we lose the full impact of any one of the
modifiers, which might benefit from more discussion:
Multiple adjectives:
The patient was a tall, gray-haired, anxious, marasmic
elderly man.
Multiple adverbs:
The neurosurgeon operated quietly, skillfully, carefully,
decisively, and seemingly effortlessly.
When you find yourself stringing several modifiers together,
ask if all are really desirable. Do I truly need all of the follow-
ing adjectives?
Peer reviewers found the article to be timely, interesting, schol-
arly, articulate, and comprehensive.
Metaphors and Similes
A metaphor is an implied comparison: “For the patient in the
critical care unit, his wife’s arrival at the bedside was always a
ray of sunshine in his dull day.” At the beginning of this chap
ter I wrote of ideas and structure as our blueprint, and para
graphs, sentences, and words as our tools. The words
used in this way represented metaphors. In contrast,
an explicit comparison is a simile: “A meal without wine is
like a day without sunshine.” In fact, the word
ing evolved from Greek words meaning
between places
to carry
, can itself be considered a metaphor. Our struggle as
writers is to create metaphors and similes that are novel, and
perhaps even memorable, as when Flannery O’Connor, in her
A Good Man is Hard to Find
, depicts the face of the mother
as “broad and innocent as a cabbage.” <
We often use metaphors and similes in medical writing,
and some are embedded in our medical terminology: “coffee-
ground vomitus,” “cotton-wool exudates,” “leonine facies,”
and “spider nevi.” We say that a penetrating injury “invaded
the abdominal cavity.” Medical similes include poorly per-
fused feet that are “cold as ice” and the anemic patient whose
skin appears “pale as a sheet.”
Walt Kelly’s Pogo said that, “Words are for people who
can’t read pictures.” But words can be used to create vivid
images in our minds. Consider the following: Tobacco causes
the deaths of 400,000 Americans each year. Big number. To
be more specific, in the United States more than 1,000 per-
sons die each day of the effects of tobacco use. This has a little
more punch. But try this word picture: The loss of life in the
U.S. due to tobacco use is the equivalent of three jumbo jets
crashing each day. For me, this image has dramatic impact!
Metaphors and similes enrich our writing, and the chief way
we go wrong is mixing our images:
Following three days of gastroenteritis, the patient was bone-
dry, like an old prune.
After a night on duty, the surgical resident was dog-tired, like
Onomatopoeia and Alliteration
Onomatopoeic words, also called echoic words, sound like
the things they represent. In nature we have “cuckoo” and
“whippoorwill.” In medicine we find “hiccup,” “murmur,”
“belch,” “croup,” and “cough.” My favorite onomatopoeic
word is
, which describes elephantine rumbling
of the intestines. These words are often short and strong, and
sometimes colorful. When used correctly, they add strength
to your writing.
Alliteration, the repetition of the same letter or syllable in
successive words, can be a different story. When writing I am
often tempted to use alliteration, which appeals to my sense
of play. But there is the reader to consider.
Alliteration almost always annoys an audience. The previ-
ous sentence, of course, is an example of alliteration. Some
authors seem drawn to this form of expression, insisting that
it provides emphasis. Experienced writers tend to purge allit-
eration from their manuscripts.
Diseases, anatomical structures, remedies, and other items
named for famous physicians and scientists represent epo-
nyms. The word itself comes from the Greek word
meaning “named after.” Some of the many eponyms we
all know include Bright disease, tetralogy of Fallot, Graves
disease, Raynaud syndrome, Hodgkin disease, Hippocratic
facies, and Alzheimer disease. Note that the current custom
is to avoid the possessive style in eponyms. For example, we
now write Paget disease instead of Paget’s disease.
The eponym, admittedly a handy linguistic short-cut, is fall
ing out of favor, and today’s tendency is to replace these historic
names with more scientific terms. Hence, von Recklinghausen
disease is now properly called neurofibromatosis, and Caffey
disease is infantile cortical hyperostosis. There are some
exceptions: I still find the eponyms Hansen disease and Down
syndrome in common use, persisting, I suspect, for euphemis
tic reasons. The use of eponyms has even become entangled
in world politics. It seems that Hans Reiter (Reiter syndrome)
and Friedrich Wegener (Wegener granulomatosis) both had
some Nazi ties, and Woywodt and Matteson have written that
“the continued use of tainted eponyms is inappropriate and
will not be accepted by patients, relatives, or the public.” <
The medical writer should follow the current custom in most
cases, stating the accepted Greco-Latin phrase, perhaps fol
lowed by the historic eponym in parentheses—for example:
relapsing febrile nodular nonsuppurative panniculitis (Weber-
Christian disease).
Parenthetically, August Bier <
> once wrote: “When a dis-
ease is named after some author, it is very likely that we don’t
know much about it.” Could the persistence of an eponym,
such as Hodgkin disease, be a marker of a medical knowl-
edge deficit? Might eponymous diseases be especially good
topics for research studies and clinical articles?
Choosing the Words We Use
Words must be chosen with care. You should strive to use just
the right word in the exactly the precise way. And you must
try to avoid words that can annoy or confuse your reader.
Using Words Precisely
The following statement about a vaccine for traveler’s
diarrhea was published a few years ago. In my opinion, it
contains an error. Can you find it?
The new, one-dose vaccine is presently given in liquid form but
Is not a liquid also an oral form? I think that the author
means to say that the new form will be a capsule or tablet.
Here are two other examples that found their way into
He complained of numbness in his feet, which was gradually
speeding proximally.
I believe that the author means that the numbness was
spreading, not speeding.
The incidence of uremic pericarditis occurs in 14–20 of
The sentence above is from one of America’s leading medical
journals. Incidence “is”; incidence does not “occur.”
As you read medical journals in the months and years to
come, look for small errors and imprecise word use. It will be
amusing and will help make you a better writer.
Words That Might Annoy
Be alert to your reader’s sensibilities. Do not call an anesthe-
siologist an anesthetist or refer to a family physician as a
family practitioner. Never write about the orthopedic sur-
geon as an orthopod. Some of the words that arose as man-
aged care jargon can irritate various clinicians, and writers
should think twice before using them. Table
lists words
that might grate on some readers.
One consideration under the heading of possibly annoy-
ing words is what we call those who receive medical care.
Throughout my career they have been patients. Recently,
however, I have heard them called “clients.” The recent emer-
gence of “client” merits scrutiny. In part, at least, the word is
an outgrowth of managed care, which also helped bring us
“provider” and “covered lives.” It also may be the discipline-
specific stylistic choice of some clinician-authors. Therefore,
let us try to understand “client” vs. “patient” by going to the
origins of the words.
“Patient” in English comes from Latin
(to suffer), then
Old French
, and later Middle English
words have denoted a suffering person receiving medical
care and that the person endured the illness calmly and with
forbearance (“patience”). “Client,” on the other hand, comes
from the Anglo-French word
, meaning a person who
is dependent on another. The word entered the English lan-
guage to describe those who depended on lawyers, and later
metamorphosed to include customers of other services. But
not of physicians. When I am next ill, I wish to be considered
a patient and not a client.
nnoying words (and abbreviations)
Words that may annoyWhy the word annoys some readers
ur readers are physicians, nurse practitioners,
physician assistants, clinical psychologists and
other clinicians. “
rovider” is a lumping term
that originated with third-party payers.
any are
offended by this term, and the journal
Family Physician
has specifically ceased its use
his is supposed to refer to “primary care
provider” or “primary care physician.”
he abbreviation can also stand for phencyclidine
(phenylcyclohexyl piperidine) also called “angel dust,”
pulmonary capillary pressure, prochlorperazine, and
Pneumocystis carinii
overed lives
his phrase is another illegitimate spawn of the
managed care payers. We treat patients, or per-
haps clients if that is your discipline’s preference.
We do not care for “covered lives,” a term that
only dehumanizes those persons that we serve in
our practices
id-level provider
urse practitioners and physician assistants do not
like this term, which is perceived as disrespectful
he sick person is a patient—or perhaps a man,
woman, child, or person—but not a case.
are what lawyers argue in court
dministrators like to talk about “customer service,”
as though we were selling used cars
Misused Words
Medical writers often misuse words. Sometimes it is hospital
team conversation showing up in manuscripts. It may be an
attempt to be “scientific.” Perhaps the author is abusing the the
saurus. Examples of misused words include using
when we mean symptoms, using
as a verb when
, and dropping adverbs such as
somewhere in an otherwise perfectly good sentence.
The patient hopefully will recover.

The clinicians and family all hope that the
patient will recover.
All adverbs, most of which end in -ly, must modify a spe-
cific word that is not a noun. I hope that you will not allow
adverbs such as
, or
to wander about
in your sentences like lost children.
lists some words that, I hope, you and I will not
misuse in the future.
Some words (and phrases) we misuse
Word or phrase
ow we misuse the word
his is a plural word.
o write that “the data shows” is
he correct phrase is: “
he data show…”
itigate means “to lessen in intensity or force.”
hus it is
wrong to say that an infusion of dextrose in water mitigated
the insulin-induced hypoglycemia.
he addition of
“against” is redundant and, in a sense, is a double negative
Moving On
In this chapter, I have covered basic elements of article topic
and organization, as well as issues in composing paragraphs,
writing sentences, and selecting words. In the next chapter,
I discuss putting it all together to create an article, with an
eye to publication.
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Sobel RK. MSL—Medicine as a second language. N Engl J Med.
Dirckx JH. The language of medicine. 2nd Ed. New York:
Praeger; 1983:85.
O’Connor F. A good man is hard to find. In: The complex sto-
ries. New York: Farrar, Straus & Giroux; 1971:117.
Woywodt A, Matteson E. Should eponyms be abandoned? Yes.
BMJ. 2007;335(7617):424.
Bier A. 2uoted in: Strauss MB. Familiar medical quotations.
Boston: Little, Brown; 1968:116.
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_3,
© Springer Science+Business Media, LLC 2011
From Page One to the End
“Begin at the beginning,” the King said gravely, “and go on
until you come to the end. Then stop.”
From Lewis Carroll’s Alice’s
Adventures in Wonderland
In Chap. 1, I reviewed your motivation to write, discussed
how to find needed information, and enumerated the impor-
tant questions that must be asked about any writing project.
In Chap. 2, I discussed the blueprint for your project—the
idea and structure—and the tools you will use, namely para-
graphs, sentences, and words. Now let’s look at putting it all
together, from page one to the end, starting with your idea
and how to handle to it.
Medical writing actually begins with a phase called pre-
writing, when you think about your topic and what you want
to say about it. Flower and Hayes describe the process in this
way: “Because writing as an act of thinking is messy and mys-
terious compared to the concrete product, we tend to leave
composing up to the vagaries of chance and god-given talent
to relegate it to independent warm-up exercises designated
as l
-writing.’” <
> Prewriting generally begins with a topic
You might begin with a nice focused subject such as “the
new drug that cures the common cold: indications, adminis-
tration, side effects and cost.” Or perhaps you have just con-
cluded the seminal study on whether or not eating rhubarb
daily cures baldness; the medical world is awaiting the report
and it is time to write up your results. Generally, however,
your idea will be something like “the office approach to”
acute sinusitis or chronic pelvic pain, or perhaps hospice
care of the patient with terminal cancer.
With a general topic idea in mind, the next step is to limit
the topic and find the best way to approach it. We discussed
this briefly in Chap. 2. Because deciding on the concept and
structure—how you will handle your topic—is so important,
I will return to this process here, using the review article as
a model.
Let us use sinusitis as an example of a general-interest
topic. How might we limit the topic and organize an article?
Logical questions are: Shall I write on pathophysiology,
diagnosis, or treatment, or all three? Shall I write on acute
or chronic sinusitis or both? Shall I cover adults or chil
dren or both? Is there any logic to covering women vs. men
as patients? If covering treatment, should I include both
medical and surgical therapy? How about herbal as well
as traditional medical therapy? The following lists some
of the article concepts possible with the general topic of
Common precursors of acute sinusitis
Microorganisms found in acute sinusitis
Complications of bacterial sinusitis
Occupational issues in chronic sinusitis
Chronic sinusitis in men and women: is there a difference?
Causes of sinusitis in children and adolescents
Recognizing bacterial sinusitis: common signs and
Uncommon presentations of acute sinusitis
Acute vs. chronic sinusitis: how to tell the difference
When to image the patient with sinusitis
Warning signs in the patient with acute sinusitis
The best drugs to use in acute sinusitis
Current surgical therapy of chronic sinusitis
Herbal therapy of sinusitis
Treating chronic sinusitis: an evidence-based approach
Managing chronic sinusitis: treatments that do not work
When to refer the patient with sinusitis
Any symptom, sign, or diagnosis in medicine can yield
many ideas for an article. Here is a useful exercise. Pick
a general area—such as skin rash, abdominal pain, or
pneumonia—that interests you, and then think of at least 15
approaches to a review article about this topic.
If there is one aspect of an article you want to get just
right, it is how you deal with your topic. A copyeditor can
correct spelling, fix grammatical errors, and untangle con-
voluted syntax. But a copyeditor cannot fix structure. Think
of a house: copy-editing represents redecorating. Structural
change, moving walls and raising roofs, is major reconstruc-
tion, much more ambitious. Because finding the best concept
and structure for the article is so important, I will return to
the topic again in Chap. 6.
After selecting a focused topic and deciding on a structural
concept, the experienced writer embarks on a “gestational
period” during which the idea is pondered from various view-
points, thinking about cases, lists, headings, examples from
personal experience, and what really should be shared with
the reader. During the gestational time, you will collect and
organize data that will be needed for your paper.
The “data phase” is important because it provides the basic
facts you will present in your article. You will need these facts—
for example, in a headache article I may tell that migraine
headaches affect 18 of women and 6 of men during their
lifetimes—when you begin to actually write. In the end, you
will need to know the source of these figures. Not having nec
essary data at hand will break your creative train of thought, a
cognitive interlude that could result in disconnected prose.
What you need before you start writing varies a little
with the type of article or book chapter you are writing.
will cover the differences later as we discuss writing case
reports, editorials, reports of original research, and so forth.
However, for all articles you will need your basic research
tools, notes, outline, and references.
Basic Research Tools
Every writer’s research tools were discussed in Chap. 1. To
review, these included a computer with a word processing
program, medical dictionary, classic specialty-specific refer-
ence book, and access to clinically-oriented Web sites. Here
I want to discuss one more information collection tool: net-
work research. Let’s assume that I want to learn how many
parking spaces are in the parking lots at Miami International
Airport. I would start by calling someone in the airport
administrative offices, who will refer me to someone who
knows something about parking, and then this person will
know some more specifics about the various lots. I would
wager that I could get the exact answer by the seventh tel-
ephone call. This is network research.
If I wanted to find out whether someone is working on
the brilliant research question I just dreamed up, I would
embark on some network research. I would search PubMed,, MDConsult, or Google Scholar to find out
who is writing on the topic currently, including reviewing the
references cited in recently published papers. Then I would
turn to the telephone or e-mail and call these authors. My
favorite question is: “Who else could I contact that might
know about this topic?”
How you save and organize your notes is very personal, and
your method is very likely to change over time. After all, few
today use 3- by 5-in. index cards any more.
In preparing this book, I have used a combination of paper
and computer. For my research, I have photocopied article
and book pages. I have also printed PubMed abstracts from
computer screens. For each of these paper documents, I have
been careful to include the full identification of the sources.
Published article printouts typically contain full citation
information. Printouts of Web pages come with the Web site
identified. For book pages, this is easily accomplished by
creating a small piece of paper telling the source and then
taping it so that it is photocopied onto each page. I believe
that including the full source on every note page is important
to help avoid later confusion about the source of ideas and
phrases. It is much too easy to become an accidental pla-
giarist if you make notes without careful attribution. (More
about plagiarism in Chap. 5).
Notes may include personal “bright ideas.” These can
come at any time, and getting them in your notes can be
like catching a sunbeam. In 1974 economist Arthur Laffer
had an idea about the relationship between tax rates and
tax receipts. So as not to let it get away, he scribbled it on a
napkin, and later this idea became the
Laffer Curve
that was
the foundation of the supply-side economics we remember
from the President Reagan era. Your “bright idea” notes can
be recorded on paper, or, as I have done in working on these
chapters, added to a Microsoft (MS) Word document labeled
“Booknotes.doc.” I arrange these “bright idea” notes by chap-
ter. Then as I begin work on a new chapter, I “cut and paste”
the notes into the first draft, thereby avoiding retyping.
I suggest that you be expansive in assembling notes. What
seems not pertinent today may be an idea that proves useful
later. After you complete your project, what was not used
can be discarded or saved for another project. It is perfectly
okay that, in the end, more than half your notes will probably
not be used, at least in the current project. Assembling these
thoughts helped clarify your thinking, and perhaps suggested
an idea for another paper.
As you have already discovered, I am an outline advocate.
I like to determine the topic and concept first, and then
think about the general structure of the article. For example,
assume that you are writing an article on the general topic
of edema. The concept might be “five uncommon causes of
edema.” Then the outline’s major headings could be:
Selected Causes
Clinical Significance
From here you might expand the outline to the next level of
Why the issue is important
Selected Causes
Sodium overload
Cyclic edema in women
Medication use
Clinical Significance
When to consider an uncommon cause
What is important in daily practice?
After taking notes and thinking about the topic, you might
further expand the outline to include topics to be covered
under each subheading:
This will be a summary of the main sections: back-
ground, the five selected causes of edema, and the clini-
cal significance of these causes.
How often do we see patients with unexplained
What clinicians are likely to see these patients?
Definitions: “localized” vs. “generalized” edema
Why the issue is important
Value of early therapy
Dangers of missed diagnoses
Selected Causes (give presentation and diagnostic features
of each)
Sodium overload
Cirrhosis of the liver
Nephrotic syndrome
Protein-losing enteropathy
Cyclic edema in women
Medication use
Nonsteroidal antiinflammatory drug (NSAID), estro-
gens, corticosteroids, antihypertensives, and others
Clinical Significance
When to consider an uncommon cause
What is important in daily practice?
You can see how the expanded outline grows. It will be very
useful when you write the first draft because you will already
have made many of the critical decisions. My expanded outline
for this book is now the Table of Contents. Yet, despite my strong
advocacy for outlining, I want to say a word about flexibility.
It is important that the outline does not become a straitjacket.
Be willing to modify and enhance your plan. New ideas will
emerge as you write, and sometimes will be good enough to
prompt a change in the outline. I always hope that the change
is minor (redecorating) rather than major (moving a weight-
bearing wall). Embarking on a structural change when halfway
through the first draft is, at best, a frustrating activity.
Managing references during article preparation is an art. There
are many ways to manage references, and the method you
choose will vary with the number of references in your article
or book chapter. If your article has relatively few references,
used in each of these chapters. First, remember that each page
of notes should contain the full reference source. Then as I cre
ate a sentence that calls for a reference citation, I type the full
source in parentheses at the end of the sentence, and put it in
bold font so I can find it easily later. It looks like this:
dso I can ênd it easily later. It looks like this:
(Taylor RB.
Medical writing: a guide for clinicians, educators and
researchers, Ed 2. New York: Springer;2012:71.)
Then I continue to write and revise successive drafts. At the
end, when I consider the article or chapter almost done—and
beyond any major changes—I substitute sequential numbers
for the references, and I move the citations to the reference
list using the MS Word “cut and paste” feature. In the end,
the manuscript sentence will be:
The method may seem a little primitive, but it works well for
me, perhaps because my writing rarely has a large number
of reference citations.
Another way to manage references is the use of EndNote
software. This sophisticated program allows users to search
online bibliographic databases and to keep track of their
references. Once you have mastered its use, you can create
and edit bibliographies readily. The disadvantages are cost
(currently 299 for the full product) and the steep learning
curve facing the new user. The program is not “intuitive” and
the online instructions are challenging. You can learn more
about EndNote software by starting with
searching “Endnote,” and then following the trail.
EndNote software is great for experienced and prolific
medical authors, especially if compiling long lists of citations.
However, in my opinion, beginning medical authors should
use my more primitive “cut and paste” method, and spend
their energy learning how to be better writers.
How Much Preparation Is Enough?
It is possible to over-prepare to write. Some authors seem to
become mired in the prewriting and data acquisition phases
phase and never emerge. When you have your topic, research
tools, notes, outline, and references all together, the time has
come to begin the first draft.
Getting Started
Setting the Stage
Do not begin to write the first draft until you have set the
stage. Yes, you already have your research tools, notes, and
so forth, but there is one more thing you will need for an
outstanding first draft: uninterrupted time. Collecting data,
constructing an outline, and later revising are all important
grunt work that can be accomplished in discontinuous peri-
ods of time. This is not true of writing the first draft, which
is the truly creative part of the work. For this effort, you will
need several hours of uninterrupted time. (See Chap. 1 for
some hints on how to find this elusive block of time). For the
average length article, and with adequate preparation, you
should plan on 2–3
h to create the first draft. When writing a
first draft, I have joked to my colleagues that, if interrupted,
when I open the door I expect to see flames in the hallway.
Not being interrupted also means not stopping to look
things up. The first draft is about getting your thoughts down
on paper in a logically organized way. It is not about spelling,
minor grammatical errors, or perfect word choice. This is not
the time to consult the Thesaurus. Do not stop writing to look
up details online; this can come later in the revision phase.
Where and How to Begin
When faced with an empty computer screen, what do you do
next? For both beginning and experienced authors, getting
the first few words in type can be the most difficult step in
writing. Jordan and Shepard <
> state, “The first few words
are like a plunge into an ice cold pool. It isn’t so bad after the
start has been made.”
Here are some diverse ways to get started:
As the King advised Alice, start at the very beginning and
keep going. Some very experienced authors can do this,
and can intuitively control the length of the finished arti-
cle. I admire these gifted individuals, and hope someday to
achieve this exalted state.
Expand the outline with chunks of words, jumping about
as the spirit moves you. In the edema article outlined
above, I might write a paragraph about a patient I saw
with edema, and then another paragraph covering how
sodium overload occurs and how it may be recognized. In
the end, I will fit these disparate bits and pieces together
like a jigsaw puzzle, using the planned structure, to create
a draft of the article.
Create the tables and figures. This is one of my favorite
methods. Many articles and book chapters are built around
one or more tables. Creating these tables—making deci-
sions on column headings and what to include—can bring
clarity to the entire piece you are writing. In writing this
book, I first assembled my expanded outline and notes. My
next step was to create the tables for each chapter, all the
way to the end of the book.
Write the abstract. In general, I advise writing the abstract
last. After all, it is a synopsis of the article, and you won’t
really know the full content of the article until it is done. But
when at a loss for a beginning, writing a tentative synopsis
can focus your thinking and get some words on paper.
Answer the WIRMS question:
What I Really Mean to Say
d If having trouble getting started, answer the WIRMS
question in one to three sentences, and see if this starts the
flow of words.
Delaying Tactics
At this point, I want to talk about delaying tactics. When it is
time to sit down and write, almost any other activity seems
to be more interesting or urgent. My favorite delaying tactics
are getting coffee, surfing the Web in search of one more nug-
get of information, or rearranging items on my desktop. For
others, they are making a telephone call or answering e-mail
messages—anything but engaging the brain and writing.
For some authors, actions such as sharpening a handful of
pencils are actually rituals that signal them that it is time to
write. For others the activities are impediments to writing,
and should be recognized for the undesirable behavior they
Words One, Two, and Beyond
The actual opening sentence of a paper is important, first to
get words on the screen, and second to establish the direction
and tone for the article. The first sentence often states the
problem in general terms. For example, “Unexplained edema
can be a diagnostic challenge.” Or, “Osteoporosis is a com-
mon problem of women over age 60.”
An alternative opening for an article or book chapter is
to present a clinical vignette: “The patient was a 32-year-old
woman, in otherwise good health, with swelling of the feet
and hands for more than 6
months.” Such a first sentence
piques the interest of most clinicians. Here is another from
the literature: “Ms D, a healthy 36 year-old woman, wishes
to donate a kidney to her mother, who has diabetes and end-
stage renal disease.” (Pavlakis M. JAMA. 2011;305:592).
Whatever the first sentence, the beginning of an article
should set the stage and get the article moving. Not all arti-
cles begin with the general, unassailable statement. Table
lists examples of other ways to start an article or a chapter.
ome ways to begin an article or chapter
he beginning
Purpose of the article
his paper presents an evidence-based approach to
the management of the common cold.
cope of the article
his paper discusses five causes of generalized
Viewpoint of the paper
alling clinicians “providers” insults our
Quotation from
a respected source
n a recent report in
Getting Stuck
American newspaper writer Gene Fowler (1890–1960) once
commented: “Writing is easy. All you do is stare at a sheet of
blank paper until drops of blood form on your forehead.” <
> At
some time while writing the early drafts, you are likely to get
stuck. The words just won’t come. You look out the window,
go out for the mail, or play with the dog. You engage in all the
delaying tactics listed above. You wonder if you are having a
TIA (transient ischemic attack, a small stroke). Face it. You have
writer’s block, a temporary affliction that strikes every author
eventually. You are waiting in vain for the muse to appear. You
may be postponing writing until your ideas are absolutely,
100 perfect. Perhaps the cause relates to the fear of others
criticizing your work; maybe you suffer from excessive self-
criticism. Or, for the time being, you are out of words.
Here are some methods to help get unstuck:
Brainstorm the main idea. Forget your careful outline for
a while. Write down lots of new ideas about your topic. Do
this as rapidly as you can. (That is why they call it “brain-
.”) Expand a few of them. Can you think of cases to
use as examples?
Revisit the outline. Go to each main heading and write
down what you mean to present in each section. Expand
the outline to include some phrases you will use in the
actual writing.
Review your notes. Add new ideas, maybe short para-
graphs, as they occur to you. Add examples and quotes.
Leapfrog. Stop trying to write sequentially. Jump around
in your draft to the next section that interests you. Then fill
in the gaps later.
Change your writing method for a while. Leave your com-
puter and use pen and paper.
Reread what you have done so far. As you look over what
you have written, maybe new ideas will come to you.
Change your writing time. We are almost all either morn-
ing or evening people—larks or owls—and probably write
during our best time. If stuck, try writing during your “off
time.” That is, if you are a morning person, try writing in
the evening for a while.
: R
Prepare a lecture. Imagine that you must present your
paper to colleagues tomorrow morning. How would you
organize and present the information?
Talk to a colleague. Discussing your project with an
insightful coworker can help bring out the ideas hiding
just below the surface.
Rewrite. If desperate, try restating a key section of what
you have already written.
Rest your mind. If all else fails, try delaying tactics that
actually rest your mind. Take a walk, listen to classical
music, watch football on television, or meditate.
Eventually you will get unstuck, and you will finish the
first draft. Next comes the less creative, more tedious, but
very essential task—revision.
When I begin revising a work, I think of the words of Irish
poet Oscar Wilde (1854–1900): “I was working on the proof
of one of my poems all the morning, and took out a comma.
In the afternoon I put it back again.” If only we medical writ-
ers had the time to make such leisurely revisions. But hap-
pily, unlike writing the first draft, revisions can be made in
discontinuous bits of time. That is, revising a manuscript is
tuning, not creating. You can stop and start without causing
damage. Yes, that is the good news.
On the other hand, revision, editing your own work, may
seem like extracting your own impacted molar. It must be
done, but it can be painful. The analogy of this editing and
tooth extraction is appropriate because of the origins of the
. This word comes from Latin words
, meaning
“to give” and
, meaning “out.” In Latin, these root words
, meaning “to put out.” <
> Thus, the editing func-
tion is chiefly one of “putting out,” and this is especially true
of revising (editing your own work).
There is, however, one major difference between revising
(removing your own molar) and editing (having the proce-
dure performed by someone who probably has more skill
than you). King <
>, an experienced editor, describes this
difference very well: “If, when engaged in editing, you feel
that major changes are in order, you cannot be sure that any
alterations you propose will express what the author wanted
to say. You may be distorting his meaning. In revision, how-
ever, you are in control at all times. You have complete free-
dom to make all the changes you want.”
There are probably as many ways of revising as there are
writers. With that said, I wish to consider some principles.
The first principle is the number of revisions. The astute
reader has noted that the previous section of the chapter was
titled “Beginning: The First Draft.” An article should undergo
at least three preliminary drafts before the final version. In
performing the three pre-final drafts, you may choose to fol-
low this pattern:
First revision
: In the first look at your creative first draft,
look at the “wholeness” of the paper. At this stage, try not
to be too focused on small spelling and grammatical mis
demeanors. Instead, verify that your structure is sound and
that what you say is really appropriate for your intended
audience and the target journal (or the edited book, if writ
ing a book chapter). It is okay to fix the level of a heading
or two, but the emphasis must be on reviewing the organi
zation, logic, and validity of what you have written. Does it
all hang together? Have you said what you wanted to say?
Second revision
: The second time through the manuscript
is when you verify. Look for errors in spelling, grammar,
and syntax. Check carefully for factual errors. Be sure
to run your Microsoft (MS) Word spelling and grammar
checker, but do not rely on it to pick up every spelling
error, especially when it comes to small, common words
such as “one” and “on.” If a sentence or paragraph is in
the wrong location, now is the time to move it. If a heading
is needed, insert it now. If you find superfluous phrases or
wordy constructions, eliminate them.
Third revision
: By now you have checked for any major
problems, and repaired minor errors. Before undertaking
the next revision, it is a good idea to put the paper away
for a week or two. This cooling-off period will “disconnect”
you from the writing, and when you read the paper again,
you will often wonder: How could I have ever written this
: R
In the third revision, you vigorously polish your work to
make it shine. The emphasis here is on clarity and style.
You will simplify words, seek the best way to express your
thoughts, and eliminate unnecessary verbiage. You will also
be looking for danger signs: inappropriate stance, favored
but inappropriate phrases, and cuteness.
Style and Clarity
Style, in writing, describes the way ideas are expressed. It
has to do with word selection, how the words are arranged
into sentences, and how the sentences are linked together
to create paragraphs. Whether or not quotes and borrowed
material are used is an element of style. Style includes the use
or absence of humor, playfulness, and even one’s self in the
writing. Style represents the fingerprints of the author. As an
editor of multi-author reference books, I have received some
manuscripts created by two or three authors. If one author
wrote the first half and author number two the second, I
tell when authorship changes within the chapter, even if
the manuscript has the same font throughout. The shift in
authorship is clear because the style abruptly changes.
Norton <
> states, “Remember that a straightforward and
unadorned writing style has its own elegance.” We should all
strive for the style Norton describes, clear exposition of ideas,
written in the smallest words and cleanest sentences possible.
If such writing seems a little bland, it can be flavored with
some variety in word choice, alternatively constructed sen-
tences, and a few carefully selected quotations.
Clarity in writing refers to the simple, direct expression of
ideas. In medical writing, clarity is often the victim of com-
pleteness. How often do we read convoluted sentences with
abundant phrases strung together just so that everything is
included before getting to the terminal period? Such convolu-
tion is most often seen in the results section of the abstract,
but can occur anywhere in a medical article. Just to illustrate
what I mean, here is a sentence that is complete, but is less
than crystal-clear:
As they begin to study medicine, and especially the pathogen
esis and early manifestations of disease, medical students are
likely to be taught by lecturers that use the same notes from
year to year, prompting complaints that the teaching is not
responsive to advances in clinical practice, but on the other
hand, delighting the students who can purchase typed notes
from members of previous classes, feeling secure in the knowl
edge that the lecture content has not changed, and allowing
them to skip classes, while studying for examinations from
notes that might otherwise not be considered outdated if only
the professor updated the content a little each year, a task
unlikely to be seen as a high priority by a professor whose
chief interest, and whose main source of salary support, is
Whew! It is okay to breathe now. My trusty MS Word spell-
ing and grammar checker did not highlight this sentence as
being too long.
Weighty Words and Sentences
Good style calls for careful word selection. During revision,
you should seek all the heavyweight words in your article
and, whenever possible, replace them with those that are
shorter and perhaps less “Latinized.” Doing so will make
your article easier to read (style) and understand (clarity).
Oliver Wendell Holmes (1809–1894), writing more than a
century ago, remarked: I know there are professors in this
country who “ligate” arteries. Other surgeons only tie them,
and it stops the bleeding just as well <
>. Table
lists some
weighty words and good choices to replace them.
Alternative Ways to Express Your Thoughts
Experienced writers have a bank of alternative words and
constructions to express their ideas. The beginning writer
does also, but in a different location. For the experienced
author, the reservoir is in his or her head, deposited there
by years of experience. For the neophyte, the reservoir is the
Thesaurus, whether a book or as part of the MS Word pro-
gram. I will first discuss alternative forms of expression, and
then the use and misuse of the Thesaurus.
In the last paragraph, I wrote of the “beginning writer” in
the second sentence, and then referred to this person again
in the fourth sentence. I used the word
to avoid
: R
using the term
beginning writer
again, in sentences one and
two I used the word
, and in sentence three
substituted. These are alternative words.
In the paragraph just above are two alternative construc-
tions. Can you find them?
In the first sentence “wrote of” in the first part of the sen-
tence became “referred to” in the second part. In the third
sentence the active tense “I used the word” alternates with
the passive “was substituted.”
I must speak sternly about use and abuse of the Thesaurus,
the best-known version being the work of physician Peter
Mark Roget, published in 1852. Properly used, the Thesaurus
is an excellent source of synonyms and can give a list of alter-
native words when you find you have used favorite words
repeatedly. For example, searching my MS Word Thesaurus
for “word” yielded the following:
elected heavyweight words and suggested replacements
eavyweight word
ood choice as a replacement
tart, begin
top, end
Changing the search to the plural form “words” gave a very
different list:
After reviewing the lists for alternatives to
, I might
from the first list, and
from the second list. I probably would not use
which seems to connote verbal, not written, expression. Nor
would I choose to use
, which denotes the total stock of
words on a language.
On the other hand, it is possible to misuse the Thesaurus.
By consulting the Thesaurus for synonyms for only three
words, this simple sentence,
might become
The patient had an uninteresting hurting in the low rear.
The opportunities for malapropisms are endless, especially
when one tries to use the Thesaurus to create an air of erudi-
tion. I call the act of consulting a Thesaurus to find a complex
word to replace a short one “Thesaurus abuse.” This is my
term, and you read it here first. I hope that no reader of this
book engages in this nefarious practice, and that you resolve
today to use the Thesaurus only to seek the best word and
appropriate alternative ways to express your ideas.
Removing Stuff
If you are like me, your first draft is chock full of stuff, burst-
ing like an overfilled Christmas stocking. The stuff—items
typed because you wisely did not stop your creative journey
to ponder best words and ideal sentence structure—needs
to be dÂbrided during revision. Remember from above that
much of editing is “taking out” stuff.
: R
A favorite writing principle is called
Occam’s razor
William of Occam was an English philosopher and theologian
who lived in the 14th century, and held the enviable title of
Doctor Invincibilis and Venerabilis
. The Occam’s razor prin-
ciple arose with his statement, “Entities assumptions used to explain things> should not be multiplied
beyond what is needed.” <
> According to this dictum, you
should “shave off” anything superfluous to the core message.
Say only what is needed and no more. That applies to unnec-
essary words, paragraphs, and even sections of an article.
Removing Words
Good candidates for removal are instances of “doubling.” This
occurs when you use two words with virtually identical mean
ing to express the same thought. Some examples to show that
saying it twice is not better than saying it once are:
This is my
She had a
potentially fatal
The physician was
about the patient’s
Other words begging to be removed are redundant phrases.
Consider how the following awkward sentence can be
The patient was admitted to the hospital for the speciêc,
express purpose of ruling out the admittedly somewhat remote
possibility that he might have pancreatic cancer.
Sometimes the words to be removed are vacuous adjec-
tives and adverbs, such as the modifier
American writer
Mark Twain (1835–1910) had a simple solution: “Substitute
every time you’re inclined to write
; your editor will
delete it and the writing will be just as it should be.”
Removing Paragraphs and Sections of the Article
Sometimes you must remove entire paragraphs and sec
tions, or perhaps move one to another location. The removal
process is usually prompted by one of two events: First, you
realize that the paragraph is inappropriate, irrelevant to the
core message, or perhaps illogical, silly, or contradictory
to something appearing elsewhere in the paper. In such
instances, removal is needed. In the second instance, the jour
nal editor mandates that your 20-page paper be shortened to
10 pages. In such instances, you are unlikely to find that half
your words can be eliminated by fine-tuning sentences one by
one. In such a case, major surgery is required, and you will
probably need to jettison one or more parts of the article.
Danger Signs
In revising your drafts, be alert for danger signs: red-flag
phrases, the statement that warms your heart, and cuteness.
Red-Flag Phrases
We all recognize a red flag as a sign of danger. Possible trouble
lies ahead. A red-flag phrase is what I call a cluster of words
that should warn you, during revision, that you risk getting into
trouble. You may be about to write something that will under
mine the credibility of your article or invite criticism by experts
in the field. You may even be exposing that you could have dug
more deeply during your research phase, or spent more time
analyzing data. Table
lists my favorite red-flag phrases.
ed-flag phrases
ed-flag phrase
ongue-in-cheek translation
here are no prior published
studies on the topic of…
didn’t spend much time
searching the literature.
uthorities agree that…
We discussed this over coffee.
t is well known that…
am right about this.
One can reasonably
assume that…
really hope that what
am about to
say is true.
t is interesting to note that…
t least
think it is interesting.
he data clearly show that…
y intuition makes me believe that what
am about to write is correct.
t is evident that…
itto above, and my statistics are shaky.
n other words…
am about to repeat myself.
ased on the results presented,
all practicing clinicians should…
t must be done this way!
rial attorneys
love this language.
Further studies are required
to further investigate…
need another research grant.
: R
The Statement That Warms Your Heart
Sometimes you will find a wonderful thought and you just
must get it in. You may believe that you have found the odd
fact during your research, and even though it is superfluous
to your research, you really want to include it somewhere
your report. This is generally a signal that you should take
it out.
Someday you may even be tempted to include a phrase
that, to those in the know, is a subtle personal attack on a
rival. Such thoughts should never even occur on your moni-
tor screen.
Other candidates are the instances of alliteration as dis-
cussed in Chap. 2, which sound so good in your head, and
read so poorly. Also consider eliminating the tendency to
“name something.” As I type this, I am considering taking
out the term “thesaurus abuse” above, but I decided that the
invented expression has value. I hope this turns out to be a
good decision.
I began Chap. 1 by asserting that being a good clinician or
academician does not make one a capable writer. It also
does not make one humorous. Most of us are not actually as
funny as we think, and writing humor is especially difficult
because we are not blessed with the inflections and timing
that help make stories funny. Thus when you and I attempt
humor we often become “cute.” Cuteness in a medical article
is terrible.
“You can observe a lot by just watching.” One way begin-
ning writers introduce cuteness is the popular quotation—the
Yogi Berra expression or the passage from the Peanuts comic
strip. Sometimes using such quotations enhances your writ-
ing, especially when a Mark Twain aphorism or a passage
from Shakespeare is woven as a colorful thread into the fab-
ric of the prose. Sometimes.
Of course, some levity can make reading more enjoyable.
In Table
I created fanciful translations of the worrisome
phrases. Did these attempts at wit work for you or not? If
not, please consider them to be planned examples of what
not to do.
The Colleague as a Critical Reader
When you have finished at least three revisions and are
almost ready to prepare the final draft, it is time to pass the
manuscript to a colleague for critical review. The process
is sometimes called “informal refereeing.” If your critical
reader does the job you expect, you will learn at least some
of the weaknesses in your paper and be able to correct
them before submission to your target journal. Believe an
experienced writer when I say that it is much better to find
the manuscript’s flaws before it leaves my office than to
have the errors discovered by the journal’s peer reviewers
and thereby trigger rejection by the very journal that I most
wanted to publish the paper.
What are the characteristics of the critical reader? This
colleague must understand the science involved and know
the principles of good writing. More important, the critical
reader must not be intimidated or overly impressed with
your writing skills. Reading the article and reporting that it is
flawless has wasted everyone’s time. You need someone who
is tough, honest, and not afraid to use the red pen liberally.
Among medical writers, this has been called “benign brutal-
ity.” Of course, there is the understanding that, when your
critical reader is writing an article sometime in the future,
you will provide a reciprocal reading.
Must the critical reader be a clinician in your same spe-
cialty? No. In fact you may just want to send your manuscript
to two types of readers: One would the local expert in your
field, who will point out your errors of commission and
omission. The other may be the naÈve reader, someone not
an expert in your field. The naÈve reader will be able to let
you know if your article is intelligible, and if you have too lit-
tle or too much detail, and too many unanswered questions.
Your invited naÈve reader may be someone who knows a little
about your field of medicine, but not too much. I, a family
physician, have served as critical reader for a gynecologic
oncologist who was an international medical graduate and
whose English language skills lacked some of the subtleties
needed for precise written prose. A totally nonmedical person
may also review the article, looking for clear English and
logical development of the message. For decades, my best
critical reader has been my wife, a non-physician medical
educator who is a successful author in her own right.
Instructions for the critical reader are important. You
are not asking for redaction—the process of word-by-word,
sentence-by-sentence editing. And you do not merely wish
for general comments. Being told, “This is just simply a
wonderful article,” is no help at all. Here are some specific
questions for the critical reader:
Can you state in one sentence what the article is trying
to say?
Is what I am saying medically (or scientifically) sound?
Are there any errors of fact?
Should the structure be changed in some way?
Is my prose clear?
How can the article be improved?
Completing a manuscript and letting it go is not easy for
some. As a veteran editor of more than a dozen multi-author,
compiled reference books, I have heard a lot of excuses for
late manuscripts. Some that I have received are presented in
There are some ways to help you finish the job. One is to
establish a deadline: I will definitely finish the article and get
it mailed before the end of the month. Then stick to this dead-
line, even if you must work evenings and weekends. Another
method to reach closure is to establish a reward goal: When
I finish and mail the manuscript, I will take a long weekend
and go to the beach. As for me, I have a nice trip planned for
just after I submit the manuscript for this book.
Carroll L. Alice’s Adventures in Wonderland. London: Macmillan;
Flower LS, Hayes JR. Problem-solving strategies and the writ-
ing process. College English.1977;39(4);449–461.
Taylor RB. Medical writing: a guide for clinicians, educators,
and researchers, Ed 2. New York: Springer; 2012:71.
Excuses that have been offered for late or missing manuscripts
Illness or injury:
Jordan EP, Shepard WC. Rx for medical writing. Philadelphia:
WB Saunders; 1952:7.
Fowler G. 2uoted in: Roberts SK. Taking a technological path
to poetry prewriting. The reading teacher. 2002;55(7):678–687.
Partridge E. Origins: a short etymological dictionary of modern
English. New York: Macmillan; 1966:177.
King LS. Why not say it clearly? Boston: Little, Brown;
Norton SA. Read this but skip that. J Am Acad Dermatol.
Holmes OW. 2uoted in: Strauss MB. Familiar medical quota-
tions. Boston: Little, Brown; 1968:609.
Benet WR. Reader’s encyclopedia. 3rd ed. New York: Harper &
Row; 1987:706.
Plimpton G. Writers at work. New York: Viking Press;
Brooks P. The house of life: Rachel Carson at work. Boston:
Houghton, Mifflin; 1972:1–3.
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_4,
© Springer Science+Business Media, LLC 2011
Technical Issues in Medical Writing
Increasing organization in the field of medicine, as in every
other field of human endeavor, has raised the level of contribu-
tions to medical literature. Far too often, however, physicians
still prepare their contributions with a striving and agony and
delay comparable to the delivery of human progeny by one
untutored in the refinements of obstetrics.
American physician and author Morris Fishbein (1889–1976) <
Some of the “striving and agony and delay” described by
Fishbein can be related to the technical aspects of medical
writing, including the preparation of tables and figures (aka
illustrations), perseverating over borrowed materials and
copyright issues, and corralling herds of reference citations.
In contrast to the past three chapters, which have covered the
concept and prose aspects of medical writing, this chapter
addresses some nuts-and-bolts issues you will face. Do not,
however, think that constructing tables and figures is any less
creative than composing words and sentences; in fact, devel
oping these supplements to the text may be the most innovative
part of writing your article. Other practical issues—such as
copyright, permissions, and reference citations—may become
important as you seek publication of your work.
Tables are lists of words and numbers; they do not contain
artwork. If what you are presenting includes a drawing,
photograph, or diagonal lines that connect data (such as an
algorithm), it is a figure (see Figures, below). Tables offer the
following advantages:
Presenting data: A table is usually the best way to arrange
data sets or lists, especially long lists.
Combining words and numbers: Tables allow the clean
presentation of groups of words and numerical data.
Avoiding unintelligible complex sentences: A table is usu-
ally better than a long string of items in a 75-word sen-
Breaking up the flow of text: Tables allow some variety in
the appearance of your article by introducing something
other than page after page of long paragraphs.
There are two types of tables—the so-called text table and
the more formal table. The 4-item list in the last paragraph
(about the advantages of tables) is a text table. In fits nicely
into the flow of prose and it introduces some variety into
how information is presented. Text tables should be logi-
cal groupings and must be relatively short. They need to be
“introduced” in the text, but do not require separate legends.
Because they are integrated into the flow of the paragraph,
no citations (such as see Table
) are needed.
Formal tables are separated from the written paragraphs,
and are cited in the text. Table
, which lists the character-
istics of a good table, is an example of a formal table. And
just cited it in the text.
About Tables
In many articles, the table is the key feature you want to
present. For example, if you wished to describe the presenting
symptoms and signs of meningococcal infection, a table would
be an economical way to do so. In this instance, I
would con
struct the table before beginning to write the prose.
Do not use too many tables in your article, because this may
cause difficulty in page layout. I recently reviewed an article
with nine manuscript pages and ten tables. I advised the
author to find a way to do without at least half the tables.
Every table must have a title that describes its content,
and the table with its title should be able to stand alone. Here
is what I mean: A lecturer speaking on your topic, such as
childhood infections or headache, should be able to trans-
pose your table directly into a PowerPoint slide and have it
make sense. Thus, all abbreviations used must be explained
in the table, either in a footnote or in the table itself.
Tables should not duplicate what is written in the text. If
you find that you have listed the same headings or presented
the same data in two tables, then maybe you need to combine
the tables. Although Table
lists the characteristics of a
good table, I might expand on one or two items in the text.
When it comes to borrowing items from existing publica-
tions, tables are like artwork. If you wish to borrow someone
else’s table for use in your article, even a short list from a
PowerPoint presentation, you need written permission. You
also need permission if you “adapt” a published table, or even
an unpublished table that a colleague has created, perhaps
for a lecture presentation. For these reasons, I advise authors
haracteristics of a good table
What I mean to say is…
ot too long or wideThe ideal table fits on a single journal or book
page. Tables that run over to a second or even
third printed page are difficult to fit into the
publication and for the reader to follow
learly written titleThe title should make sense without referring
back to the text
ot too much textIf you are inserting long paragraphs into a table,
maybe the information should be in the text
and you don’t need a table at all
ot too many columnsProbably the ideal table has three to five columns.
More than five columns may be needed, but
to create their own tables whenever possible. In this book,
there are no borrowed tables.
In editing book chapters, I find that tables are especially
prone to errors during production. One reason that tables are
error-magnets lies in the difficulty of constructing a table and
communicating this through the editing and “type-setting”
process. Columns especially tend to become jumbled. I have
found many errors introduced at the hands of copyeditors
who, understandably, do not know the medical meaning of
what is in the table. Then things continue during proofread
ing. When reading proofs, we authors seem to focus on the
prose and forget to read the tables carefully, allowing errors to
slip through. The more complex and data-laden the table, the
more the author seems reluctant to proofread it carefully.
Here, in another text table, are some technical tips on con-
structing tables for medical articles:
Be sure that it is clear at first glance what your table is
intended to tell.
Keep your column headings concise.
Include units of measurement in table headings.
When percentages are used, include numbers (numerator,
and denominator if pertinent).
Strive for readability. The stub, a term describing heading
and line captions that are listed at the left side of a table,
describes each row of figures in the field. The column to
the right of the stub is often used to present normal values,
for the benefit of the reader who might not be familiar with
the range of data being presented.
Do your best to use round numbers. Tables are generally
not the place to list numbers to the 4
decimal place.
Align decimal points vertically.
Be consistent in your tables, using similar titles and head-
ings throughout your article or chapter.
What Journal Editors Want
The Journal of the American Medical Association (JAMA)
instructs authors to use the “table editor” of word process-
ing software to build tables, presenting each piece of data in
its own cell in the table <
>. Tables must have titles (legends)
and each column must have a short heading. If the table is
borrowed, the source should be identified in the table foot-
note according to the style of the journal. Tables must be
numbered in the order in which they are cited in the text.
Although manuscripts should be submitted double spaced,
tables are sometimes an exception to this rule. JAMA requests
that submitted tables be single spaced, while the International
Committee of Medical Journal Editors (ICMJE) instructions
call for double spaced tables, all just one more reason to read
instructions carefully <
2, 3
Footnotes in Tables
Sometimes a footnote is needed, perhaps to explain the pres-
ence of an empty cell, or to tell why your percentage num-
bers add up to 100.8. If you must use footnotes, consult
the journal’s instructions for authors to find the journal’s
preferred footnote symbols and sequence. For example, the
ICMJE Uniform Requirements for Manuscripts Submitted
to Biomedical Journals states that symbols, when needed, be
used in the following sequence: , e, f, €, ]], , , ee, ff, €€,
]]]], , etc <
Submitting Tables
Like most journals today, JAMA requests that authors copy all
tables onto the disk to be submitted or include the tables at
the end of the text document for electronic submissions <
Sometimes, in a large clinical trial, there are backup data
too extensive to be included in the print version of the paper,
but which may be included in the electronic version of the
journal and deposited in an archive accessible to readers.
Sir Arthur Conan Doyle, Jane Austen, and James Joyce did
not need to worry about figures. Neither do Tom Clancy or
Maya Angelou. In fact, few authors in history have included
illustrations in their work. One exception was Lewis Carroll,
who illustrated the original version of
Through the Looking
with figures that he drew himself. The medical his-
torians among us may be interested to know that Carroll
was a migraineur, and some have speculated that his line
drawings represented visual distortions experienced during
his migraine auras, a phenomenon called metamorphopsia.
For today’s medical authors, figures are an integral part of
the writing.
Figures contain art and look more or less like a picture.
This is a broad definition because figures include photo-
graphs and shaded drawings, line drawings, graphs, and
algorithms. I prefer the term
all are cited in the text using the word
, as shown below
when I cite the figures in this chapter. Most medical review
articles, research reports, and book chapters are enhanced
by including figures.
About Figures
One or more carefully selected and meticulously constructed
figures can turn an average article into a great one. Some
articles you decide to write will be clearly deficient without
a figure or two. For example, let’s imagine that over the
past year I have encountered three instances of sixth cranial
nerve paralysis presenting as the initial manifestation of a
pituitary tumor, and I wish to report these cases. Such a case
report will be greatly enhanced by the addition of magnetic
resonance images and perhaps by a photograph of one of
the patients. One illustration may be just right and two or
three too many. The reader needs to see only one photo of a
patient with ocular esotropia. Presenting illustrations show-
ing the identical physical finding in two more patients adds
As with tables, each figure must have a descriptive legend
that allows the illustration to make sense on its own. The
ICMJE Instructions is explicit in stating that many published
illustrations “will be used directly in slide presentations.” <
JAMA sets a limit of 40 words on figure legends, which strikes
me as quite reasonable <
Displaying photographs or even drawings in which the
person is recognizable presents special issues. Subjects must
not be identifiable or their pictures must be accompanied by
written permission for use. A parent or guardian’s signature
will be required for a child <
>. Some journals provide model
permission forms for patients or their “agents” to sign.
Here are some technical tips on constructing figures for
medical articles:
Assure that the reader can easily discern what the figure
is all about.
Identify each figure by Arabic number with a correspond-
ing citation in the text.
Create and submit the figure legend (caption) separately
from the figure itself.
Try to size your figures to fit column width. For most jour-
nals the figures should be 39, 84, 129, or 174
mm wide and
not higher than 234
mm. For books, figures should be 80
or 122
mm wide and not higher than 198
Describe all digital modifications or enhancements of photo
graphic images.
Indicate any magnification in photographs by using a scale
bar within the figure.
Do not use faint lines in drawings.
Use consistent lettering throughout your figures.
Types of Figures
Photographic Images
Photographic images submitted to biomedical journals must
be high quality, with good resolution. Half tone art, defined as
photographs, drawings, or paintings with fine shading, should
have a minimum resolution of 300 dots per inch (dpi), accord
ing to the Instructions for Authors of the
Journal of Neurology
which I have chosen as a representative specialty-oriented
clinical journal <
>. JAMA Instructions for Authors states,
“Adequate resolution of an appropriately sized image is essen
tial to producing an excellent image in print. Each component
of a composite image must meet the minimum technical
specifications individually. Digital photographs are most fre
quently unsuitable for print publication because of inadequate
resolution.” The Instructions go on to tell that combination
art work—which may contain halftones, line drawings and
color—should have a minimum resolution of 600 dpi <
For color art, you should consult the journal as to specific
requirements such as color prints, positive transparencies,
or color negatives. Also determine if there will be a cost to
you to include color images. The
Journal of Neurology
that color art is free of charge for online publication. In
some instances, the print version of your paper may present
black and white images, with color images used online. In
this instance, and because some colors look alike when con-
verted to halftones, you must check to see if your color image
converts clearly to black and white. You can get a good idea
how the conversion will look by simply using your office
photocopy machine to print a black and white copy of the
color image.
9-rays, which are actually photographic images, often lack
good contrast, a problem that is magnified if the image must
be enlarged. Figure
combines a good-quality photograph
and an x-ray that clearly shows the fracture.
If submitting actual photographic prints, publishers gen-
erally prefer that figures be prepared as sharp, glossy
black-and-white photographic prints, usually 127
in.) <
>. Some journals will not accept images larger
than 203
mm (8
in.). Letters and other symbols
must be large enough to be read if and when the figure is
reduced. Not all journals have the same requirements.
Line Drawings
Sometimes line drawings, defined as black and white art with
no shadings, can illustrate what you want to show better than
a photograph. This is especially true in illustrating body anat
omy. These drawings can sometimes be done by you and used
directly in the article or book. Figure
is an illustration of
a line drawing done by the chapter author and included in a
clinical reference book. In other instances you may draw a
rough draft, which is then converted into the final artwork
by a professional artist. For example, JAMA Instructions for
Authors states: “All illustrations for JAMA articles are created
by the JAMA medical illustration staff in collaboration with
authors. Provide conceptual sketches in any common file
format, text descriptions, literature references, and a working
title and legend for development of the illustration.” <
> The
New England Journal of Medicine (NEJM) states: “Medical
and scientific illustrations will be created or redrawn in-
house. If an outside illustrator has created a figure, the
Journal reserves the right to modify or redraw it to meet our
specifications.” <
> Most journals,
however, lack the resources
A line drawing hand
drawn by the author to illustrate a laceration
repair (
rom Taylor [
], with permission).
of JAMA and NEJM. The
Journal of Neurology
for Authors tells what is required for figure submissions,
describing width of lines (0.1
mm) and the minimum resolu
tion of scanned line drawings and line drawings in bitmap
format (1200
dpi). Such detailed instructions connote that for
most journals, the figure you submit may well be what ends
up in print.
Today it is customary to have medical figures, especially
drawings, prepared by a professional medical illustrator.
Working with a medical illustrator can be an art in itself.
When your illustration involves a professional, it is ideal to
make personal contact and decide together how you will col-
laborate. In most instances, I have created my best effort,
with labels, and given it to the medical illustrator to be made
into professional-quality art. When doing so, you must be
sure that your illustration is anatomically correct. If a vein is
medial to an artery (as in the groin), then you must draw it
so. Some medical illustrators know more anatomy than the
average medical student; some do not. What is certain, how-
ever, is that it is expensive to alter completed line drawings.
When a professional medical illustrator creates art, there
are special permission issues, including future use of the
work. In the instance of “outside” medical illustrators, the
NEJM Instructions to Authors states: “The author must
explicitly acquire all rights to the illustration from the artist
in order for us to publish the illustration” <
A computer can be used to create some uncomplicated
drawings. Computer drawings are often acceptable provided
they are of comparable quality to line drawings. Figure
an example of a line drawing created on computer.
Sometimes very simple drawings can be added to your
electronic manuscript using a conventional office scanner,
set at a minimum of 600
dpi (dots per inch). Drawings in
shades of gray need 1200 dpi or greater, which may not be
available on your office scanner.
There are four basic types of graphs: line graphs, bar charts,
pie charts, and complex graphs. Line graphs are often the
best choice when showing what happens over time (Fig.
A bar chart can also show trends over time, or it can be used
line drawing created on computer showing a family genogram (
rom Taylor [
], with permission).
to compare relative amounts such as the incomes or work
hours of various medical specialties. Choose a pie chart to
show proportions such as how many of your clinic’s patients
have private insurance, Medicare, Medicaid, or no insurance
at all. Complex charts may be scatter diagrams or a combina-
tion of lines, bars, or even pie drawings.
Computers have made graph creation quite easy. Several
software options are available and can sometimes be as
simple as using the Chart Wizard feature on your compu-
ter’s Microsoft Excel program. I found a good tutorial at <
>. Keep in mind that various pub-
lications have different requirements for graphs and charts.
JAMA requires high-quality resolution—600 dots per inch
(dpi) <
>. NEJM requests resolution of 1200
dpi/ppi <
Algorithms are combinations of graph and table. The word
comes from the name of a 9th century Persian
Days of menstrual cycle
Hormonal levels
line graph
that illustrates hormone changes through the menstrual
cycle (
rom Taylor [
], with permission).
mathematician and astronomer, al-Khwarizmi, whose writ-
ings gave us the decimal position number system we use
today. The algorithm is an excellent way to show a decision
tree, as shown in Fig.
. I like to use an algorithm to illus-
trate specific steps in clinical reasoning: If the patient has
oral azoles
Evaluate for
GC, Herpes
n algorithm that illustrates a decision tree for vaginitis symptoms
rom Taylor [
], with permission).
this symptom, do this and not that. If there is this physical
sign, obtain this laboratory test, but that one is not needed.
On the negative side, I find algorithms a little difficult
to construct both medically and technically. On the medi-
cal side, decisions often depend on more than one variable,
and the algorithm may not allow presentation of all the
possible influences on a diagnostic or therapeutic decision.
Technically, algorithms generally call for diagonal lines or
even lines that bend around boxes; I find these difficult to
draw on a computer, and errors can occur in production.
In the end, I use an algorithm when it is clearly the best
way to present a decision tree. Otherwise I prefer figures that
are easier to create and to comprehend.
Submitting Figures with Your Manuscript
Your figures, like the rest of your manuscript, will almost
certainly be submitted electronically, a requirement of most
journals today. In regard to your figures, be sure to identify
the graphics program used to create the graphs, charts and
diagrams. The NEJM Instructions for Authors states: “All
text, references, figure legends, and tables should be in one
double-spaced electronic document (Word Doc or PDF).
You may either insert figures in the text file or upload your
figures separately. We prefer the former, but this may not
work well for complicated graphics, which should be sent
separately. It is permissible to send low-resolution images for
peer review, although we may ask for high-resolution files at
a later stage.” <
If you have questions about adapting your favorite
PowerPoint slides or using Adobe Illustrator or other pro-
grams, call the journal’s editorial office.
For readers who like to know the meaning of JPG, GIF,
lossy and raster files, I have expanded the 2
edition glossary
to include the meaning of some arcane technical terms.
Do not worry too much about copyright. The law and the ethics
of medical publishing protect us quite well. And the protection
extends beyond the printed word. If you create a PowerPoint
slide, write an unpublished thesis, or even draw a clever
diagram, you own the rights to your intellectual product.
Copyright is a form of protection provided by United
States law to authors of “original works of authorship,”
including literary, dramatic, musical, artistic, and certain
other intellectual works. Section
106 of the 1976 Copyright
Act generally gives the owner of copyright the exclusive right
to do and to authorize others to do the following:
Reproduce the work in copies or phonorecords;
Prepare derivative works based on the work;
Perform the work publicly in the case of performance art;
Display the copyrighted work publicly <
As broad as copyright protection seems to be, it does not
extend to ideas, concepts, principles, systems, or factual
information described in the work. Nor is an improvised
speech protected by copyright—unless and until you write it
down somewhere <
The Copyright Act holds that copyright in the work of
authorship immediately becomes the property of the author
who created the work as soon as it is in some fixed form, such
as a book or article <
>. In fact, you hold copyright to your
work as soon as the pen leaves the paper, or perhaps even
when your fingers leave the keyboard although ownership
of online work may seem a little murky. The Copyright Act
states: “Copyright protects loriginal works of authorship’ that
are fixed in a tangible form of expression. The fixation need
not be directly perceptible so long as it may be communicated
with the aid of a machine or device.” <
> For this reason, we
medical writers should afford online creative works the same
copyright respect as printed material.
The intellectual property rights of the author are separate
from the publication of the work, a fact that the new medical
writer discovers shortly after receiving the first “We would
like to publish your article” letter. Upon acceptance of an arti-
cle by a medical journal, you will be asked to sign a “release
of copyright,” assigning rights to the journal. Here is what
the NEJM requires: “The Massachusetts Medical Society
is the owner of all copyright to any work published by the
Society. Authors agree to execute copyright transfer forms as
requested with respect to their contributions accepted by the
Society. The Society and its licensees have the right to use,
reproduce, transmit, derive works from, publish, and distrib-
ute the contribution, in the Journal or otherwise, in
any form or medium. Authors may not use or authorize the
use of the contribution without the Society’s written consent,
except as may be allowed by U.S. fair-use law.” <
There is one more important exception to the “author
holds the copyright” principle: the “work made for hire.” This
includes a work prepared by an employee within the scope
of employment and a work ordered or commissioned, such
as an instructional text or a translation. There may or may
not be a written agreement that a work is considered a work
made for hire <
>. In addition, many books are, by contract
between author and publisher, works made for hire. This
book is one of those.
In fact, with a work made for hire or, for that matter,
with any published medical article or book, copyright rarely
becomes an issue, even though medical publishers insist that
copyright be assigned to them, in writing, as a condition of
publishing the work. That means that of all the books and
articles I have published, I currently own the copyrights to
only a few of them. The few exceptions are old books that are
out of print and the publishers have returned all rights to me
as a courtesy.
In all other instances, the publisher holds the copyright. As
I type these words, I own the copyright to them; by the time
you read this, the publisher, Springer-New York, will hold
copyright. And the rights to the article I wrote a few months
ago are held by the journal that published it.
What is the significance of not owning the copyright to my
articles and books? Not much. I can think of two items to
mention. One is that I must seek permission from Springer
Publishers if I wish to use big chunks of text, tables, or figures
from my Springer books in writing for any other publisher.
The same holds true if I want to re-use a table or figure in one
of my articles previously published in various medical jour-
nals. Getting such permission involves sending a request (see
below), and this has not been a large problem. The second
time copyright ownership comes to my attention is when
other authors request permission to use something published
in my books. The publisher now charges a fee for this permis-
sion and shares the revenue with me; on royalty statements
I occasionally find a (very small) payment for “permissions
granted.” Parenthetically, I always wonder what small part
of my work someone felt moved to borrow, who borrowed it,
and where was it subsequently printed. Although I never find
out, I remain grateful to the anonymous person who seemed
to value something I created.
Inexperienced authors sometime wonder whether some-
one will steal their great idea if they submit a proposal to a
journal or book publisher. I am happy to report that medical
editors have much higher moral standards than most politi-
cians or chief executive officers of large corporations. Also,
there really are very few article or book ideas that are revo-
lutionary and worth pilfering. You are quite safe in sending
proposals and article ideas.
I wrote above that you should not worry excessively about
copyright to your work. In contrast, you should be very con-
cerned about permissions if you intend to borrow words,
tables, art, or anything else from previously published work,
even your own. In Chap. 5, I discuss plagiarism. Here I dis-
cuss the situations in which you need permission to use bor-
rowed material and how to get the documents you need.
Let’s first look at what’s free: All government publications
may be used without seeking permission. For example, in
the previous section I listed the rights protected by the 1976
Copyright Act. What appears on the page is almost word for
word what is on the U.S. Copyright Office Web site. I did
not use quotations around the material because I edited out
some discussion about sound recording, pantomimes, and
choreographic work, which we are unlikely to encounter in
medical writing. I did, however, give attribution by citing
the Web site, because that allows the reader to seek more
in-depth information and because it is the ethical thing to do.
However, if I had not attributed the words by citing the U.S.
Copyright Office as the source, I would have technically been
within my legal rights.
Items not protected by copyright include slogans, short
phrases, and data that are considered common and author-
less property such as standard calendars, height and weight
charts, and tape measures and rulers <
>. Also considered fair
game are works in the “public domain.” This can actually
be a confusing area, especially with the estates of long-dead
authors still holding rights. I suppose that “public domain”
would include the sonnets of Shakespeare and the Dialogues
of Plato, although a question might arise about the latter
since someone may hold rights to a specific translation of the
original work. Recently, when seeking images for a transla-
tion of my book
White Coat Tales
, I visited the web site of
the National Library of Medicine (NLM) <
>. Here a found
an image of a bust of Hippocrates, ideal for my purpose.
The NLM website stated: “The National Library of Medicine
believes this item to be in the public domain.” Now what do
I do with that? Can I—and my publisher—trust this evasive
When Do I Need to Seek Permission
for Use of Borrowed Material?
Part of the answer is easy. You need permission to reproduce
any previously published table or figure. You also need per-
mission to “adapt” any table or figure. If you use data from
four studies to create your own table or figure, I think that the
creation is yours and no permission is needed; but you should
identify your data sources in the table or figure legend. Some
editors may disagree with my opinion about tables or figures
based on multiple published studies and will require that you
seek permissions from all sources.
The next gray issue is the use of text (phrases, sentences,
and paragraphs) from published sources. All borrowed work,
even a few words, should be attributed to the source. This
may be done in a number of ways, attributed in the text as
I did with the Pogo quotation in a previous chapter or cited
as a formal reference. This protects you from allegations of
theft. You borrowed the words and told where you got them.
What about a few sentences or more? When do you need to
seek permission for use? This is a bit of a legal neverland, and
the answer is not nearly as clear as with tables and figures. The
doctrine involves “fair use” and you will see allusions to need
ing permission to borrow
lengthy quotations
. What constitutes
“fair use” and how long is a “lengthy quotation?” Keytlaw, an
online legal information resource, tells that Section
107 of the
Copyright Act lists 4 factors considered in fair-use issues <
7, 8
The nature of the use, including whether commercial or
The nature of the copyrighted work
How much of the work is used in relation to the whole
Any possible effect on the future value of the copyrighted
It is very, very rarely that a legal issue arises when credit
is given for reasonable use of borrowed words. Allegations of
plagiarism are one thing; legal complaints are quite another,
and are unlikely when the author has used a quotation with
careful attribution to the source. I don’t think anyone has
provided chiseled-in-stone definitions of
fair use
, since all legal issues are ultimately settled by trial
or negotiated agreement. Court decisions have described fair
use as including “short passages of a scholarly or technical
work, for illustration or clarification of the author’s observa-
tions” and “reproduction by a teacher or student of a small
part of a work to illustrate a lesson.” <
> I will go out on a
limb and state that you should seek permission if you are
quoting more than 100 words, even with attribution.
Obtaining Permission for Borrowed Material
Who Must I Contact to Obtain Permission?
I always start with the publisher, and I include in my letter
) a question about anyone else that must be con-
tacted. Since publishers always hold copyright to published
articles and books, their permission for borrowed use should
be sufficient. Nevertheless, some permissions editors (yes,
such persons exist) insist that you also seek permission from
authors; some do not.
grant the per
One special problem may be medical illustrations created
by a professional illustrator. The artist may have contracted
with the author and publisher for “one-time” use of the fig-
ure you wish to use. In this instance, you will need to track
down the artist, an often difficult quest, and obtain written
permission. You will also almost certainly be asked to pay a
fee. Here is an example of the exasperation that can occur:
A few years ago I sought permission to borrow a brilliant
and complex figure that had been previously published in a
specialty-oriented medical magazine. The magazine happily
offered permission (for a fee), on the condition that I also
obtained the artist’s permission. Try as I might, I could not
locate the artist, and thus my book chapter lacked that what
would have been a helpful illustration.
Who Is Responsible for Getting Permissions?
The answer is short and direct: You are. The author is respon
sible for getting acceptable permissions and submitting them
with the manuscript. I have reprinted in this book two bor
rowed illustrations (from the same journal). I sent a request
for permission as soon as the book contract was signed, long
before I began working on the chapter containing the figures.
There is one very good reason to seek permissions early. The
article or book cannot be published until all permissions have
been submitted and approved. When you consider the difficulty
you may encounter in finding the person or persons who can
actually sign your form, it pays to get moving on this task.
One of the surprises in medical writing may be the cost of
permissions. A typical fee is 100–300 per table or figure used.
In updating Chap. 7 of this book I sought to use a 12-word
short poem published in a specialty journal. The fee to use
this three-line work? 100, or 8.33 per word. Be prepared.
How Do I Obtain Permission?
Today, most permissions are requested online. Publishers’
Web addresses can almost always be found in a Google
search, as described in Chap. 1. You will be asked to describe
the material you wish to borrow and where it will be printed.
Sometimes this system works smoothly.
In other instances, you may wish to use an old-fashioned
request letter. In my experience, no publisher has ever
questioned my standard permission request, as shown in
, although some have qualified their responses and
others respond by sending their own form.
My chief problem arises when publishers qualify their per
missions. These qualifications include limitations included in
an email response or imprints stamped my letter, telling me
that the permission for use is “valid for only one edition of
the book,” “not to include electronic media,” or “for English-
language publication only.” I wish publishers would not do
this, especially when they are charging me. But they do. If any
of these issues are important to you, I think you need to con
tact the permissions editor and ask what needs to be done.
I hope that all the above has persuaded you to create your
own tables and figures whenever possible. It is usually easier
than getting (and paying for) permission, and you have added
something new to the medical literature.
Virtually all medical writing contains references, and I am
happy to report that most follow the model of the ICMJE. In
fact, the instructions for JAMA, NEJM and ICMJE all differ very
slightly, notably in how they choose to cite books as sources.
Do not worry about this. The differences are minor, usually
regarding punctuation or how to list terminal page numbers.
The information needed is the same for all and, if your style is
not exactly what the journal uses, the copyeditor will make the
small changes in periods, commas and semicolons. In my opin
ion, this issue will not cause rejection of a good paper. Table
lists examples of the three most common types of citations.
suggest that you copy this table and tape it to your computer.
Number references in the order that they appear in the
text. Do not alphabetize your reference list unless this is the
style of your journal. Citation numbers in the text should
follow the journal’s style, which may be superscript or in
parentheses. I believe that the way you present your text cita-
tions, just like how you punctuate your reference list, is not a
deal-breaker. Just be sure all the information is included and
is presented clearly and consistently.
Do not “borrow” someone else’s list of citations. It is per-
fectly permissible to use a published list as basis for your
research, just as you would use PubMed to review current
research on your topic. But then you must seek out and
review the original publications, reading each paper cited
carefully to be sure that the source says what you think it
does. If you do not do this, someone knowledgeable in the
field will surely spot the “cognitive dissonance,” and correct
you in a letter to the editor.
Here are some more tips regarding the correct use of
Have the right number of references, not too many and
not too few.
Avoid using citations from the so-called grey literature,
such as abstracts from scientific congresses, as references.
Do not cite a “personal communication” as a reference,
except in extraordinary circumstances in which vital infor-
mation is unavailable from a public source.
If you really must cite a paper known to be accepted but
not yet published, you should first obtain written permis-
sion of authors to cite their paper. Such articles are then
typically designated as “in press.” Many such designations
are then updated later in proofs.
Verify all reference citations against an online biblio-
graphic source such as PubMed.
xamples of the three most common types of references
Article citation
: If six authors or fewer list all; if seven or more authors list the
When you are finished with the paper, keep all your copies
of reference files you reviewed, permission letters received,
and perhaps even brilliant tables and figures that were not
just right for the current article. They are likely to be useful
in future writing.
are from Taylor RB.
Family medicine: prin-
ciples and practice
. 6th ed. New York: Springer-Verlag; 2003.
I am indebted to the contributing authors who created these
Fishbein M. Introduction. In: Medical writing, 3rd ed.
Philadelphia: Blakiston: 1955.
Journal of the American Medical Association. Instructions
for authors. Available at:
[email protected]
Uniform Requirements for Manuscripts Submitted to Biomedical
Journals: Manuscript Preparation and Submission: Preparing a
Manuscript for Submission to a Biomedical Journal. Available[email protected]
Journal of Neurology. Instructions to authors. Available at:
New England Journal of Medicine. Author Center: new manu-
scripts. Available at:
Internet4Classrooms: Excel-create a chart/graph. Available at:[email protected]@chart.htm.
U.S. Copyright Office. Copyright basics (Circular 1). Available
National Library of Medicine: Images from the history of medicine.
Available at:

KeytLaw: Fair use: Available at:
Taylor RB. Family medicine: principles and practice. 6th ed.
New York: Springer-Verlag; 2003.
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_5,
© Springer Science+Business Media, LLC 2011
What’s Special About Medical Writing?
Writing is a historical act. The role of written communica-
tion has been to document human history; our knowledge of
human culture and values exist because someone has written
about it.
American physician and educator John J. Frey <
There are written works—such as the
and the
the American Declaration of Independence and
From Chairman Mao Tse-Tung
, the latter known to many of us
as “The Little Red Book”—that have changed the world. There
is also writing that is lost, or has not been deciphered yet. We
know little about early central African cultures because no
one recorded what happened at the time. Our knowledge of
Mayan and Inca cultures is deficient because most of their
writing was destroyed by zealous Christian conquerors.
Native American languages were first written in 1921, when a
phonetic alphabet of 86 symbols was developed by a Cherokee
named Sequoyah; this feat was honored when the redwood
tree was named
>. It was 1952 when we began to
decipher the written language of ancient Crete <
In the sciences, writing records the evolution of ideas,
sometimes even the journey from wrong-headedness to
wisdom. In the middle ages, influenza was considered to be
caused by celestial “influence,” although we now know that
the cause is a virus. We once treated a variety of illnesses
by bleeding the patient; now this therapy is reserved for the
management of polycythemia. One of the joys of writing over
a lifetime is to read your own past published works, just to
see how prescient (or how wrong) you were.
Poetry, short stories, mystery novels, historical documents,
and other types of writing all have their peculiarities and con
ventions. Medical writing is, first of all, factual. It is expository.
Opinions must be clearly stated as such. Values, when offered,
are typically implied, rather than stated. Credibility often rests
on evidence cited. The chief virtue is knowledge, especially
new knowledge.
In a sense, the peculiarities of medical writing are what
make it special: These include the imperative that what is
printed is as accurate as current knowledge allows. We strive
to state things correctly and precisely. We should avoid jar-
gon, be exact in what we say, and be careful with abbrevia-
tions and acronyms. Perhaps I use the “we” pronoun here
because, in contrast to our colleagues who write fiction, there
is the tendency of medical authors to write as groups. Finally,
we clinician-writers face a minefield of ethical issues that can
impair our credibility or worse.
Types of Journals
Medical journals are not all alike. Although many journals
do not fit into the categorization I am about to use, I think
of medical journals in a hierarchy consisting of very broad
types. I hope you see the merits of this hierarchy; you will
certainly sense its lack of specificity.
Broad-Based Peer-Reviewed Journal
A peer-reviewed journal is defined by the International
Committee of Medical Journal Editors (ICMJE) <
> as “one
that has submitted most of its published articles for review
by experts who are not part of the editorial staff.” These
journals are at the top of the scholarly food chain. Most of
their content is composed of reports of original research.
They contain advertising, but also have a large base of paid
subscriber support.
Many hold that there is a “big four” of peer-reviewed
journals that are read and respected internationally: the
New England Journal of Medicine
The Lancet
British Medical Journal
(BMJ), and the
Journal of the
American Medical Association
(JAMA). For example, the
British Medical Journal
, published by the BMJ Publishing
Group, “aims to publish rigorous, accessible and entertaining
material that will help doctors and medical students in their
practice, lifelong learning and career development.”
The BMJ has a weekly circulation of more than 100,000. The
NEJM is published by the Massachusetts Medical Society,
although its circulation far exceeds the number of physicians
in the state.
is published weekly by Elsevier Publishers
and can be accessed on line at
JAMA is published by the American Medical Association and
members receive the journal as a membership benefit; many
non-AMA members subscribe.
Most of the more than 4,000 scientific and medical jour-
nals published in the world are peer reviewed. Few have
strong support from paid subscribers.
Specialty Oriented Peer-Reviewed Journals
Because it pulls no punches in its name,
is one of my
favorite journal names. It is the official journal of the British
Society of Gastroenterology, and is edited by the BMJ journals
department. Membership in the Aerospace Medical Association
includes a subscription to the peer-
reviewed monthly journal,
Aviation, Space, and Environmental Medicine
. The
Journal of Surgery
, published by Elsevier Publishers, is the
official publication for six different surgical societies. There is
also the
Journal of the American College of Surgeons.
Some of
these publications are owned by specialty organizations and
are heavily subsidized by dues. Others are more dependent
on advertiser support.
Not all of these journals publish reports of original
American Family Physician,
published by the
American Academy of Family Physicians, publishes peer-
reviewed review articles and virtually no original research.
Its total circulation exceeds 180,000.
Controlled-Circulation Journals
These publications are almost entirely dependent on advertis-
ing for survival. They are sometimes called “throw-aways,”
but I have always considered the epithet to be unfair and
elitist. The truth is that practicing physicians read journals
such as
Postgraduate Medicine
, and
. Years ago, I had the experience of publishing an
article, “How to See Patients More Efficiently in Your Office”
in one of these journals,
Physicians’ Management
, and in the
same month I published a scholarly article in a peer-reviewed
research journal. Several of my colleagues in community
practice congratulated me on the practice-based article; none
mentioned the research report.
Most of the controlled-circulation publications specialize
in some way. There is
The New Physician
, published by the
American Medical Student Association, with articles about
education and health policy issues pertinent to medical stu-
, covering diseases of the skin;
Hospital Practice
presenting topics related to inpatient care; and
Practice Management
, with articles about economic issues in
family medicine.
Indexing and the Impact Factor
Most medical journals are “indexed” although some are not;
those that are not would like to be. A medical journal such as
can be—and is—“indexed” in three ways: Index Medicus,
the Excerpta Medica Database (EMBASE), and the Institute
for Scientific Information (ISI). What does this all mean, and
why might it be important for the medical writer?
Briefly stated, indexing means that the publications in a
journal are listed in one of the three databases noted above.
Publishing your article in an indexed journal means that
when an author or a scientist consults PubMed or another
reference site on your topic, your article will appear on the
list. Without indexing, your article is not found by others and,
although brilliant and ground-breaking, it may languish in
Note that whether or not your article is indexed is deter-
mined not by the excellence of your article, but by the jour-
nal in which it is published. Each of the index organizations
makes ongoing decisions as to which journals are indexed
and which requests are denied. Index Medicus/MEDLINE
makes its decisions based on:
Scientific merit of a journal’s content: validity, importance,
originality, and contribution to the field
The objectivity, credibility, and quality of its contents
Production quality
An audience of health professionals
Types of content, consisting of one or more of:
Reports of original research
Original clinical observations with analysis
Analysis of philosophical, ethical, or social aspects of
Critical reviews
Statistical compilations
Descriptions or evaluations of methods or procedures
Case reports with discussions
The report of original research is not the only type of article
included in Index Medicus. Review article journals may be
The Three Index Databases
Index Medicus
and its online counterpart, MEDLINE, are
used internationally to provide access to the world’s bio-
medical literature. Both are part of the National Library of
Index Medicus
currently contains more than 5,500
titles. For more information, go to:
Excerpta Medica
database, is a biomedical
and pharmaceutical database that gives information to medical
and drug-related subjects. EMBASE contains approximately
23 million indexed items and more than 7,500 current, mostly
peer reviewed journals. It is especially good for drug-related
searches. Access EMBASE at:
The Institute for Scientific Information, a business of the
Thompson Reuters Corporation, publishes
Journal Citation
(JCR) and the
Science Citations Index
. The ISI
of Knowledge
is a research platform helping the reader find
information in the sciences, as well as in the humanities and
arts. You can access the Thomas Reuters Web of Knowledge—
Science at:
The Journal Impact Factor
In the 1960s, ISI developed the journal “impact factor.” What
is the impact factor and how does it relate to my favorite
journals? First proposed by Garfield <
>, the impact factor is
a method of rating the influence of a journal on the scientific
community and comparing this numerically to a large number
of other journals. It does so by measuring the number of cita
tions to articles published in a journal averaged over 2
then this number is divided by the total number of articles
published in the journal over the same period. Citable articles
can include review articles and editorials, as well as reports
of clinical trials, a fact which can influence editorial decisions
as journal editors scramble to achieve the highest impact fac
tors possible. On the other side of the coin, scientists often
consider a journal’s impact factor when deciding where to
submit their research reports.
As an example to illustrate the importance some attach to
the Impact Factor, I recently received an unsolicited (junk?)
email from
The Lancet
, “Have you heard?
The Lancet’s
Impact Factor has recently gone up to 30.76—just one more
reason why you should read the independent and authori-
tative voice in global medicine.” A month later I received
another message, reporting that the
Irish Journal of Medical
has nearly doubled its Impact Factor to 0.696. In
fact, this numerical rating is typical of most medical journals,
two-thirds of which have an impact factor of less than 1. In
an effort to protest the Impact Factor process (and inciden-
tally raise its lagging rating) one journal published a single
editorial that cited a year’s worth of papers that had been
published in that journal <
lists the current impact factor for some selected
journals; the higher the number, the greater the presumed
mpact factors of some leading medical journals
mpact factor
ournal of Medicine
ournal of the American Medical Association28.899
Annals of
nternal Medicine
ritish Medical
Archives of Surgery
ata from:
“impact” of the journal. Just for the record, the impact
of the protesting journal described above was 0.66 before
the citation-laden editorial, a figure that was subsequently
increased to 1.44 by the maneuver.
As might be expected, some researchers are critical of the
impact factor. Ojasoo et
al <
>. observe: “The choice of cita
tions is subjective and the non-pertinence of the citations is
well known. Several variables may intervene, such as the
type of journal and its size, domain concerned, language of
the publication, self-citations, coding of the articles depend
ing on their nature, and the choice of the manuscripts pub
lished (lhot papers’).” The impact factor is an indicator of
citation numbers and not of their quality, and can certainly
not be used to assess an author’s work <
>. Some journals
post their current impact factor on their Web sites. In an
ideal world, your article will be published in the journal
with the highest possible impact factor, but without mak
ing a special effort you may never learn the number and its
comparators. Although the impact factor is seldom of great
importance to the beginning medical writer, you will encoun
ter the term and should know what it means. I will return to
the impact factor in Chap. 12, when I discuss getting your
work in print.
How Clinicians Read Medical Journals
As a medical writer, you should pause to consider how clini-
cians read the medical literature, which is important in how
you construct your articles. Do clinicians read each journal
cover to cover, beginning with page one, studying all sections
of each article? No, they don’t. In practice, I propose three
ways in which clinicians read journals: They graze, hunt, and
gorge <
Clinicians are most likely to
the paper journals that
cross their desk, and they do so when they have “spare time.”
There are just too many publications to read each in depth.
For example, I receive JAMA and NEJM each week, several
monthly journals in my specialty, and about four controlled
circulation publications. In fact, as a subscriber I
receive previews of these publications on line. The only way
to handle the volume is to
. By this I mean that I read
the table of contents carefully. If I see a title that looks inter-
esting, I will turn to the first page of the article and read the
abstract. If I am very interested in the method and results of
the study, I will read those sections and the summary. I esti-
mate that I read the abstract of every third or fourth article,
and then I read about one-fourth of these in depth.
In fact, several journals include a synopsis of major arti-
cles. One of these is the NEJM, which publishes “This Week
in the Journal,” a section early in each weekly issue that
presents a brief synopsis of each major article. JAMA summa-
rizes the issue’s articles in “This Week in JAMA.” These short
summaries may be all that many busy clinicians read.
The grazing habits of readers have implications for medi-
cal writers: First, compose your title with great care, because
this is likely to be the only part of the article read by most of
your intended audience. Then, devote the same care to the
abstract; of those who turn to your article, most readers will
stop here. Of course, I tend to pay more attention to my two
“major,” broad-based journals—JAMA and the NEJM—and
to the leading journal in my specialty. This means that less
prestigious publications get less attention.
Do I have data to support the grazing assertions above?
Not really. I can state that what I describe is how I read
journals. I did a literature search when I wrote the edito-
rial cited in reference 8, and found a small, diverse, and
largely unhelpful group of studies on how we clinicians read
the medical literature. If your reading habits are different,
would be pleased to hear from you.
When clinicians need information about a specific problem,
for answers. Years ago, I would hunt in my file of
journal clippings or go to the library. Now hunting is done
online. Seldom do I go to a paper journal to hunt for a
clinical fact. My file of journal clippings, already a historical
curiosity when I wrote the first edition of this book, is now in
recycling heaven.
The tendency to hunt makes it vital that your important
studies are published in indexed journals. Those who read
your work are likely never to hold the actual journal in their
hands; but by locating your work online and citing it in future
scientific articles, these writers disseminate your findings
and advance medical knowledge.
We writers would like to think that each reader ponders every
word we write. To do so would be to
—to take in way
too much. Perhaps the most sedentary, semiretired, literarily
omnivorous emeritus professor has the time to read every
golden word of every article in every journal. Few of us have
this luxury.
CTD, for short, used to describe someone in whom death is
Jordan and Shepard <
> propose a nicely written defini-
tion of jargon: “Jargon refers to technical expressions used
by a profession or cult which by no stretch of the imagina-
tion can be considered good English and which are often
confusing, not only to those outside the fold, but often also to
those within it.” American medical jargon can be especially
bewildering to physicians for whom English is not their first
language. How would such a physician interpret the slang
, and
frequent flier,
terms actually
unlikely to confuse any American clinician? Table
some examples of medical jargon and slang. The careful
medical writer uses such terms rarely. If jargon or slang is
used in your writing for some special reason, be sure your
purpose is clear and provide your reader with the meaning
of the word used.
Medical jargon and slang: some selected examples
argon or slangWhat you probably mean to say
o initiate therapy with a digitalis derivative; or perhaps
to perform a digital rectal examination
rain wreckWhen one thing after another has gone wrong
repared for surgery
Acute abdomenAcute disease affecting an abdominal organ, often
requiring surgery
Absence of abnormalities
ymph node
o appendectomize
o perform an appendectomy
o buff (a chart)
Accuracy and Precision
When I am frantically searching for the treatment of a dis-
ease, it helps me little to read that the patient should receive,
“a first- or second-generation cephalosporin, 250–500 mg
every 8 to 12 hours.” Might the writer have identified one
or two preferred drugs in this crowded pharmaceutical cat-
egory? Could there have been a little more specificity in the
dose and frequency of administration? And what might be
the recommended duration of therapy? It is even more frus-
trating if a drug is mentioned without a recommended dose.
Worst of all, by far, would be a wrong dose.
In my files is an Errata Notice, received from a major
medical publisher and referring to what was a newly pub-
lished major medical reference book. Happily I was not the
author or editor of the potentially fatal error that prompted
the following notice:
116–1 on page 880 and the bottom line in the left-hand
column on page 881 erroneously indicate that the dilution of
epinephrine to be used for intracardiac injection in cases of
A recent NEJM issue contained an error notice as follows:
Emergence of Multidrug-Resistant Pandemic Inëuenza A
(H1N1) Virus (Correspondence, N Engl J Med 2010;363:1381–
1382). In the êgure (page 1381) the term “275 Histamine”
should have been “275 Histidine.” We regret the error.
“Reading maketh a full man; conference a ready man; and
writing an exact man,” wrote Francis Bacon (1561–1626).
The value of months of research and writing can be under
mined by a single factual error in a published paper. If you
have published a book with an error, a reviewer will unfail
ingly discover this mistake and report to the world when
writing the critical review. In the many stages between your
keystroke and the printed page—copyediting, typesetting,
and correcting proofs—there are ample opportunities for
errors. The careful author will pay close attention at each
Abbreviations and Acronyms as Sometimes
Misleading Shortcuts
Among the items that can cloud meaning and introduce
errors are abbreviations and acronyms (AA). They can also
annoy readers and cause eyes to glaze over.
As a reader, I wish that writers would use fewer abbrevia-
tions. The rule is that you can create any abbreviation you
wish as long as you identify it with first use. For example,
created an abbreviation—AA—for the phrase
and acronyms.
From now on in this chapter I am free to use
either the phrase or the abbreviation. The problem is that
may not use the abbreviation for another six pages, and the
reader using this book as a reference source and encounter-
ing this abbreviation later on must search this entire chapter
to discover that, on these pages, AA does not mean Alcoholics
Anonymous, aplastic anemia, or Australia antigen.
Here are some of my guidelines for the use of abbreviations:
Don’t use more than one abbreviation in a sentence. Think
twice if you are tempted to write something like, “The
patient who has IUGR or PPROM has an increased risk of
PTL and PTB.” (Translation for those who don’t do mater-
nity care: The patient who has intrauterine growth retarda-
tion or pre-term premature rupture of the membranes has
an increased risk of pre-term labor and pre-term birth).
Do not use an abbreviation in an article title. Sure, there
will be exceptions such as “d prevalence in the U.S.”
However, generally you should spell out all words in the
title. Remember that you should explain an abbreviation
with first use, and the title is not the place to do this.
Try to avoid abbreviations in the abstract. Here it will be pos
sible to explain the abbreviation, but since most of your read
ers won’t read the body of your paper anyhow, why break the
flow by introducing your abbreviation meaning here?
Be wary of “standard” abbreviations. What is standard
today can change. Do you remember when “mg” was the
When properly selected, abbreviations can be a space-
saving convenience. If used improperly, they can introduce
confusion. Table
lists some examples of abbreviations that
can be misunderstood. In addition, at the end of this book
have included in Appendix
3 a handy list of commonly used
These are words made up of initial letters or syllables or a
group of words. An acronym usually is typed in all capital let-
ters. For example, SCUBA is an acronym for “self-contained
underwater breathing apparatus.” Writing scuba or Scuba
is incorrect. World War II gave us a rich trove of acronyms:
AWOL (Absent WithOut Leave), SONAR (SOund NAvigation
Ranging), and CINCUS (Commander In Chief of the United
States Navy).
We pronounce the acronym as a word; CINCUS is pro-
nounced, “Sink us.” TURP, representing transurethral resec-
tion of the prostate, is pronounced “turp,” rhyming with
xamples of abbreviations that may mislead readers
bbreviationWhat the abbreviation might mean
his abbreviation means blood pressure, doesn’t it?
ot always.
may also indicate bedpan, bathroom privileges,
bullous pemphigoid, or even
When you see
“burp.” In contrast, abbreviations are pronounced letter
by letter; human immunodeficiency virus infection is pro-
nounced “H-I-V,” sounding out all the letters. But acquired
immunodeficiency syndrome has become the acronym AIDS.
Some day we may, in fact, have forgotten what the four letters
once stood for, just as most persons today know of SONAR,
but don’t recall the origin of the word.
Here are some examples of medical acronyms:
ACE inhibitors: angiotensin-converting enzyme inhibitors
are used to treat hypertension and other illnesses.
CABG: pronounced “cabbage,” the acronym stands for
coronary artery bypass graft.
CREST syndrome: a cluster of limited scleroderma skin
manifestations and late visceral involvement that includes
calcinosis, Raynaud’s phenomenon, esophageal dysmotil-
ity, sclerodactyly, and telangiectasia.
ELISA: with the enzyme-linked immunosorbent assay, the
addition of “test” is redundant.
GOMER: from “Get Outta My Emergency Room.” The
somewhat cynical author Shem describes the GOMER as
“a human being who has lost—often through age—what
goes into being a human being.” <
PPACA: The Patient Protection and Affordable Care Act of
2010, which some believe will prove to be a prime example
of the law of unintended consequences.
RICE: rest, ice, compression, and elevation are all used to
treat acute injuries.
Problems with Stance
Both beginning and experienced medical authors can have
problems with stance. By this I mean overstating or under-
stating your conclusions, especially in research reports.
Overstatement and Hubris
Hubris is excessive self-confidence. It represents pride that
may approach arrogance. It can take several forms. The
clinician who holds fast to a shaky diagnosis, refusing to
seek consultation, is exhibiting hubris. What about hubris in
medical writing? One manifestation of hubris is
attempting to
write far beyond your professional experience and
data. Here is a fanciful example: “Based upon our study of
9 subjects who developed fatigue following use of the drug
placebomycin, we recommend that clinicians use great cau-
tion in prescribing this medication.” Well, that would be an
extreme example of hubris, but you get the idea. Editors
can quickly sniff out when they are being shoveled a load of
stuff. Another hubristic act is making confident
statements about what the future holds, which you should not
do in any medium that can be read a decade later.
In medical writing, the most common manifestation of
overstatement and hubris occurs in presumptuous phrases,
such as, “All clinicians shouldd” and “It should be apparent
at this point thatd”
lists more such words that should give you pause
if you use them in your conclusions.
Understatement and Waffling
Just as bad as overstatement is understatement. By understat
ing perfectly good work, you undermine your valid findings
ubristic words and phrases
Major finding
aradigm changing
t is certainly true that…
ne must conclude that…
We can all agree that…
and your own credibility. Table
lists some words that should
alert you that you might be understating your conclusions.
Medical writing is often done in teams. In research, teams
are important because various people can bring different
abilities: expertise in research methods, access to subjects,
grant-writing experience, personal contacts in grant funding
agencies, and statistical skills. Writing groups may be clini-
cians with similar abilities and experience, or may include
the young person with ambition and energy, the mid-level
professional who knows how to get the job done, and the
senior person whose participation helps assure eventual
Writing as a team has other advantages: If I have a good
writing or research idea and share it with others on a team,
at a later time one of them is likely to have his or her own
good idea and I might be included. In this way we all gain
writing experience and entries on our curriculum vitae (CV).
And, very important, our publication successes help advance
medical knowledge and understanding.
Working as part of a team can help get the job done in a
practical way. When everyone on the team has a task vital
to the success of the project, no one is going to want to let
the group down. In my college sociology class, the professor
Waffle words and phrases
t appears that…
t is conceivable that…
t is very possible that…
called this a “group effect.” It certainly helps keep the writing
project moving.
Guidelines for the Writing Team
Every writing team has implicit rules for how each person
will act. Some groups have more explicit rules. The following
are my suggested guidelines for the writing team:
Choose a leader. The leader is usually the one with the
“good idea” and the one who calls the meetings. The
person who leads need not be the most senior person,
but the leader must have a strong commitment to the
Agree to regular meetings of the writing team. These meet-
ings may be monthly or every 2
weeks. The frequency is
not as important as the fact that the meetings are accorded
priority on everyone’s schedule. Also, all team members
must show up or at least send a progress report. If some-
one misses several meetings, the group must question that
person’s commitment to the project.
Decide on the role of each member of the team. The key
person is the one who will lead the writing. In most cases,
this person will compose the first draft, based on contribu-
tions from all. Then all team members will submit revision
suggestions. In an efficient team, the lead writer has dis-
cretion to accept or reject revision suggestions.
Establish deadlines and then stick to them. Breaking any
writing project into achievable deadlines makes it seem
much more manageable. An example of admittedly-tight
deadlines for a review article might look something
Data collected by end of month 1
Outline completed by the end of month 2
First draft completed by the end of month 3
Second draft completed by end of month 4
Third revised draft finished and read by peer reviewers
by end of month 5
Final draft completed and in the mail in month 6
Decide early on the order of authorship. The person who
has done most of the writing should usually be the first
author, but not always.
Why Problems Develop in Writing Teams
Problems can develop in writing teams for a number of
Confusion about leadership. In this instance, the team mem
ber who agreed to be in charge is not leading. One person
should be tasked with the job of taking charge, assigning
roles, setting agendas and keeping the group moving.
Disagreements about how authors will be listed. Teams
have been known to dissolve in anger over this issue.
Consider the intrigue that surrounded the authorship of
the original
Gray’s Anatomy
, published in 1858. It seems
that the book was a collaborative effort of surgeon and
anatomist Henry Gray and Henry Vandyke, at that time
a surgeon apothecary who would later become a physi-
cian. In her book, Richardson describes the political she-
nanigans that led to Gray’s enduring fame and Vandyke’s
obscurity (at least in regard to the book
Gray’s Anatomy
>. In short, every person who contributes to the work
should be considered for authorship and every person
whose name is listed at the top of a paper as author should
qualify for authorship. That is, each listed author should be
ready to assume professional responsibility for some por-
tion of the work <
There is a slacker in the group. Someone is not getting
the job done, and the problem is especially onerous if the
slacker has a vital responsibility, such as getting funding
or performing statistical analysis. When this occurs, mem-
bers of the writing team need an “intervention,” with a
gentle, but firm confrontation.
Group wordsmithing. Wordsmithing by two people is tedi-
ous. Attempting wordsmithing by more than two people
can be like fingernails on a chalkboard. Wordsmithing is
and should be a solitary activity, based on written, repeat
suggestions from others on the team.
The power play. Someone in the group is exerting undue force.
The power play may be a challenge to the leader, or it might
be an attempted veto: “I won’t let this paper be submitted with
my name on it unless this sentence is omitted.” When this
happens, the whole team must be involved in negotiating a
satisfactory solution without caving in to power.
In 2009, the ICJME developed an electronic uniform disclo
sure form and placed it in the public domain. You can find this
at the website:[email protected]
Not only authors can have conflicts of interest. Peer review
ers and editors may also have ethical dilemmas; I discuss this
in Chap. 12.
Project-Specific Industry Financial and Material Support
This week I came across a report describing in a trial involv-
ing 32 healthy young adults who experienced “robust working
memory enhancement following administration of American
ginseng,” For the convenience of the article’s audience, the
article identifies the drug by both generic name (
P. quinquefo-
) and brand name (Cereboost) <
>. I was intrigued by this
seemingly safe way to boost cognitive function, until I noted
that the “work was supported by a grant from Naturex, Inc,
maker of Cereboost,” a notation that undermined the report’s
credibility, for me, at least, as well as tempering my urge to
recommend the product to my younger patients or rush to
the pharmacy to purchase the drug for personal use.
In discussions of conflict of interest, project-specific indus-
try support for research may even seem to affect outcomes.
A survey of randomized clinical trials conducted over a
decade reveals that “trials funded by for-profit organiza-
tions were more likely to report positive findings than those
funded by not-for-profit organizations. As a group, these
surveys raised questions regarding the design and conduct
of industry-funded clinical trials, as well as ethical concerns
about potential violations of clinical equipoise.” <
> As a
physician, I value this study for the perspective provided and
as a writer, I admire the finely-crafted phase “potential viola-
tions of clinical equipoise.”
The JAMA requires that all financial and material support
for research and the work “be clearly and completely identi-
fied in the Acknowledgment. The role of the funding organi-
zation or sponsor in the design and conduct of the study, in
the collection, analysis, and interpretation of the data, and
in the preparation, review, or approval of the manuscript
should be specified.” <
Because this issue is so crucial, and at the risk of redun-
dancy, I am next going to quote the ICMJE <
> on project
specific industry support:
Editors should require authors to describe the role of out-
side sources of project support, if any, in a study design; in
the collection, analysis and interpretation of data; and in the
writing of the report. If the supporting source had no such
involvement, the authors should so state. Because the biases
potentially introduced by the direct involvement of supporting
agencies in research are analogous to methodological biases
of other sorts (e.g., study design, statistical and psychological
factors), the type and degree of involvement of the supporting
agency should be described in the Methods section. Editors
should also require disclosure of whether or not the support-
ing agency controlled or inëuenced the decision to submit the
I was in a writing workshop in which someone asked a medi-
cal book editor what he thought was the biggest problem he
faced. His answer surprised me: plagiarism.
Inappropriate use of the words of another may start early.
study by Segal et
al. found evidenced of plagiarism in 5.2 of
application essays to residency programs at a single large aca
demic medical center <
>. No one is immune from the accusa
tion: Even American author Helen Keller (1880–1968) was once
accused of plagiarism. Nor are those of high rank immune. In
2008, the Harvard Crimson Newspaper carried a headline:
“Harvard Medical School Professor Caught Plagiarizing.” <
The clinician with a good article idea should write it up.
Let’s look at the sentence I just wrote. In the long history
of literature, I believe that it is mathematically possible that
am the first person to put those 11 words together in exactly
this way. On balance, my 11-word sentence does not describe
a brilliantly inventive thought, and a claim to being the first
to write this sentence must remain a presumptive guess.
However, and modesty aside, if you or any other author
wishes to use my sentence you should make clear that it is a
quotation from this book and give full credit to the source.
Not all accused of plagiarism are truly guilty. I have faith
in the goodness of my fellow humans and I choose to believe
that some errors arise from doing research without not-
ing carefully what were personal thoughts and what were
someone else’s words. I think of this as “accidental plagia-
rism.” Yes, such plagiarism is unacceptable, but you can see
what happened. I suspect that accidental plagiarism is most
likely to occur when authors depend on others (students or
research assistants) to do their research for them.
The rules of using borrowed material and how to obtain
permission are covered in Chap. 4. If the little voice in your
subconscious whispers that you may be using someone else’s
work inappropriately, listen carefully to the message.
Ghost and Honorary Authors
Flanagin et
al. <
>. did a study of 809 corresponding authors
(the author self-identified as the one to contact about an
article) of articles published in JAMA, NEJM, and
Annals of
Internal Medicine
plus three other peer-reviewed, smaller-
circulation journals that publish supplements (
Journal of Cardiology, American Journal of Medicine,
American Journal of Obstetrics and Gynecology
). The authors
found that 19 of articles had evidence of honorary authors,
11 had evidence of ghost authors, and 2 had evidence
of both. Honorary authors were more prevalent in review
articles than in research reports. The journals in the study
described are among those considered to be some of our best.
The suspected prevalence of honorary and ghost authors is
appalling, especially since authors published in these prestig-
ious journals are generally respected academicians.
A furor, and litigation, arose a few years ago regarding the
drug rofecoxib, marketed by Merck and Company. Ross et
reviewed documents pertinent to the issue. They concluded:
“This case-review of industry documents demonstrates that
clinical trial manuscripts related to rofecoxib were authored
by sponsor employees but often attributed êrst authorship to
academically afêliated investigators who did not always dis-
close industry ênancial support. Review manuscripts were
often prepared by unacknowledged authors and subsequently
attributed authorship to academically afêliated investigators
Nor are medical reference books exempt from ghost
authorship. As part of a recent legal discovery in lawsuits
against the drug company now known as GlaxoSmithKline
(GSK), documents emerged that, to use the
New York Times
headline: “Drug Maker Wrote Book Under 2 Doctors’
Names, Documents Say.” <
> In their November 29,
2010 report, the
goes on to state: “The 269-page
Recognition and Treatment of Psychiatric Disorders:
Psychopharmacology Handbook for Primary Care,
is so far
the first book among publications, namely medical journal
articles, that have been criticized in recent years for hid
den drug industry influence, colloquially known as ghost
writing.” The book, listing as co-authors two prominent
academic psychiatrists, has been considered by some to
be especially favorable to an antidepressant manufactured
by GSK. In the
article, Dr. David A. Kessler, former
commissioner of the US Food and Drug Administration was
quoted as follows: “To ghostwrite an entire textbook is a
new level of chutzpah.” <
In commenting on these reports, I can only say: If you
wrote it or otherwise contributed substantially, put your name
on it. If not, do not allow yourself to be listed as an author.
Who 2ualifies as an Author?
Certainly neither you nor I would allow ourselves to be listed
as an author—and especially a lead author—on a paper writ-
ten by someone in a pharmaceutical company when we had
had no hand in the writing process. Nor would we want to
suffer the fate of several of the co-authors of a paper by Sudbo
al. (Sudbo J, et
al. Lancet. 2005;366(9494)1359.) According
to Swedberg, “several of the 13 co-authors claimed they were
not aware of the submission or the full result.” <
> But not
all questions of authorship are quite as clear.
Perhaps it will be helpful to identify what does not con
stitute authorship: Collecting data, acquiring funding, and
providing administrative supervision does not constitute
authorship <
>. Neither does being the department head
who is aware of the study, but takes no active role in the
investigation or actual preparation of the report.
And so who is an author? Here is the opinion of the ICMJE:
“Authorship credit should be based on 1) substantial contri-
butions to conception and design, acquisition of data, or
analysis and interpretation of data; 2) drafting the article or
final approval of the version to be published. Authors should
meet conditions
1, 2, and 3.” The report goes on to say: “All
persons designated as authors should qualify for authorship,
and all those who qualify should be listed.” <
Richard Smith, former editor of the British Medical
Journal, offers us a practical concept of what constitutes
authorship, citing that each author must assume
full intel-
lectual accountability
. “If your paper is about to be presented
at a big conference in Acapulco and suddenly the lead author
is taken ill or drops down dead, could you get on a plane and
go to Acapulco, make a presentation and answer all the ques-
tions? If you couldn’t you are not intellectually accountable.”
Donning his editorial hat, Smith goes on to opine, “About half
of authors don’t meet those criteria.” <
Duplicate Publication
In 2011, the Journal of General Internal Medicine (JGIM)
described the following series of circumstances: “Recently
it came to the attention of JGIM’s editors that a manuscript
just published online in another journal (Article B) bore
a clear resemblance to a manuscript published in JGIM
approximately six months earlier (Article A). On closer
inspection, there was a reason for concern. Both papers
reported on a quasi-experimental evaluation of a quality
improvement intervention. The titles, by-lines, and abstracts
were similar and the methods sections almost identical.
Moreover, entire paragraphs of the introduction and discus
sion sections were almost the same.” <
> The authors go
on to ask: “Had an editorial crime been committed? And if
so, was this a felony, a misdemeanor or merely a technical
breech akin to jaywalking?” <
Duplicate publication is publishing the same material
two or more times, and this can include both print and
electronic media. Catherine DeAngelis, MD, MPH, current
editor-in-chief of JAMA, states that “duplicate publication is
dishonorable—in whatever way it is couched.” <
Spin is reporting research in a way that could distort the
interpretation of results and mislead readers. Boutron et
studied 72 reports of randomized clinical trials. They identi
fied spin in the titles of 13 articles, and in the Results and
Conclusion sections of the abstracts of 27 and 42 reports,
respectively. In
the main text, spin was found in many instances:
Results (21
reports); Discussion (31 reports); and Conclusions
reports). The authors found spin in at least two of these sec
tions of the main text in more than 40 of reports <
Spin may occur in an effort to find something “significant”
to report. Spin may also occur in the setting of industry-
sponsored trials, when the industry sponsor has a financial
interest in a positive result in the trial of their new antide-
pressant or antibiotic. Bouton et
al. suggest, “The use of spin
in scientific writing can result from ignorance of the scien-
tific issue, unconscious bias, or willful intent to deceive.” <
I suspect spin when I read language such as “non-inferior” or
“nearly attained statistical significance.”
Chaps. 6 through 11 discuss the various types of medical arti-
cles, chapters, and books. First, let’s review what is common
to all great medical writing.
A topic of general interest
. Your topic must answer the ques-
tions, “So what?” and “Who cares?” The general medical
reader is probably not interested in a rare tropical disease
never seen in the U.S. or Europe, but may be interested if
you can tell something new about problems in daily prac-
tice, especially if you have data to share.
Meaningful information about the topic
. I use the “Monday
morning” question. If I read this article over the weekend,
might it possibly be of help to me in the hospital or office
on Monday morning?
Objectives clearly stated
. Tell your reader early in the article
what to expect. This is especially important in a research
report, in which the research question should be clearly
articulated in the introduction.
A structure that presents information clearly
. Don’t start
writing until you have the structural concept clearly in
mind. The structure tells you and the reader where you
are going. Of all components of medical writing, this is the
most difficult to repair later.
Articulate and authoritative prose
. Good data presented
in bad prose may be rejected by a journal. King <
> has
summarized the requirements for good expository writing
in a single sentence: “Know what you want to say, say it
clearly, and then stop.” Be very selective in your use of
long sentences, big words, and AAs.
Tables and figures that complement the text
. Used
judiciously, they can be the most important part of your
A clear, concise title
. Label your work clearly and in a way
that readers may recall later.
Frey JJ. Elements of composition. In: Taylor RB, Munning KA,
eds. Written communication in family medicine. New York:
Springer-Verlag; 1984:4.
Wallechinsky D, Wallace I. The people’s almanac. Garden City,
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Highet G. Explorations. New York: Oxford University Press;
International Committee of Medical Journal Editors. Uniform
requirements for manuscripts submitted to biomedical journals.
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Garfield E. The history and meaning of the journal impact fac-
tor. JAMA. 2006;295(1):90–93.
Schutte HK, Svec JG. Reaction of Folia Phoniatrica et
Logopaedica on the current trend of impact factor measures.
Folia Phoniatr Logop. 2007;59(6):281–285.
Ojasoo T, Maisonneuve H, Matillon Y. The impact factor of
medical journals, a biometric indicator to be handled with care
(in French). Presse Med. 2002;31(17):775–781.
Taylor RB. How physicians read the medical literature. Female
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Jordan EP, Shepard WC. Rx for medical writing. Philadelphia:
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Shem S. The house of God. New York: Dell; 1978.
Richardson R. The making of Mr. Gray’s Anatomy: bodies,
books, fortune, fame. New York: Oxford University Press;
Journal of the American Medical Association. Instructions for
authors. Available at:
Okike K, Kocher MS, Wei E9, Mehlman CT, Bhandari M.
Accuracy of conflict-of-interest disclosures reported by physi-
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Kassirer JP. Why should we swallow what these studies say?
Advanced Studies Med. 2004;4(8):397–398.
Scholey A, Ossoukhova A, Owen L, et
al. Effects of American
ginseng (Panax quinquefolius) on neurocognitive function: an
acute, randomized, double-blind, placebo-controlled, crossover
study. Psychopharmacology (Berl). 2010;212(3):345–56.
Ridker PM, Torres J. Reported outcomes in major cardiovascu-
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Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_6,
© Springer Science+Business Media, LLC 2011
How to Write a Review Article
To write an article of any sort is, to some extent, to reveal
ourselves. Hence, even a medical article is, in a sense, some
thing of an autobiography.
American surgeon J. Chalmers DaCosta (1863–1938) <
The review article is the Rodney Dangerfield of medical
writing. Review articles get no respect, even though, as dis-
cussed in Chap. 5, they are often indexed and counted in cal-
culating a journal’s Impact Factor. Actually, many respected
academicians write review articles, for both subscriber-based
and controlled-circulation journals. Why do they do so?
The answer is that most academic clinicians focus on one
disease, such as Parkinson disease or heart failure, and by
writing review articles, they assert their claims—mark their
territory—on topics such as renin levels in hypertension or
advances in the surgical management of prostate cancer.
In addition to the fact that many are written by prestig-
ious authors, another reason that review articles should get
more respect is that they are usually very well written. When
presenting a new way of organizing known data or discuss-
ing how to manage a perplexing problem in the office, the
article must be skillfully composed if it is to hold the reader’s
attention. The reader must think that the content is worth the
effort to read. For this reason, most review articles are both
peer reviewed for medical content and carefully edited to
make them comprehensible <
This will not be a long chapter because, by using the review
article as an example of how to approach concept and struc
ture, I have already covered several of the most important
topics. In Chap. 2, I discussed general ways to develop an idea
into the structure of an article, and in Chap. 3, I discussed
how the idea and structural concept could be developed into
an expanded outline. Chapter 4 covered how to construct
tables, figures, and reference lists. Nevertheless, there are still
some things to discuss about writing review articles.
What Is a Review Article?
Fundamentally, the review paper is an essay. It has similari-
ties to the essays you and I have been writing since junior
high school: It has a topic, a beginning, development of the
theme in a logical manner, and an ending. Some may say
that the review paper is not an original publication, that it
is merely a re-organization of known facts, and hence is not
new knowledge. I understand the “non-original” viewpoint,
especially if held by a research scientist. It is true that review
papers add no new data to the literature. However, I believe
that review articles are original in that they bring new thinking
to the readers. They provide us with practical insights and offer
new approaches to old problems. In this way they are innova
tive and they expand medical understanding.
There are some various types of review articles. We are
all familiar with the traditional types. Sometimes called
clinical updates, traditional review articles bring together
known facts in a meaningful, ideally evidence-based, way
Examples include how to approach a clinical problem
such as “Current Concepts: Triple Negative Breast Cancer”
(Foulkes et
al. NEJM. 2010;363:1938.) and how to accom-
plish something such a geriatric assessment (Elsawy et
Am Fam Phys. 2011;83:48) or perhaps how we did it, such as
the article titled “Three Innovative Curricula for Addressing
Medical Students’ Career Development” (Navarro et
Academic Medicine. 2011;86:72).
Taking a closer look, we find that the prototypical clinical
review article will present material along the lines of: This is
how it’s done today. Disease-related topics tend to fall into
a few sometimes-overlapping categories, three of which are
diagnosis, treatment and prevention. An example of a review
article about diagnosis is “Gestational diabetes mellitus: why
screen and how to diagnose” (Karagiannis et
2010;14:151). The second of these is the “Management”
category: This is how we treat it. In the November 15, 2010
issue of
American Family Physician
are articles with the titles
“Caring for Pregnant Women and Newborns with Hepatitis
B or C” and “Medical Therapy for Asthma: Updates from the
NAEPP Guidelines.” Another category is “Prevention:” an
example in the December, 2010 issue of
Clinical Perinatology
is a review titled
Prevention of Mother-to-Child Transmission
of HIV: Antiretroviral Strategies.”
Some review articles are based not on a disease, but upon
a clinical presentation. Recently I met with one of our faculty
who had accepted an invitation to write an article on the
approach to the patient with dyspnea. This type of review
article—the diagnostic approach to a symptom such as pelvic
pain or a clinical sign such as splenomegaly—is an especially
difficult challenge, simply because the path to diagnosis
is likely to meander into the turf of several specialties. Yet
another type of review article has to do with “current status”
reports such as “Learning Disorders in Epilepsy,” published
or “Health Insurance Politics in Federal Court,”
published in a current issue of
And some review arti-
cles combine categories. An example is the article “Venous
Ulcer: Diagnosis, Treatment, and Prevention of Recurrences,”
published in the
Journal of Vascular Surgery
In addition to the traditional types, there are specialized
review articles that are discussed later in the chapter. These
are the literature review discussing the state of the art, the
meta-analysis, and the evidence-based clinical review.
Who Publishes Review Articles and Who Reads Them?
Who Publishes Review Articles?
Not all review articles are published in controlled-circulation
journals—the “throw-aways.” Many journals, even some of
the most prestigious ones, publish review articles regularly.
They may carry a general label, such as “Review Article” as in
New England Journal of Medicine
(NEJM), or “Review(s)”
as in the
British Medical Journal for the American Physician
(BMJ-USA). Another site is the “Clinician’s Corner” in the
Journal of the American Medical Association
(JAMA), where
there was a recent review article titled “Sarcoidosis: Clinical
Presentation, Immunopathogenesis, and Therapeutics.”
(Ianuzzi et
al. JAMA. 2011:305:391).
The fact that virtually all journals publish review articles is
favorable for the new author. If you write a thoughtful, well-
organized article in competent prose, you should eventually
see it in print if you are persistent in seeking publication.
Realistically, your chances of success with the international
“big four”—
The Lancet
, NEJM, JAMA, and BMJ—are not
promising, for the very good reason that these leading pub-
lications seek contributions from the world’s leaders in each
Do not despair. The many refereed journals in your spe-
cialty and the dozens of broad-based controlled-circulation
journals need a constant supply of review papers, and
because of the ongoing need for good articles, they cannot
wait until the world authority in the field decides to submit
a review article. In the less “prestigious” journals, those with
the lower impact factors (see Chap. 5), your chances of pub-
lication are good.
I recommend contacting the journal editor first. An early
discussion with the editor about your article idea can help
avoid disappointment. It also establishes a personal relation-
ship and may help assure an eventual favorable decision.
Try for telephone contact whenever possible; an e-mail is a
more impersonal second choice. Table
lists some journals
that may be appropriate targets for your article. In addi-
publishes journals in the following areas:
urology, cardiovascular medicine, neurological diseases,
obstetrics and gynecology, gastrointestinal disorders, and
primary care.
can be contacted at:
The contact information listed in Table
may be different by the time you read this book: editors, tel-
ephone numbers, and e-mail addresses change. Try the listed
contact information as a beginning, and then use “network
research,” as described in Chap. 3, to get the correct person
on the line. If this fails, use Google to search for the journal
name and then seek the editor’s contact information. Later
in the chapter, I will discuss how to structure your initial
approach to the editor.
Selected journals that publish review articles
Advanced Studies in Medicine
Johns Hopkins School of Medicine
Galen Publishing,
340 Somerville, New Jersey 08876
elephone: (908) 253-9001
American Family Physician
Publication Division
American Academy of Family Physicians
omahawk Parkway
eawood, Kansas 66211-2672
elephone: (800) 274-223
liggott Publishing
oston Post Road,
onnecticut 06820-4027
elephone: (203) 662-6400
Cortlandt Forum
Who Reads Review Articles?
The quick answer is: Almost all clinicians. This includes not
only physicians, physician assistants, and nurse practition-
ers, but also medical students, residents, and fellows. Other
readers may be health policy experts and even attorneys.
My review articles on headaches have prompted calls from
attorneys across America, asking me to review records in
professional liability cases involving patients who presented
with headaches.
As I noted in Chap. 5, readers tend to “graze” review
articles, actually reading only those whose titles seem com
pelling. Some busy physicians save these articles to read as
relaxation in the evening. Others take a pile of review article
tear-outs to read at the hospital cafeteria lunch table, on
long plane rides or—not recommended—at the poolside on
Journal of General Internal Medicine
Room M200-
PW, Wishard Memorial Hospital
1001 West
Referring physicians also read review articles and the
names of authors who write often on a topic become familiar.
Many nationally known specialists in narrow fields attribute
some patient referrals to review articles that they have
published in medical journals.
Getting Started
Let us begin with the premise that you would like to write a
review article as a way of getting started in medical writing.
What should you do next? Begin with the work you do each
day, which may be seeing patients in the office, acting as a
hospitalist for inpatients, performing surgery, or caring for
elderly individuals in a nursing home. Within the scope of
your work, find what intrigues you, and ask yourself, what
have I learned in my years of practice that I would like to
share with my colleagues?
Along with being a bit of an autobiography, as DaCosta
observed above, writing a review article soon becomes a
learning exercise for the author. There are two phases. First,
you must learn whether anyone else has recently published the
article you are planning to write. Do this by searching PubMed,
BioMedLib, MDConsult, Google Scholar, or your own favorite
Web-searching site. Be cautious with any conclusion that you
have happened upon virgin territory—a topic that no one
has written about yet. There two reasons to question such a
conclusion: First, there is a lag between publication and when
you will find the report on the Web site, and, second, some
controlled-circulation journals are not indexed at all.
The second phase of learning comes as you learn more
facts about your topic. A fairly thorough search is useful early,
even at the stage of deciding whether to write the
all. It can avoid disappointment later.
Next comes thinking about how to handle your chosen
How to Handle Your Topic
As you think about how to organize your article, it is often
helpful to scan your target journal, and look at how authors
there have organized what they wanted to say. Let us now
look at some published review articles to see how the authors
dealt with their material (Table
I did not need to search very far to find the examples in
. Publications containing traditional review articles
such as the ones listed cross our desks every day. Let’s look
at the ways the listed examples approached their subjects:
The article in JAMA about the physical examination of obese
patients features a handy table titled: “Practical suggestions
for performing the physical examination in obese patients.”
Five selected conditions are discussed in the eyelid disorders
article. In the article on heat effects of climate change, the
authors grouped problems under various types of environ-
mental problem. The heart failure review article lists and
discusses the medications used. The article on prisoners’
Structure of selected review articles
Article title
Article concept and structure
Reexamining the physical examination
for obese patients (JAMA. 2011;305:193)
Guidelines as to how to perform
physical diagnosis effectively when
the patient is obese
A review of common eyelid conditions
for the primary care physician
(Adv Stud Med. 2003;3:563)
Diagnosis and treatment of blepha-
roptosis (drooping upper eyelid) and
four other conditions; several photos
Health effects of climate change
(JAMA. 2004;291:99)
An overview of the health effects
of heat waves, floods and droughts,
air pollution, water-related diseases,
and more
Heart failure: update on therapeutic
options (
onsultant. 2003;43:1649)
An overview of what experts now
consider optimum therapy with
health includes tables on the prevalence of mental disorders,
seroprevalence of markers for hepatitis B virus, and the rates
of tuberculosis in prisoners in low-income countries. The
erectile dysfunction article in
Emergency Medicine
a textbook overview of the problem, but leaves unanswered
why this is an “emergency medicine” problem.
In each instance, the authors were writing on areas in
which they worked each day. They believed that they had
something that may help colleagues in their daily practices,
and they organized their articles in ways that may enable us
to remember the points made.
Many review articles are organized using one of the time-
tested models. Here are three of them:
The approach-to-disease article
: This type of article tells
how to diagnose, treat and/or prevent a disease, such as
stroke or gastric cancer.
The clinical manifestation/diagnosis article.
Here the author
begins with a presenting symptom or clinical sign—such as
chest pain or diplopia—and describes the path to diagnosis.
The organized-by-list article.
A favorite of mine, this type
of article might have one of the following titles: “Five
Indications for Imaging in Patients with Headache,”
“Seven Ways to Improve Efficiency in Your Office,” or “Ten
Uncommon Side Effects of Commonly Used Drugs.”
Consulting with the Journal Editor
As I mentioned briefly above, I urge that you contact the
journal editor, preferably by telephone. This call can help
you better understand the editorial process. Making personal
contact with a journal editor might not only help with the
current article; it may be the beginning of a relationship
that can be rewarding in the future. Medical journalism is a
relatively small community, and medical editors often change
jobs from one publisher to another.
Contacting the editor can also save you hours of wasted
effort. It is not a good idea to prepare a review article for a
favorite journal and submit the manuscript, only to have the
editor reply that they have a very similar article scheduled for
publication next month.
When you call the editor you should be prepared to discuss
the following:
The topic and how you will handle the subject matter.
Why you are qualified to write on this topic.
How many tables or figures you plan for the article.
When the manuscript will be completed.
If you have any possible conflict of interest.
Most editors are able to give you an encouraging or dis-
couraging answer over the telephone, which is all they can
do at this time. The editor usually cannot promise acceptance
without seeing the completed article. As an interim step, the
editor may request to see an outline showing a draft abstract
and major headings. If you submit an outline, I suggest add-
ing a copy of your abbreviated curriculum vitae.
In addition to the general categories described above, there
are three special types of review articles: the literature
review, the systematic review, and the evidence-based clinical
review. The literature review is usually recognizable, but not
always. The boundaries between the systematic review and
the evidence-based clinical review are often not clear.
Literature Review
The literature review is written to present the state of the art.
Sometimes the authors use the phrases
literature review
, or
state of the art
in the title. If not, you can usually recognize a
literature review by the general title, and the absence of the
words such as
study of
clinical trial,
effects of
. Another tip-
off that you are looking at a literature review is a long list of
references, in the general range of 100,
perhaps more.
In the world of medical writing, literature reviews serve
several useful purposes:
To summarize research on a topic as a bridge to applied
use. That is, to present data for those who are not actively
involved in the field, but who need to know the latest infor-
mation to provide good patient care.
To synthesize knowledge as a springboard for future
To support academic rigor in a field.
To serve as a database for health policy decisions.
An example of literature reviews is a recent article titled
“Medical Progress: Hemodialysis,” presenting a discussion of
“the medical, social and economic evolution of hemodialysis
therapy”. The article has 95 reference citations (N Engl J
Med. 2010;363(19):1833–1845). Another example, conven-
iently labeled as a literature review is titled “Breast Cancer
during Pregnancy: A Literature Review” (Minerva Gynecol.
In the
Journal of General Internal Medicine
(JGIM) is
an article titled, “Detection, Evaluation, and Treatment of
Eating Disorders: The Role of the Primary Care Physician.”
What brought this article to my attention was the structured
abstract with the headings: Objective, Design, Measurements
and Main Results, and Conclusion. So far the abstract could
be summarizing a research article. The tip-off that this is a
review article is that, in the body of the abstract, the design
is described as “A review of the literature from . . .,” and the
conclusion is a single sentence: “Primary care providers have
an important role in detecting and managing eating disor-
ders” (JGIM. 2000;15(8):577–582).
Another example of the state-of-the-art literature review is a
thoughtful article titled “Defining and Measuring Interpersonal
Continuity of Care” (Ann Fam Med. 2003;1(3):134–143). This
is a literature review of 146 reports on the topic of continuity
of care in the clinical setting. The authors provide analysis
based on the commonality of findings in various diverse arti
cles. And so the question arises: Is this article best described
as a literature review or a systematic review, discussed next?
The literature review is not very difficult to write. Modern
computer technology makes assembling 100 papers on a
topic merely a morning’s work. In this and earlier chapters
have told you how to develop a concept and convert it into
an outline. There is no reason why the beginning writer can-
not create a credible state-of-the-art literature review.
There is, however, another difficulty that must be faced.
A leading expert in the field usually is the person invited to
write the state-of-the-art literature review on a clinical topic.
Add to this fact the reality that literature reviews are often
long articles—by this I mean more than 20 double-spaced
manuscript pages. It takes a lot of space to catalog and dis-
cuss 100+ articles on any topic. And so, when presented with
a long article by an unknown author, the journal editor will
look carefully to see if you are qualified to present the state
of the art to the journal’s readers.
I do not wish to discourage you from writing literature
reviews, but I suggest that such an effort should be done
under the tutelage of an experienced and respected mentor,
or perhaps postponed until you are a recognized authority on
your career topic.
The Systematic Review and Meta-Analysis
Systematic reviews are actually a type of scientific investiga-
tion. What’s different from clinical trials is that the “subjects”
are a cluster of previous published studies that meet strict
criteria. Thus, in a systematic review, the investigators cast
a wide net in the ocean of bibliographic databases, and then
throw overboard studies that do not meet criteria such as
sufficient sample size or appropriate randomization. The
process is called “systematic” because studies examined are
subject to a reproducible search strategy, in contrast to a
“convenience sample” of papers I happen to have in my file
drawer. The chief value of systematic reviews is that they pro-
vide insights into clinical events based on data from a variety
of sources, settings, and investigative approaches.
Sometimes the primary studies are reviewed and
summarized, without attempts at statistical analysis. The
product of this effort is called a qualitative systematic review.
In contrast, when statistical methods are used, the result is a
quantitative systematic review, or meta-analysis.
Meta-analysis is a method of combining the results of
several studies into a summary conclusion, using rigorous
pooling methods and quantitative strategies that will allow
consideration of data found in diverse research reports. In a
sense, meta-analysis is a data-oriented, statistically-grounded
research study about research studies. Writing a meta-analysis
review paper calls for a knowledge of statistical methods that
is outside the scope of this book, and that is beyond the skill
set of most clinician authors. This means that, if you are as sta
tistically challenged as most of us, you should not undertake a
meta-analysis without a close collaborative relationship with a
coauthor who is well trained in statistical analysis.
As mentioned above, the boundaries between state-of-the-
art reviews and the meta-analysis can sometimes be fuzzy.
The paper titled “Parental Feeding and Childhood Obesity in
Preschool-age Children: Recent Findings from the Literature”
(Thompson et
al. Issues Compr Pediatr Nurs. 2010;33:205)
describes findings in 18 articles, some qualitative and some
descriptive, cross-sectional studies, but provides little in
the way of quantitative data. Thus this paper might be best
described as a systematic review, but not a meta-analysis.
Most easily recognizable are the systematic reviews and
meta-analyses that are so identified in the title. For example,
consider the helpful title, “Meta-analysis for the Effect of
Medical Therapy vs. Placebo on Recovery of Idiopathic Sudden
Hearing Loss.” (Labus et
al. Laryngoscope. 2010;120:1863).
The authors are very clear on what you will find in the article.
In the
Journal of the American College of Surgeons
is another
example of a clearly titled article: “Laparoscopic Surgery
Performed through a Single Incision: A Systematic Review of
the Current Literature.” (Pfluke et
al. Journal of the American
College of Surgeons. 2011;212:113).
The examples listed above and other similar systematic
reviews often cite relative risk, odds ratios, confidence inter
vals, and data that are very reminiscent of reports of clinical
trial research. The JAMA Instructions for Authors <
> state,
“Manuscripts reporting results of meta-analyses should include
an abstract of no more than 300 words using the following head
ings: Context, Objective, Data Sources, Study Selection, Data
Extraction, Data Synthesis, and Conclusions.” Explanations of
what to include in each category are on the Web site.
The tendency to consider the systematic review as a type
of research places special burdens on authors. By this I
that conclusions must be supported clearly by data, and
not by opinion. An article in the
Archives of Surgery
“Laparoscopic surgery: an excellent approach in elderly
patients” set out to explore the following hypothesis: “A review
of the literature will show that laparoscopy is safe and effec
tive for the treatment of surgical diseases in elderly patients”
(Weber et
al. Arch Surg. 2003;138:1083). The author selected
“all relevant studies that could be obtained . . .” Their search
covered three procedures: laparoscopic cholecystectomy (16
studies), laparoscopic antireflux surgery (four studies), and
laparoscopic colon resection (10 reports). Okay so far, even if
the review curiously included some surgical textbooks. Their
conclusions, however, seem to me to move beyond the data:
“Despite underlying co-morbidities, individuals older than
years tolerate laparoscopic procedures extremely well.
Complications and hospitalization are lower than in open
procedures. Surgeons need to inform primary care physi
cians of the excellent result of laparoscopic procedures in
the elderly to encourage early referrals.” Can we generalize
from three procedures to
laparoscopic procedures in the
elderly? Maybe yes, maybe no. The articles studied addressed
surgical outcomes such as return of bowel function and car
diopulmonary morbidity. Did the 30 studies have anything
to do with informing primary physicians? Also, although,
according to the authors’ criteria, there were generally bet
ter surgical outcomes when laparoscopic procedures were
compared with open surgery, did the 30 studies show that
referrals are beneficial to the patient? A review regard
ing safety and efficacy of a procedure seems to have evolved
to conclusions that might strike some readers as marketing.
This study—which began as more-or-less systematic review—
just might be an example of hubris, discussed in Chap. 5.
Evidence-Based Clinical Review
The evidence-based clinical review is a special type of sys
tematic review that is focused on a clinically relevant ques
tion <
>. The emphasis is on evidence-based medicine (EBM)
studies, which can be found through sites such as those
listed in Table
. Here is an example: 2uestion: “Which
drugs are best when aggressive Alzheimer’s patients need
medication?” Answer: “Atypical antipsychotics are effective;
so are selective serotonin reuptake inhibitors (SSRIs), and
they may be safer. (Strength of recommendation :
A, multiple randomized controlled trials ).” (J Fam
Pract. 2010;59(10):595–596).
Evidence-based clinical reviews pay special attention to
the quality of the studies included for analysis. The U.S.
Preventive Services Task Force has been a leader in pointing
out that study quality matters, and that the internal validity
of a study is an important consideration as well as looking
at whether the authors reported a randomized clinical trial,
cohort, or case–control study <
The journal
American Family Physician
has been a leader in
advocating for the evidence-based clinical review article. This
journal asks authors of evidence-based clinical review articles
to “rate the level of evidence for key recommendations accord
ing to the following scale: level A (randomized controlled trial
, meta-analysis); level B (other
evidence); level
C (con
sensus/expert opinion).” Siwek et
al <
> have written an excel
lent paper that I recommend to anyone planning to write an
evidence-based clinical review article. A
more recent paper
vidence-based medicine (
M) sources on the Web
eb site
Agency for Healthcare Research and Quality
(AHRQ), previously known as the Agency for
are Policy and Research (AH
a good source for clinical
guidelines and evidence reports
andolier: contains summaries of articles
MJ Publishing Group:
presents general
M information,
M tools,
and summaries of evidence;
registration is required
ochrane Database of Systematic Review:
contains systematic reviews from the
nstitute for
linical Systems
): a good site for disease management
and prevention guidelines
presents a strength of recommendation taxonomy (SORT) to
grade evidence in the medical literature <
We go wrong writing review article in predictable ways.
Since the review article is the first project many beginning
medical writers undertake, I think it is useful to summarize
some of the mistakes we make as beginners. In thinking
about it, some of us more experienced authors continue to
make some of these errors:
Unimportant topic
: Do not waste effort writing a review
article on a topic that no one cares about. Field-test your
idea with colleagues in the office or hospital. If you are
planning to write a
How to do it
article on a new way to
recognize borderline personality disorder or a procedure to
trim hypertrophic toenails, ask several colleagues whether
they might be interested in reading such an article.
Stale rehash
: Be sure that you are saying something new
about the topic. Step 1 is a literature search. Step 2 is a
talk with a few experienceed clinicians. Step 3 is a call to
a journal editor. Take these steps to avoid writing an article
that is not publishable because it tells nothing new.
A timely topic, but already perhaps too timely
: The call to
the editor of your journal may reveal that your up-to-the-
minute topic, such as revised guidelines for managing
childhood obesity, is such a great idea that an article is
already in press. You may change your target journal.
Certainly you have gained useful information.
Getting lost along the way
: Make an outline with major
headings, and stick to it.
Article too long
: Some editors say that this is one of the
most common problems in medical writing. Why is it, with
writing being such hard work, that we all tend to over-
write? Review articles should generally be about 16–20
double-spaced manuscript pages, total including refer-
ences. State-of-the-art literature reviews are the exception,
and may be longer.
Too many or too few references
: Avoid this mistake by
studying similar articles published in your target journal.
Submission to the wrong journal:
Don’t waste your time—
and compromise the timeliness of your article—by submit
ting to journals that don’t publish review articles, or that are
likely to accept only articles written by the internationally-
known expert in the field.
This chapter has been much like a review article; it had an
introduction, topic development using four major headings,
a summary, and a few references. In fact, this chapter could,
with very little modification, be published as a journal article.
The point is that classic review articles and book chapters are
much alike.
There are also similarities among review articles and
case reports, editorials, letters, and book reviews. On the
other hand, there are important differences among these
article types. In the next chapter, I discuss four more writing
DaCosta JC. The trials and triumphs of the surgeon. Philadelphia:
Dorrance; 1944, Chapter 2.
Siwek J, Gourlay ML, Slawson DC, Shaughnessy AF. How to
write an evidence-based clinical review article. Am Fam Phys.
Journal of the American Medical Association. Instructions for
authors. Available at:
Harris RP, Helfand M, Wolff SH, et
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R.B. Taylor,
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and Researchers
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© Springer Science+Business Media, LLC 2011
our familiar realm of experience that we feel compelled to
share the observation with others.
One cannot set out today to write a case report without a
case. I might decide this weekend to write a review article
about unusual types of primary headaches or an editorial
about why we clinicians should receive more pay for what we
do. But to write a case report I need a patient with a disease,
and then I must sense that there is something unusual about
what I have observed.
When considering writing a case report, your next task
is a literature review. In many cases you will find that what
you have found is not nearly as uncommon as you originally
believed. Just because you have first encountered an unex-
pected side effect of a drug, for example, does not mean
that this side effect has not been seen and reported by many
others. Prior reporting validating your observation, in itself,
need not prevent you from writing the report. What makes a
great case report is the case-related analysis that advances
our collective medical knowledge.
In a sense, the case report is a focused review article. What
is different is the emphasis on one or more actual cases, with
a rationale for why the findings are being reported, and an
evidence-based analysis of what has been found. Or there may
be an unusual twist to the story. For example, one case report
describes a 47-year old Mexican woman with Huntingdon
disease misdiagnosed by a
(a Mexican folk healer)
as being the victim of a magic spell. The report begins with
the patient’s chief complaint: “
No puedo quedarme quieta
which means, in English, “I can’t stay still” (Penaranda et
J Am Board Fam Med. 2011;24:115).
I think that highest accolades go to those case reports that
change what we do in practice. For example, Muench and
Carey reported a case of a 38-year-old patient with schizophre-
nia who suddenly developed diabetes mellitus and ketoaci-
dosis 12
months after starting the atypical antipsychotic
medication olanzapine. The authors note that, including their
case, there have been 30 such reports in the literature. What
is noteworthy, in my opinion, is that on November 10, 2003,
my clinician colleagues and I received a “Dear Healthcare
Provider” letter from a pharmaceutical manufacturer stating
that, “The Food and Drug Administration (FDA) has requested
all manufacturers of atypical antipsychotics to include a
warning regarding hyperglycemia and diabetes mellitus in
their product labeling.” (Muench et
al. J Am Board Fam Pract
2001;14:278; and Letter from Janssen Pharmaceutica, Inc.,
dated November 10, 2003). This report and others on this
topic appear to have prompted FDA’s action.
Some case reports are published as letters to the editor.
Shortly I will discuss letters to the editor as a model of medi-
cal writing. Here I will offer one example of a letter-style case
report: In the Correspondence section of the
New England
Journal of Medicine
(NEJM), Cox et
al. describe a family with
a 46,99 disorder of sex development in which three adult
males were determined to be female according to karyotype.
(Cox et
al. N Engl J Med. 2011;364:91).
Types of Case Report
There are fundamentally two types of case report. The first is the
observation of some unusual disease manifestation occurring
in a single patient. For most clinicians, this is your most likely
pathway to a published case report. One example is a report of
an unusual lesion of the finger in a 53-year-old man, with some
excellent color photos of a superficial acral fibromyxoma of the
index finger (Meyerle et
al. J Am Acad Dermatol. 2004;50:134).
Diagnostic images or photographs greatly enhance the “single-
patient” case report. In the end, this type of report must derive
its value from the novelty of the finding, and the perception
that other physicians should be aware of your case.
The second type of case report includes more than one
observation. It may be several patients with an uncommon
disease, such as an increased incidence of leukemia in a sin-
gle neighborhood. Or perhaps you have recently encountered
three young adult patients with argyria (silver poisoning).
An example from the literature describes a cluster of blas-
tomycosis victims in a rural community (Proctor ME et
Mycopathologia. 2002;153:113).
Format for the Case Report
Itskowitz and Lebovitz report a case of a 77-year-old woman
who was not taking antibiotics and who nevertheless
pseudomembranous colitis (PMC) (Itskowitz MS et
al. Adv
Stud Med. 2003;3(10):571). In their article the authors
present the classic format for a case report:
: The first paragraph discusses why the case is
unusual: “Almost all cases of PMC reported during the past
3 decades have been associated with antimicrobial use.”
This seems to be is valid justification for the report. As a
practicing clinician, I need to know that non-antibiotic-
associated PMC can occur.
Case description
: The authors present the relevant data,
including medical history, physical findings, results of tests
and procedures, and treatment received.
Literature review
: Nine instances of nonantibiotic PMC
were found in the literature.
: Here the authors discuss microflora of the
intestine and other possible causes of PMC.
: What it all means is this: “When more common
causes of acute enteritis and colitis have been ruled out,
PMC should be considered in patients who develop persist
ent diarrhea, even without a history of antibiotic use.”
: Sixteen references are listed. I think this
number is about right. The case report is not intended to
be a state-of-the-art literature review.
The case report should not be too long. If your case report
exceeds 12 double-spaced manuscript pages, consider
What about the “first ever” report? Mukherjee and
Shivakumar report a case of sensorineural hearing loss fol-
lowing ingestion of sildenafil (Viagra.) These authors write:
“We could not find any previously reported cases of sildenafil
induced hearing loss and to the best of our knowledge, this is
the first case report of sildenafil induced sensorineural hear-
ing loss in the world literature” (Mukherjee B et
al. J Laryngol
Otol. 2007;121:395). This is a bold assertion, somehow espe-
cially since I now note that hearing loss is reported as a con-
cern on television commercials for popular drugs for erectile
dysfunction. Just to check, I searched two of my favorite
sites—PubMed and Google Scholar—and could not find an
earlier report. It seems that Mukherjee and Shivakumar may
be justified in their “first ever” assertion.
The sildenafil/deafness connection described a new and
unexpected side effect of a popular drug. Such instances are
not extremely rare and the subsequent case reports are valu-
able additions to the literature. Newly discovered syndromes
can be another thing altogether. I suggest that you think twice
before you claim to have elucidated a new syndrome. Such
hubris may be severely criticized. If you have, in fact, found
the first case ever of jejunal pregnancy, your colleagues—not
you—should record your primacy.
Editorials are fun to write. They are generally short, and
thus do not take weeks of labor. They rely on your experi
ence and intuition, and thereby don’t always call for a major
research effort. And they allow you to express your opinion.
Unfortunately, not too many beginning writers have the chance
to write and publish editorials. But some are successful.
The term
comes from the word
. The con-
notation is that the writing is by the publisher, the editor, or
a designated authority. The topic usually reflects the indi-
vidual’s opinion, and you may see the term
, short for
opinion-editorial. Today, journal editors are busy producing
budgets and correcting errors of careless authors, and they
often lack the specialized knowledge to produce the expert
content needed, so they do not write all editorials. In fact,
the British Medical Journal has created a worldwide virtual
group of patients to act as editorial advisors, some of whom
have contributed editorials, articles and letters <
There are fundamentally two types of editorial: those
invited by the editor or publisher and those that are volun-
teered. Invited editorials may be focused, as in an invitation
to comment on a specific research study being published, or
the invitation may be open-ended: “Would you care to write
an editorial for a coming issue of the journal?” Such an invi-
tation is sometimes related to an up-coming theme issue of
the journal, perhaps on a topic such as advances in robotic
surgery or issues in medical student education. These open-
ended invitations usually are extended to prestigious experts
in their fields or members of the journal’s editorial board.
Most journals publish editorials; the September 16, 2010
issue of the
New England Journal of Medicine
has four and
the November 6, 2010 issue of
British Medical Journal
(BMJ)-USA has five—count’em, five—editorials. Your best
chance of having an editorial published is to submit a bril
liantly written opinion piece on a topic about which you have
special knowledge. For example, those of us who practice in
Oregon have enjoyed a unique opportunity with the Oregon
Health Plan. This innovative plan explicitly rations health
care to needy patients according to “the list,” a catalog of
diagnosis–treatment pairs laboriously negotiated with atten
tion to fairness and to efficacy of interventions. A number of
Oregon physicians have written editorials about this plan,
with their chief authority being that they practice in the state
of Oregon.
Some Types of Editorials
The Salesmanship Editorial
Such editorials are really prefaces to an issue of the journal.
They usually begin, “In this issue of the journal, we present d”
Then the editor goes on to tell why they chose to publish the
five studies on amino acids in rat livers that occupy the pages
that follow.
The Editor’s Opinion
In the January 31, 2004, issue of the BMJ, editor Richard
Smith contrasted his journal with the
, in the sense
that we clinicians “merely” deal with health issues, while
at a World Economic Forum held in the Swiss ski resort of
Davos each year, political leaders and economists can claim
to be “committed to improving the state of the world.” He
concludes, “Health must now—and perhaps forever—take a
subservient place to lofty goals” (Smith R. Economics First;
World Health Third, Fourth, or Nowhere. BMJ 2004;328:0).
Here Dr.
Smith discusses his opinion about where medicine
stands in the paradigm he describes. As editor, he has the
prerogative to state his opinion; readers are free to agree or
disagree. In fact, I suspect that Dr. Smith will be most happy
if his editorial provokes vigorous discussion.
Editorial Comment Accompanying a Published Study
“It is easy to imagine why children who are raised on farms
might grow up healthy: there is plenty of fresh air, exercise
and exposure to sunlight. . . Surprisingly, according to the
findings of Ege and colleagues in this issue of the Journal,
the mechanism responsible for these health effects appears
not to be related to clean living but instead to bacteria and
fungi from the barnyard . . .” So begins an invited edito
rial (Gern JE. N Engl J Med. 2011;364:769) commenting
on a research report titled “Exposure to Environmental
Microorganisms and Childhood Asthma,” published in the
same issue of the NEJM.
A Journal of the American Medical Association (JAMA)
article on buprenorphine implants for treatment of opioid
dependence (Ling et
al. JAMA. 2010;304:1576) is supported
by an accompanying editorial by a general internist who,
after some paragraphs describing the background to the
problem, writes, “Thus, the study of subdermal buprenor-
phine implants reported by Ling and colleagues in this issue
of JAMA is an important addition to the literature because
this method of medication administration may address limi-
tations of sublingual buprenorphine, in particular adherence
and diversion” (O’Connor PG. JAMA. 2010;304:1612).
As mentioned above, this type of editorial is an opportunity
for the clinician to offer a “front-line” viewpoint. I suggest
that practicing clinicians write to the editors of their favorite
journals, offering to submit “invited commentary” related to
research articles accepted for publication. Be sure that your
letter is very well written, since this and the curriculum vitae
that you include are the evidence the editor considers in
deciding whether or not to invite you to contribute.
Sharing Special Insight
In the
Journal of General Internal Medicine
(JGIM), Singer
writes about homelessness as a health hazard (Singer
JGIM 2003;18:964). The author, unknown to me, lists
his name and address as Jeff Singer, MSW, Health Care for
the Homeless, Inc., Baltimore, MD. I strongly suspect that
Mr. Singer has firsthand knowledge of the problems described
in his editorial.
Sometimes a journal editor requests an editorial from an
individual known to have a special viewpoint on a controver-
sial topic. The journal can then publish the editorial, with the
disclaimer that the opinion expressed is that of the author
and does not necessarily reflect the opinion of the journal
or publisher. Nevertheless, the journal editor got what was
wanted in print.
Special insight editorials often concern health policy. I
cially enjoyed the title of the editorial discussing uncertainty
about the constitutionality of the Patient Protection and
Affordable Care Act (PPACA): “Can Congress Make You Buy
Broccoli? And Why That’s A Hard 2uestion” (Mariner et
NEJM. 2011:364:201).
Writing an Editorial
Classically, an editorial is a critical argument <
>. As such it
should develop the thesis in a logical manner:
Present the problem
. Early in the first paragraph, tell your
reader the issue you are addressing. The first sentence is
a good place to do this. An exception may be the use of a
vignette to introduce the problem, sometimes called “the
hook” in nonmedical writing. For example, the editorial on
homelessness as a health hazard (mentioned above) begins,
“Jim, a Korean War veteran in his seventies, lives in a’ 79
Cadillac. Unable to afford housing, his hygiene is quite poor;
access to water is limited to restaurant bathrooms . . .”
Provide an early clue as to where you are headed.
PPACA/broccoli editorial begins as follows: “The continu-
ing uncertainty over the constitutionality of the Affordable
Care Act (ACA), illustrated by conflicting trial court rulings
and scholarly commentaries, raises the question of why
this constitutional question is so hard to answer. There are
at least four reasons.”
Here the authors have provided a clear indication of
what will follow, that is, a four-part discussion.
Offer evidence to support your opinions
. Here is where you
should visit the literature and offer an evidence-based
argument. Select your references carefully, to avoid allow-
ing your editorial to become a review article.
Describe your personal insight
. What you are writing is,
after all, your own opinion. It is okay to say what you
think. It is even better to back up this opinion with a per-
sonal anecdote—the concrete example that breathes life
into your general statements.
Offer counterevidence
. Not everyone will agree with you.
Present the other side of the issue in an unbiased and
respectful manner, and then say why you are not con-
Provide a summary
. A single closing paragraph is usually
all that is needed at this point. Describe your conclusion,
ideally linking what you write here to what you said in
paragraph one. Perhaps include the implications of your
conclusion to practice or to society. Then stop.
List you reference sources
. I rarely write an editorial with-
out references, but I only include a few.
Include headings, sometimes
. Your editorial may include
headings to break up the flow of prose and to help the
reader remember the structure of your article. Headings
are especially useful for long editorials.
Letters to the editor offer a wonderful opportunity for the
aspiring medical writer. There is no requirement that the
author be a distinguished professor, no randomized clinical
trial is needed, and there is a reasonable chance of publica
tion, at least in the journals that have limited readership.
LaVigne <
> advocates for this type of writing model: “Letters
to the editor merit your consideration as a publication option:
first, because letters and short pieces stand a better chance
of being published than longer articles, and second, because
published letters to the editor generally are titled and indexed,
thus making them retrievable as articles in the journal.”
The academic clinician will note that, even though letters
are not always refereed, published letters are, being indexed,
legitimate entries on a curriculum vitae. Whether or not one
should list “rapid responses” on one’s curriculum vitae is a
grey area.
Types of Letter
There are many types of letter to the editor. Here are some
of them:
Three Stanford University School of Medicine professors
wrote commenting on a “Perspective” paper published in
NEJM on teaching medical students about cost consciousness
in patient care (Cooke M. NEJM. 2010;362:1253). The letter
begins, “We commend Cooke’s efforts in her Perspective arti-
cle to increase readers’ awareness of the near-universal igno-
rance of actual costs associated with the delivery of medical
care” (Rivas et
al. NEJM. 2010;363:888).
In my opinion, such a letter written by the average clini-
cian has little chance of being published. In fact, I really
don’t think that the authors added anything to our fund of
medical knowledge regarding an important topic, and prob-
ably the journal space could have been better used in some
other way.
New Idea to Add
As a practicing clinician you may have a thought that
expands the knowledge presented in an article. Perhaps you
have seen an illustrative case, and your fellow clinicians
would benefit from the knowledge. In response to an article
American Family Physician
(AFP) about management of
diabetic foot ulcers, two readers wrote to add the following:
“An effective adjunctive therapy for wound debridement that
was not mentioned is maggot therapy” (Summers et
al. AFP.
2003;68:2327). They support their addition with a clear dis-
cussion and six references.
Differing Perspective
In August 2010, the NEJM published an article describing the
risk of suicide-related events in depressed patients treated with
antiepileptic drugs (Arana et
al. NEJM. 2010;363(6):542–551).
Offering another viewpoint, ;ebley and Ferrando write,
“We would be cautious in interpreting these findings, since
antiepileptic drugs are rarely used in the management
of depression, except among a subgroup of patients with
a particularly high risk of suicide” (;ebley et
al. NEJM.
Sometimes one just must disagree with something written
in an article. An editorial in
The Lancet
criticizes United
Kingdom Health Secretary Andrew Lansley for inviting soft
drink, fast food and adult beverage manufacturers to submit
suggestions as to how to deal with issues of obesity, alcohol
misuse and diet-related diseases. Lansley fires back: “The
accusation in your editorial of Nov 27 (p 1800) that I am
lputting the interests of big business at the heart of public-
health policy’ is quite simply wrong. Setting the agenda on
public health is and will always remain the responsibility of
government” (Lansley A. The Lancet. 2011;377:121).
Statement of Concern
In 2010 the NEJM published a report on the use of an oral
spleen tyrosine kinase inhibitor in the treatment of rheu-
matoid arthritis. A letter from Spain questions the study’s
inclusion criteria: “Since the cornerstone of the treatment of
rheumatoid arthritis is the optimal use of methotrexate, with
a progressive increase of the dose up to 20–25
mg per week,
we find it quite surprising that the inclusion criteria allowed
the enrollment of patients with a suboptimal response to
just 7.5
mg per week of methotrexate” (OtÌn et
al. NEJM.
Something That Must Be Shared
This type of letter is really a short editorial. Without reference
to any published article, a reader wrote to discuss the issue of
standard of care. “Medicine is not exact, and bad outcomes
happen. The notion that physicians can follow a formula and
avoid successful litigation is false” (Grant DC. Ann Emerg
Med. 2004;43:139).
Another writer describes “Music of the Heart,” in a let-
ter that begins: “The mysterious power that music wields
over many people has long been linked to its resonance with
biological rhythms such as the heartbeat, and to its parallels
with the intonations and cadences of spoken language.” He
goes on to discuss specific role of music in diagnosis and
treatment (Field MJ. The Lancet. 2010;376:2074).
Uninvited “Sounding Off” letters must be timely, pertinent,
and very well written if they are to be published.
In response to an article about the use of low-dose colchicine
in gout, a pharmacist writes that the authors “discussed the
use of low dose colchicine in gout. The treatment dose of
colchicine, which has remained at 1
mg initially, followed by
mcg every 2–3
h, for many years, should be reviewed.
However, they are incorrect to say that the current BNF
(British National Formulary) recommends a regimen for col
chicine that is unchanged since the 1966 edition. In September,
1999 the BNF reduced the total dose of a course of colchicine
from 10 to 6
mg. Before 1981 the BNF did not even state the
higher limit of 10
mg” (Cox. BMJ. 2004;328:288). Gotcha!
Transformed Review Article
Whenever I read a case report or an account of original
research presented as a letter to the editor, I often pause to
reflect that the letter probably began life in a more robust
form. As a full article, it was submitted and peer reviewed—
several times. The authors endured a few rejections by pres-
tigious journals, until a sympathetic editor suggested that,
if the findings could be shortened to 500–600 words, the
work could be published as a letter. In football, this is the
equivalent of an 85-yard drive with multiple first downs, and
then settling for a field goal. With understandable ambiva-
lence, the authors cut the article mercilessly, and accepted
publication of their case or research report as a letter to
the editor. I recently walked this path with an article on
“imprecision” in pharmaceutical advertisements published
in otherwise respectable medical journals. The article,
titled “Pharmaceutical Advertisements, Citations and Trust,”
ended up published as a letter to the editor (Taylor RB. Fam
Med. 2010;42:744). The good news: The article—correction,
letter—is off my desk and I can move on.
Writing the Letter
The successful letter to the editor is often more the result
of inspiration than persistence. The urge to write a letter
will often strike you when reading a journal article, and you
think: I know something special about this topic or have an
opinion that is important. You then do some research and the
letter, which should be fairly short, will seem to write itself.
Of course, as mentioned above, some letters do not comment
on published articles.
Think of the letter to the editor as a tightly packaged com-
bination of an editorial and a focused literature review. Limit
yourself to making a single point. Do not try to combine two
or more ideas into a short letter. In writing, you should select
each word with care to stay within tight limits imposed by
most journals. Even though you are likely to be acting upon
an inspirational urge, you must craft your letter skillfully if it
is to be accepted for publication.
Most letters to the editor comment on published articles
and, in these instances, there is a general structure that the
letter should follow:
Identify the paper
. In the first sentence, cite the paper
that is the subject of your comments. This becomes your
Reference 1.
State why you are writing
. State your agreement, disagree-
ment, concern, or other reason for writing.
Give evidence
. The evidence may be from the literature or
from personal experience. Literature-based evidence is
Provide a summary statement
. Conclude by tying all the
above together.
Cite references
. A letter to the editor will have a few ref-
erence citations, especially if offering new or contrary
Do not begin writing without reading the instructions to
authors for the journal. Most instructions list requirements
for submitted letters. The
Journal of the American Medical
, for example, states, “Letters discussing a recent
JAMA article will have the best chance of acceptance if they
are received within 4
weeks of the article’s publication.
Letters may have no more than 3 authors. They should not
exceed 400 words of text and 5 references; letters not meeting
these specifications are generally not considered.” <
The letter to the editor should be submitted online—just as
you would a review paper. That means that you should begin
with a title, and then prepare the manuscript double spaced
on plain background, just as you would like it to be published.
The letter manuscript should then be sent with a cover mes
sage indicating that you are submitting the letter for publi
cation and not merely to communicate with the editor. You
should mention any special attributes that qualify you to write
on the topic and reveal any potential conflicts of interest.
One final caution: If you are personally acquainted with
the author of the article you plan to discuss in your letter,
you may not want to write at all. If you applaud the study,
your praise may be suspect. Worse, if you criticize even some
small part of the study, your comments may be interpreted as
a personal attack.
Laura Hole, pediatric registrar in Bristol, UK wrote a review
of a book by Gardner et
al. titled
Training in Paediatrics
(London: Oxford; 2009). Her review begins with this engag-
ing first paragraph: “I was thrilled to commence my first
book review. The opportunity to condemn the hard work of a
faceless colleague with my carefully selected witty words of
deprecation seemed irresistible. Sadly, this was not to be as
I’m sorry to say
Training in Paediatrics
is rather good” (Hole
L. Arch Dis Child. 2009;95:659).
In 2010, Lee et
al. published a guide to writing scholarly
book reviews for publication in peer-reviewed journals,
describing book reviewing as a “fine art,” and presenting a
recommended strategy and a book appraisal worksheet <
Salager-Meyer offers insight into the evolution of the tone
and language of medical book reviews over the years, first
describing the mid-twentieth century, when reviews were
often laced with “face-threat intensity” and language that was
“emotional, devastating, and even down-grading.” She cites
published comments such as “blatant attack on intellectual
inquiry” and “The advice to the would-be buyer is simple:
Don’t (buy the book).” Today’s reviews, in contrast, tend to be
more civil and matter-of-fact, a welcome change for us all <
Thus Dr. Hole, mentioned above, did not take her opportunity
to pen “selected witty words of deprecation.”
Some, but not all, journals publish book reviews. Such
reviews are a regular feature in BMJ, the
Journal of the
American Osteopathic Association
The Lancet
and JAMA. In
fact, JAMA expands the concept to include “Book and Media
Reviews.” Some specialty and controlled-circulation journals
carry book reviews in each edition; others do so intermit-
tently. Not all reviews are of medical reference and textbooks:
In October, 2010, JAMA published a review a DVD release of
the first Dr. Kildare film, produced in 1937 by Paramount,
with the intriguing title
Internes Can’t Take Money
. “My Name
is Mary Sutter,” a tale of disease and suffering in Civil War
times, was reviewed in JAMA, also in October, 2010. So the
books reviewed are not all strictly scientific. Reviews of medi-
cal software are now commonly seen.
I am sorry to report that many journals, such as
American Family Physician
, that once published book
reviews no longer do so. I consider this a loss to aspiring
authors, potential reviewers, and the clinician reader.
The journal editor or the journal’s book review editor
almost always invites book reviews. Occasionally an eager
writer submits an unsolicited book review, but I doubt that
many are published. Unsolicited reviews are suspect and edi-
tors need not take chances.
On the other hand, it is not too difficult to become a book
reviewer. Any literate clinician can volunteer. Do so by iden-
tifying your one or two chief areas of clinical expertise, and
then write to the journal editor offering your services. If
selected to write a review, you will receive a copy of the book,
which is yours to keep as payment for your contribution.
Published book reviews are appropriate entries on your
academic curriculum vitae.
Types of Book Review
Technically speaking, there are not different types of book
review, but there are different approaches to the task. They
are not mutually exclusive and more than one can be used
in a single review. Whatever your approach, construct your
book review with the same care and economy of words that
you would devote to a review paper or research report.
Review in Relationship to the Author’s Stated Purpose
I believe that all reviews should follow this approach, at least at
the outset. I am a book author and editor, and I always begin my
preface with a description of the intent of the book. For exam
ple, the Preface to this book begins with this statement: “This
book is intended to make you a better medical writer.” I
my prefaces in this fashion for the reviewer, as well as the
reader. I
earnestly hope that the reviewer will judge my work
against my intention, and not against the book the reviewer
I had written. Also, as a reviewer, do not review the book
in comparison with the book that you wish
had written.
The reviewer who described
Atlas of Clinical Sleep Medicine
(Kryger MH. Philadelphia: Saunders/Elsevier; 2010) pro-
vides a good example: “The editor of the
Atlas of Clinical
Sleep Medicine
states in the preface that his aim was to cre-
ate a resource that would transmit state-of-the-art knowledge
about sleep medicine not just with words but also through
images and sound. The result is a lavishly illustrated and
well-written textbook that does exactly what it set out to do”
(Rosen D. JAMA. 2010;304:2069).
Comparison to a Classic or Standard in the Field
Every field in medicine has two or three standard reference
books, such as Harrison’s
Principles of Internal Medicine
Nelson Textbook of Pediatrics
. If and when a new book is
published to challenge the champion, it is only fair that the
reviewer make a comparison of the current front-runner.
The Biopsy of Favorite Topics
One approach to assessing the value of a book is to look up
your favorite topic, for example, myocarditis, breast cancer,
or myositis ossificans. Is the topic covered in the book? If so,
is the information complete and timely? In your review tell
the reader what you found.
An example of the biopsy approach appears in the
Medical Journal
. The review discusses one of my favorite
books, a catalog of etymologic origins of medical words
(Haubrich WS. Medical meanings: a glossary of word ori-
gins. Philadelphia: American College of Physicians, 1997).
The review says a little about the book, and then goes on to
discuss an example for each letter of the alphabet from “A”
(“ARTERY is a derivation of a Greek word for an air duct . . .”)
to ; (“;YGOMATIC was taken from the Greek
, la yoke
or crossbar by which two draft animals can be hitched to a
plow or wagon’”) (Marusiae A. Croat Med J. 1999;40:38).
On a more practical level, if I were reviewing a com-
prehensive reference on obstetrics, I might check how the
author(s) handle specific topics such as placenta previa or
antibiotic use during pregnancy. In a pediatrics text, I might
check current immunization recommendations, since they
change a little from year to year.
Overview with Criticism: Balancing Good Features with
In assessing a 219-page book about breast cancer (Walker
RA. Prognostic and predictive factors in breast cancer. New
York: Martin Dunitz, 2003), the reviewer states, “
and Predictive Factors in Breast Cancer
is a well-written,
compact reference book.” On balance, he goes on to observe,
“The biggest problem with a book that attempts to review
fast-moving fields such as breast cancer is that by the time it
is published, some material is obsolete and the newest areas
are not covered. For instance, this book has no discussion
of sentinel-node analysis and clinical trials of trastuzumab,
which were still in progress when it was written” (Rimm D.
Engl J Med. 2004;350:200).
How to Write the Book Review
In broad terms, different types of book are reviewed differ
ently. If the book is a text, intended for students, clarity is most
important and the occasional minor error is less important.
What is crucial is the book’s ability to provide the student with
concepts and templates that can aid in future learning.
The medical reference book is a different story. Here the
book reviewer must assess the factual accuracy of the book.
As Day <
> states, “Any professional librarian will tell you
that an inaccurate reference book is worse than none at all.”
Clinical decisions will be made based on what is in the pages.
It seems melodramatic to say that a factual error on the page
could kill a patient, but conceivably this could happen. (I will
say more about errors in Chap. 12).
Book reviews follow a pattern: They begin by identifying
the topic of the book being reviewed, often with a verbal
image that draws us in to read further. Then comes the analy-
sis of the work, including good points and any deficiencies.
Finally there is the summary, including who might want to
read this book. An online tutorial on writing booking book
reviews advises: “There is, of course, no set formula, but a
general rule of thumb is that the first one-half to two-thirds
of the review should summarize the author’s main ideas and
at least one-third should evaluate the book.” <
Beginning the Review
Since book reviews should not be too long, it is a good idea to
start the first paragraph by giving a strong hint of your overall
assessment. Here is a textbook example, describing the “Atlas of
Diagnositic Oncology, 4th edition” (Skarin AT, ed. Philadelphia:
Mosby/Elsevier; 2010): “This beautifully illustrated fourth edi
tion of the
Atlas of Diagnositic Oncology
promises to be a rich
source of diagnostic information for practitioners and trainees
in all medical disciplines that involve the care of patients with
cancer” (Feldman AL. JAMA. 2011;305;306).
With a little more flair: “
Black Lung
is a scholarly work, a
grim story, grimly told” (Cameron IA. Review of: Derickson A.
Black lung: anatomy of a public health disaster Cornell University Press, 1998>. The Pharos 2002;65:50).
One enthusiastic reader begins by stating, “I really liked this
book” (Neelon FA. Review of: Bittersweet: diabetes, insulin
and the transformation of illness of North Carolina Press, 2003>. JAMA 2004;291:745).
Good Points and Bad
This section, the body of the review, answers these questions:
What did I like about the book? What could the author have
done better?
Here is one example of the counterpoint. In discussing a
book about “giving news” in both everyday talk and clinical
settings, the reviewer offers praise: “Readers will come to
understand the sequential steps that make up lgiving news,’
just what makes information into news, and the different
sequences we use to deliver good news and bad.” On balance
the reviewer continues, “However, the reader not already
familiar with linguistic terms may find the book’s terminol-
ogy a bit over-technical” (Platt FW. Review of: Bad news,
good news: conversational order in everyday talk and clinical
settings . JAMA.
One more example of the balanced approach, from a
review on American colonial medicine: On the plus side, the
reviewer states, “
Medicine in Colonial America
is chockab
lock with detail presented in a clear writing style, covering
a large territory in easy fashion—a good introduction to
the novice.” And yet, on the other hand, “There are a few
errors. Samuel Johnson is misidentified as Ben Johnson”
(Murray TJ. Review of: Reiss O. Medicine in colonial America
. The Pharos
Once as I was basking in the glow of a uniformly favorable
review of one of my early books, my editor and mentor com-
mented, “A review without a single criticism of the book lacks
credibility.” In rereading the Feldman review of the
Atlas of
Diagnostic Oncology
, described above, I noted not a single
word of criticism, which I find a slightly off-putting lack of
balance. I have been blessed with some kind, yet balanced,
reviews of the first edition of this book on medical writing.
One reviewer failed to resonate with some of my humor.
Another pointed out that my discussion of packing a manu-
script for mailing was anachronistic. Yet another review sug-
gested a need for increased discussion of tables and figures.
These and a few other criticisms—obviously intended to
balance lavish praise—were instrumental in the decision to
prepare a second, and expanded, edition of the book.
When you are writing a book review, the body of the review
should answer many of the questions listed in Table
The Reviewer’s Conclusion
In the end, the reviewer should summarize his or her opinion
of the book, and which readers are likely to find it useful.
In the review of the book
Prognostic and Predictive Factors in
Breast Cancer
cited above, the reviewer ends by stating that
it “will be a valuable addition to libraries, especially at teach
ing institutions” (Rimm D. Review of Walker RA. Prognostic
and predictive factors in breast cancer Dunitz, 2003>. N Engl J Med. 2004;350(2):200–201). The pub
lisher may not be overjoyed by this summary, since libraries
Questions for the book reviewer
s the book’s topic important?
s the information timely?
s the content appropriate for the intended audience?
s the book appropriately organized?
s the writing clear?
s the style consistent throughout the book?
s my favorite topic covered appropriately?
as the author included appropriate tables and figures?
re there misspellings and minor errors?
re there significant errors of fact?
hat has been left out?
s the index adequate to find what
want to find?
re the paper and binding of good quality?
s the book worth the cost?
oes the book fulfill its stated purpose?
ow does this book compare to other similar books?
o you recommend the book and, if so, for which readers?
at teaching institutions are a very small market. For a book to
be successful, it must appeal to a larger market, generally of
practicing clinicians.
Contrast this summary with the review by Feldman, which
enthusiastically concludes, “
The Atlas of Diagnostic Oncology
is a comprehensive, well-organized, and beautifully illustrated
overview of diagnostic oncology. Its multidisciplinary nature
will make it a useful educational tool and reference text for
practicing physicians and trainees in all fields involving the care
of patients with cancer” (Feldman AL. JAMA. 2011;305;306).
Without your personal opinion, your earlier comments are
less helpful to your reader.
What Makes an Excellent Book Review and What Does Not
The excellent book review is informative and brightly written.
It offers a personal judgment of the merits of the book. But
the review must not be excessively amusing. In writing the
book review, there is a great temptation for the reviewer to
attempt to outshine the author.
With that said, good book reviews often add a little extra.
A review of
Dorland’s Medical Dictionary
begins by provid-
ing some new information. I enjoyed learning the following:
“Who uses a medical dictionary? It may surprise some that
physicians are probably not the principal users, but rather
medical students, other health care professionals, medical
transcriptionists, and perhaps even lawyers and journalists”
(Fortuine R. JAMA. 2003;290:3225).
I felt compelled to read the review that began, “Have you
ever wondered, after a hard week at work, why you decided
to become a doctor? If so, you might want to read this book”
(McClure I. Review of: Baiev K. The oath: a surgeon under fire
. BMJ. 2004;328:354).
Sometimes the review walks a fine line between writing
vividly and being too clever. In reviewing a book that presents
arguments against evolutionary psychology, the reviewer
begins, “The contributors to the volume—an eclectic mix
of biologists, sociologists, and philosophers—
evidently feel
about evolutionary psychology the way I feel about squir-
rels who steal food from the bird feeders in my backyard”
(Perlman R. Review of: Rose H, Rose S, eds. Alas, poor
Darwin: arguments against evolutionary psychology York: Harmony Books, 2000>. The Pharos. 2002;65(3):48–49).
Certainly this reviewer is assuming the “rhetorical persona of
the book reviewer,” described by Salager-Meyer <
And sometimes, the reviewer is much too witty for even
my taste. The following is beginning of a review of a book
on alternative medicine in America: “Medical doctors and
naturopaths work together to manage the publicly-funded
King County Natural Medicine Clinic in Seattle. Is this a
manifestation of Northwestern coffee intoxication?” (;aroff
L. Review of: Whorton JC. Nature cure: the history of alterna-
tive medicine in America 2002>. The Pharos. 2003;66:38).
Yes, I am well aware of the irony that I am reviewing the
writing of reviewers. And I am doing so without offering
them an opportunity for rebuttal.
Cautions When Writing a Book Review
I have at times been asked to review a book that might
be perceived to compete with one of my own books. For
example, I have written a book on back-stories of medical
history <
>. If I am sent a medical history book written or
edited by another person, I will decline to review this book.
There would be a genuine conflict of interest. This, of course,
means that during the publication life of
Medical Writing:
A Guide for Clinicians, Educators, and Researchers,
I should
not review any books on medical writing.
The second caution concerns professional relationships. In
a critical survey of articles about writing book reviews, Lee
all point out, “Interestingly, the authors of books under
review may be the most avid readers of book reviews. Authors
have invested much time and effort into writing their books,
and it is not surprising that an author would be curious about
how other scholars perceive their books.” <
> I consider the
word “curious” here to be a huge understatement. The author
will feel the pain of every unfavorable word. Criticizing an
author’s book in print is like striking someone’s child. Even
in a balanced review, the negative comments can be taken
very personally. If you are asked to review a book written
or edited by a colleague who is a personal acquaintance,
suggest that you pass the opportunity to someone else.
Declining the review helps assure an unbiased evaluation of
the book, and it can prevent the loss of a friend.
There are other medical publication opportunities. If you
have a special interest, such as poetry or medical history, you
might want to consider one of the following. I have listed
some journals as examples; I am confident that the models
described are found in a variety of journals; I have listed
some journals as examples. If you aspire to write in any of
these models, be sure to first identify your target publication,
and prepare your submission so that it looks like those that
have been published.
JAMA publishes a regular column titled “Poetry and Medicine.”
Some other journals do also. Some recently published JAMA
poems have been titled “Haitian Humanity,” “Milestone,”
and “Unassisted.” Unassisted, describing the rehabilitation
following hip replacement begins:
Today you try to throw away the cane,
You stand on the perilous edge of air,
Feeling the weight on the new hip,
A metallic guest in an aging body. . . .
(Pucciani D. JAMA. 2011;305:288)
Campo asks: Why should medical students be writing
poems? In fact, why should any of us, clinicians, educators
or researchers? He answers his question with an argument
that centers about the thesis that, “Physicians who lack a pas-
sion for language or who fail to see beauty will be at a loss
to translate these wonders in the most meaningful terms for
their lay patients and into the larger society around us.” <
I think that, of all types of writing, perhaps poetry is the most
personally revealing of all. Even if it were not to make us bet-
ter diagnosticians or lecturers, a little experience in the art
of poetry would probably make us all better medical writers,
and maybe even better humans.
About My Practice
Medical Economics
, a magazine best known for staff-written
articles about practice management and finances, also pub-
lishes commentaries about the practices of their physician
A recent about-my-practice article in
Medical Economics
titled “Making Sense—and Cents” holds that educated patients
who understand their illnesses and their management are
more adherent and satisfied, helping the practice achieve
financial success (Bobs MacBook. July 16, 2011 9:54 AM).
Another publication that publishes physician-authored prac
tice management articles is
Physicians Practice
, which recently
featured an article titled “How I Implemented a Cash-Only
Model that Works” (Forrest B. Phys Pract. 2011;21(1):19).
History of Medicine
Some journals publish articles about medical history, a
favorite topic of many clinicians. For example, in writing
about Civil War medicine, Bollet states, “Supplying armies
with fresh vegetables to prevent scurvy was always difficult,
even for the tiny, 15,000 man, pre-Civil War United States
army. Scurvy was the most common disease reported from
frontier posts . . .” (Bollet AJ. The Pharos. 2003;66(4);19–28).
9-Ray or Photo 2uiz
presents a continuing section, “Photo 2uiz.” Here
authors supply photographs or radiographs accompanied by
brief medical histories. The challenge to the clinician is to
identify the diagnosis, which is presented later in the journal.
A similar feature is found in the NEJM.
Movie Reviews
The Pharos
publishes outstanding movie reviews. A recent issue
reviews two films: “Wall Street: Money Never Sleeps” (liked
it) and “Conviction” (didn’t) (Dan PE. Pharos. 2011;74:41).
A movie review column in a journal tends to be written
by the same person each month. However, if you wish to
undertake the task, there is no reason that you could not
suggest such a column to your favorite specialty journal if
none already exists.
A Piece of My Mind
“A Piece of My Mind” is the title of a feature in JAMA. Similar
columns appear in many other publications, offering you the
opportunity to write about something you feel strongly about.
Topics that are fair game are insights from an encounter with
a patient, thoughts about the future of medicine, or reflec-
tions on how your profession affects you as a person.
One author wrote a piece titled “Impact Factor,” describ-
ing the long-term influence a teacher can have on a trainee
(Hirschtick RE. JAMA. 2011;305:230). Another physician
describes “A Modern Family,” which includes Joe, a schizo-
phrenic man who leaves an institution, and his caregiver,
Miss Elsie, a 60-year old African American former correc-
tions officer. The article chronicles their journey through
Joe’s lung cancer, hospice and eventual death (Colgan et
JAMA. 2010;304;2221).
One of the best features of this publication model is that it
is egalitarian. Publication is open to all, not just to members
of prestigious academic departments. What is submitted is
judged solely on its merits—the impact of the message and
the clarity of the writing.
Practice Tips
In the journal
, look for “Practical Pointers.” In
practice tips columns, clinicians share ways to make practice
more efficient and enjoyable. Long ago, I contributed a tip
on how to administer eyedrops to a squirming infant who
won’t open the eyes. (Do so by holding the infant face up.
Administer two to three eyedrops to the inner canthus of the
eye, even with the eyes tightly closed. Eventually the infant
opens the eyes and then the drops enter the eyes).
Gregory S. Morales, MD suggests a way to avoid the prob-
lem of patients talking as we auscultate the heart and lungs,
not realizing that we physicians cannot hear what they are
saying. He suggests: “One way to prevent this is to listen to
the lungs first instead of the heart. Ask patients to take deep
breaths and they will stop talking” (Morales GS. Consultant.
The journal
Postgraduate Medicine
also publishes practical
tips, under the heading “Practice Pearls.” Recent contribu-
tions include the a less traumatic reduction for a dislocated
shoulder, an augmented Valsalva maneuver to terminate
tachycardia, and a way to avoid trauma while removing nasal
foreign bodies. These and more practice pearls are available
Irony and Humor
Some enterprising individuals have conducted tongue-in-
cheek research studies, and you may be surprised to learn
that some of these articles find their way into print in quite
respectable journals. Here are two of my favorites: Two
British physicians quantified swearing by surgeons in the
operating room. They observed 100 consecutive elective sur-
gical procedures. They found that during an 8
hour operating
day, there were “16.5 swearing points for the orthopaedic
surgeons, and 10.6, 10, and 3.1 from the general surgeons,
gynecologists, and urologists respectively. In contrast, during
hours of ear, nose and throat surgery, little more than one
“bugger” is likely” (Palazzo et
al. BMJ. 1999;319:1611).
Here is another example of a droll observational study,
published and indexed with its abstract available on PubMed.
Rockwood et
al. “conducted a surreptitious, prospective,
cohort study to explore how often physicians nod off dur-
ing scientific meetings and to examine the risk factors for
nodding off.” Wearing tweed seemed to increase the risk of
nodding off; there was less nodding off when speakers were
raving or when they dropped the microphone (Rockwood K
al. Can Med Assn J. 2004;171:1443).
Newspaper Column
Some physicians write a column for a local newspaper or
send out a monthly newsletter from their practices. In a let-
ter published in
Medical Economics
, one clinician writes:
“For the past year, I’ve used a technique that has generated
one or two new-patient visits a week. I write a column called
Doctor Speaks from the Heart’ for the monthly newsletter
of a large retirement community that’s located near my prac-
tice” (Hoenig LJ. Med Econ. 2004;81(1):13).
Topics that might be discussed in a newspaper column or
newsletter include:
When to call the doctor if a child is sick
Who should get a flu shot
First aid for acute injuries
How to buy medicine at the lowest cost
Danger signs in common illnesses
How to prevent falls in the elderly
Thoughts about herbal remedies
Tort reform and access to care
You and I could develop a long list of topics. The key is to
keep the contributions short and pertinent. Also, be sure to
avoid medical jargon when writing for the public; write head-
ache, not cephalgia. When you undertake to write a
you are agreeing to produce a written work at regular inter-
vals, and hence the obligation should not be undertaken
lightly. However, clinicians who write for the public enjoy
the rewards of having readers in their communities remark,
liked your article in the newspaper this week.”
Apley J. Pleasures of medical writing. BMJ. 1976;1(6016):
Jordan EP, Shepard WC. Rx for medical writing. Philadelphia:
WB Saunders; 1952:32.
Lapsley P, Godlee F. Involving patients in the BMJ. BMJ.
Huth EJ. Writing and publishing in medicine. 3
rd ed. Baltimore:
Williams & Wilkins; 1999:112.
LaVigne P. Letters to the editor. In: Taylor RB, Munning KA,
eds. Written communication in family medicine. New York:
Springer-Verlag; 1984:50.
Journal of the American Medical Association. Instructions for
Authors: Letters to the Editor. Available at:
Lee AD, Green BN, Johnson CD, Nyquist J. How to write
a scholarly book review for publication in a peer-reviewed
journal. J Chiropr Educ. 2010;24(1):57–69.
Salager-Meyer F. Book reviews in the medical scholarly
literature, part II: “This book portrays the worst part of mental
terrorism.” J Eur Med Writers Assn. 2008;17(3):147–148.
Day RA. How to write and publish a scientific paper. 5th ed.
Westport, CT: Oryx; 1998:176.
Indiana University (Bloomington, Indiana) Writing Tutorial
Services: Writing Book Reviews. Available at:
Taylor RB. White coat tales: medicine’s heroes, heritage and
misadventures. New York: Springer; 2008.
Campo R. Why should medical students be writing poems?
Med Humanit. 2006;27(4):253–254.
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_8,
© Springer Science+Business Media, LLC 2011
Writing Book Chapters and Books
The most unhappy day of my life was when I sold my brains to
the publishers. . . I must have had neurasthenia or something
else, and I beg your pardon for ever having consented to write
a book. I have been sorry for students ever since, and trust
(his book) goes out of vogue, some one will have
ready an easier text.
Sir William Osler (1849–1919), comments to students
about his book <
In a herculean effort, Sir William Osler wrote the world’s
first comprehensive medical reference book,
Principles and
Practice of Medicine
. It was published by Appleton in 1892
and continued in print until the 16th edition, published in
1947, thus taking quite a long time to go out of vogue. The
effort was heroic because Osler wrote every word himself—
no contributed chapters for him—a task that took 3
His fianc refused to marry him until the manuscript was
complete. Following Osler’s retirement, later editions of the
book were a collection of contributions by Johns Hopkins
faculty members <
Writing and editing medical books and chapters can be a
lot of fun, as I suspect Osler discovered, despite his protesta-
tion above. This activity can also be immensely frustrating, as
you will learn as we go along in this chapter. In the spirit of
full disclosure, over years I have edited 18 medical reference
books and have authored six books for clinicians and five
trade books, and contributed dozens of book chapters to the
books of various editors. I have my cherished beliefs and pet
peeves about putting together medical books.
First, I will discuss medical books in general. Medical
books can be categorized in several ways. One classification
is by use: When thinking about medical books by use, we can
which are intended to be used by students
as part of a course or clerkship;
reference books
, used to look
up information; and what I call
enrichment books
, intended
to be read for pleasure and personal growth. My textbook
Fundamentals of Family Medicine
is familiar to many medi-
cal students (Taylor RB, ed. New York: Springer; 2003).
It contains 27 clinical chapters linked by case discussions
that all involve members of a large, multigenerational fam-
ily plus questions for class discussion. Dambro’s
Clinical Consult
(published annually by Lippincott Williams
& Wilkins in Philadelphia) is one of many broad-based medi-
cal reference books; I doubt that anyone other than the edi-
tor has ever read it cover to cover.
Stories of Sickness
H. New Haven, CT: Yale University Press, 1988), an enrich-
ment book written by a philosopher–physician, describes the
patient’s narration of the experience of sickness as an essen-
tial part of the act of healing. Enrichment books can be writ-
ten for a medical audience, for the so-called lay audience, or
both. Books written specifically for the lay audience, such as
Jerome Groopman’s
How Doctors Think
(Groopman J. New
York: Houghton Mifflin; 2007) are called trade books.
Looking at books another way, there are
edited books
authored books
. Edited books contain the works of two or
not listed on the cover. With many chap
ters, often written by several coauthors, large reference
books in major medical specialties may have several hun
dred contributors. If you count the contributors to your own
subspecialty’s leading reference book, I would be surprised
if the total is less than 50, and it is probably over 100 for the
largest specialties. Hence, edited books are identified by the
name of the editor, or, in the case of a book with many edi
tors, by the editor-in-chief. Edited books may take one of sev
eral forms: A true edited reference book has almost certainly
been read and actually edited by the persons named on the
cover. An anthology or conference proceedings may be com
piled without the editor having much ability to edit content
or coordinate styles.
Authored books are written by a single author or perhaps a
small team. All names are on the cover as authors. This book is
an authored book, written by me, alone. As a broad generality,
edited books are more likely to cover a wide spectrum of top
ics and be larger volumes. Authored books are most likely to
be smaller and more focused. As described by LaVigne <
specialized book, also known as a technical publication,
monograph, or scholarly work, is distinguished by the sophis
ticated level of its content. Since the specialized book is written
for an author’s colleagues and peers, it does not need to be as
comprehensive as a text on the topic, nor as comprehensible as
a book written for the general public.”
When all the above is considered, your entry into book
publishing is most likely to come as an invitation to contrib-
ute a chapter to an edited reference book.
The invitation to write a book chapter is flattering and, as one
who has extended many such invitations, I know that most
invitees say, “Yes.” As a clinician, you are most likely to be
invited to write a book chapter if you have a special practice-
based interest that you have described in print. This may be
considered one of the benefits of writing review articles. Let’s
say that your special interest is the evaluation of chest pain.
You have published several review articles in controlled-
circulation medical journals discussing the possible causes
of chest pain, the different types of angina pectoris, and the
causes of noncardiac chest pain. About this time, imagine the
plight of a reference book editor whose favorite author on
chest pain has decided to retire to a beachfront condominium
in Florida. In searching for a replacement, the editor comes
across your articles and sends you a letter or an e-mail mes-
sage. You are on your way to being a book chapter author.
Occasionally an editor needs a chapter on a topic that
is rarely covered or an emerging issue on which few have
written. In such instances, the volume editor may look for
an author who writes on a variety of topics, and invite this
clinician to take on the “hard to place” topic. In planning the
edited reference book
Difficult Diagnosis
(Philadelphia: WB
Saunders, 1985), I decided to have a chapter on the evalua-
tion of the patient with hyperhidrosis—excessive sweating.
I found no expert that had claimed that topic, and so I asked
a generalist colleague if she would be willing to take it on.
She agreed, and contributed an excellent chapter.
The Invitation to Write a Book Chapter
You feel honored to be selected as a potential author. You
are grateful, thrilled, and energized. You want to call today
and accept before the editor has a change of heart. But wait.
There are some issues to be considered.
One of the issues you need not be concerned about is
how much you will be paid for your chapter. In almost all
instances, the answer is “not very much.” Some portion
of royalties is generally allocated among the contributing
authors of a book, but considering the modest sales numbers
of even the most popular medical reference books and texts—
compared, let’s say, to the sales of Harry Potter books—the
dollar amounts are tiny. The income will not compensate for
the time involved in writing the chapter. As additional incen-
tives, however, you will (almost certainly) receive a copy of
the finished book, an entry on your curriculum vitae, and the
editor’s endless gratitude.
For the academician, a book chapter invitation presents
an important career advancement issue, even when we rec-
ognize that the greatest academic rewards come from the
publication of reports of original research. In the hierarchy
of publications that can support a bid for promotion to sen-
ior faculty status, book chapters are in the middle of the list,
below the research report, meta-analysis and definitive litera-
ture review published in a peer-reviewed journal and above a
letter to the editor and book review.
For the clinician, writing a book chapter on your special
clinical topic—for example, the treatment of resistant psoria
sis or robotic surgery of coronary artery disease—can help
establish your national reputation and thereby stimulate refer
rals from clinicians who agree with what is in your chapter.
About the Agreement to Write a Chapter
Before accepting the book chapter invitation, there are sev-
eral questions to ask. These are listed in Table
. I clearly
would not accept the invitation to write a chapter unless the
editor had a contract with a publisher. I might agree to write
contingent upon the editor obtaining a contract, but I would
not begin work until publication of the book is assured in
writing. Once you are sure that a book contract exists, I con-
sider the two most important questions on the list to be those
that concern the page allocation and the chapter deadline.
Before beginning to write you must have these items clearly
in mind. It is all too easy to write a book chapter that is much
too long, and then needs to be cut; this represents wasted
effort for both you and the editor.
The deadline is especially important because the editor
must receive all manuscripts at about the same time, review
them promptly, and get them all in print before the clinical
recommendations go out of date. One or two tardy chapters
can, and sometimes do, hold up production of a book, ulti-
mately compromising its usefulness (and sales). Or, there is
another possibility. Two years ago, my wife and I cruised on
the Norwegian Coastal Lines; ours was a working cargo and
ferryboat that stopped at more than 40 ports as we sailed
down the coast of Norway. Stops at ports of call might be
h. The captain warned us sternly on the first day,
“For those who leave the ship to visit a port, there are no
late-arriving passengers. There are only passengers who have
been left behind.” The editor may decide that your chapter
can be “left behind” and go to print without your late-arriving
contribution. This happens.
Questions to ask the volume editor when invited to contribute a
chapter to an edited book
Who is going to publish the book, and do you have a signed contract?
What other books have you edited and who has published them?
review a full table of contents or topic outline, to see what others will
Who will be some of the other authors in the book?
What will be the topic of my chapter?
s there a special way you, as editor, want the topic handled?
What is the space allocation for my chapter (stated in double-spaced manuscript
What is the deadline for manuscript submission?
engage one or more coauthors?
receive payment for my chapter?
receive a copy of the finished book?
What is Negotiable?
An agreement to write a book chapter has explicit and implicit
commitments from you and the book’s editor, aka the compiler.
You may be startled to note the casual agreement between you
and the compiler, sometimes only a verbal commitment on the
telephone. At some later time, the publisher will send you a
more formal agreement, which has at its core that the copy
right to your chapter will be assigned to the publisher.
As discussed in Chap. 4, I advise not being concerned about
this copyright assignment. First, it is standard in the trade and
is not negotiable. Second, it rarely presents a problem. The
only consideration arises when you have an innovative figure,
table, mnemonic, or similar entity in your chapter, and you
are sure that you will want to use this item in the future. In
this case, you may be able to get the publisher to agree that the
specific item is included in your chapter for “one-time use.” If
such agreement is not possible and you still wish the chapter
published, you should have no problem using your innova
tive figure or table in later work, but you will need to request
permission from the book’s publisher for such use. Obtaining
permission under such circumstances is usually quite easy.
lists items that you may or may not be able to
negotiate when invited to write a book chapter.
Writing a book chapter: what is negotiable and what is not
ossibly negotiable:
xact title of the chapter
nviting coauthors
ow the topic will be handled
eadings in the chapter
aying for artwork and permissions
Future use of a specific figure or other item in the chapter without specific per
mission from the publisher
robably not negotiable:
eneral topic of your chapter
eadline for manuscript submission
ayment for the chapter
efinitely not negotiable:
Copyright assignment
Future use of all chapter content without permission from the publisher
Preparing and Submitting Your Chapter
Writing a book chapter is much like writing a review
article, which I described in Chap. 6. They are similar
in that you must begin with a limited topic, decide on a
concept and structure for what you want to say, do care
ful research and select references carefully, write a well-
organized and authoritative essay, and then summarize
while staying within appropriate page limits. But there are
differences: The topic is likely to be assigned, the structure
and headings may be prescribed, a specific feature such
as an algorithm may be required, coordination with other
chapter contributors may be needed to avoid overlap, and
the deadline may be quite firm to assure timely publication.
An example follows.
Earlier in this chapter I mentioned the multiauthor refer-
ence book
Difficult Diagnosis.
This book presented the diag-
nostic approach to a selected group of challenging problems
with “enigmatic clinical presentations.” Examples included
fever of unknown origin, jaundice, and pelvic pain in women.
Contributors were invited from many specialties. In planning
the book, I decided that each chapter should have the same
six major headings: Background, including definitions, inci-
dence of the problem, and a laundry list of possible causes;
History, to include what I called “high-payoff questions;”
Physical Examination, including the significance of key find-
ings; Diagnostic Studies, including laboratory investigations,
diagnostic imaging, and other tests; Assessment, to include a
diagnostic algorithm; and References, but no more than 25
citations. Therapy was not to be covered unless integral to
diagnosis, such as the sometimes helpful response of gout to
colchicine. I even wrote a sample chapter, “Acute Headache,”
and sent a copy to all authors recruited, just to present a
model of what I had in mind. The authors selected were
seasoned clinicians and distinguished academicians.
Months later, when chapters were submitted, most authors
had followed directions. They used my headings, provided
tables listing possible causes of dysphagia and hypocalcemia
that I still use today, identified high-payoff questions, and
constructed useful algorithms. Only a few authors went their
own way with different headings and varying concepts for
their chapters. When the nonconforming chapters didn’t
seem to fit, the authors and I negotiated. When the “different
drummer” concept seemed to fit the topic better than my
prescribed headings, no change was recommended, although
I made a mental note that would influence author selection
for outlier chapters in a second edition.
In the end, I believe that the contributors and I created a
great book. It has innovative features and covers a special
group of challenging medical topics. I relate all this because
I believe that the success of the book can be attributed to
the hard work and skill of authors who, for the most part,
followed instructions that called for them to unify headings,
limit reference citations, and construct some items—lists of
possible causes, high-payoff questions, and algorithms—that
readers can find in (almost) every chapter.
Chapter Structure
As noted above, the book editor may be quite specific about
concept and headings, or you may be allowed to develop your
own approach. The latter is more common, and most book
editors do not prescribe structure as precisely as I did with
Difficult Diagnosis
As part of a compiled work, Joseph E. Scherger, M.D., and
I wrote a chapter, on “Writing a Medical Article” for a book
Written Communication in Family Medicine
>. Our
topic, as implicit in the title, was on how to write a medical
article, and our approach was based on a workshop that we
had presented several times. We structured the chapter as a
series of 10 steps:
Conceptualize the subject of the article
Review the literature
Select the appropriate readership and journal
Organize and outline the content of the article
Select a title
Write the first draft
Write the first revision
Submit the manuscript for review by selected colleagues
Write a final draft
Submit the paper for publication
If asked to write a chapter on a clinical topic, such as gas-
troesophageal reflux disease or incontinence in the elderly,
keep in mind that the classic headings for a clinical chapter
in a medical reference book are going to be very similar to
those in the
Difficult Diagnosis
book, with treatment and
perhaps prevention added. Or you may think of your clini-
cal SOAP note: Subjective, Objective, Assessment, and Plan.
With a few additions, such as epidemiology and prevention,
SOAP is a useful concept for a clinical chapter. If asked to
write on a disease topic and given no other instructions, think
about the topics in Table
Submitting Your Book Chapter
This should be the easy part. Do your best to make it so. If you
have carefully followed the editor and publisher’s instructions,
and have completed your chapter on time, submission should
be a breeze. Verify that you have not exceeded your page allo
cation. Read it through one last time to find the instance in
which you have repeated or contradicted yourself. Then, to be
sure that you have not forgotten anything, review the checklist
in Table
12.2 before sending your chapter to the editor.
How you actually submit your chapter will vary with the
book editor and publisher. For my last two edited books, all
manuscripts were submitted online, with only original art
arriving by mail. Your role, as a contributor, is to submit your
manuscript as requested by the editor.
In the area where I lived in upstate New York, people had
a saying: If you hire six carpenters to do a job, only two
Classic headings in book chapters on medical diseases
Clinical features
iagnosis, including history, physical examination, and diagnostic tests
will show up; one will have a sore back and the other one
will have to go home to get his tools. There is an analogous
saying in medical publishing: If you, as a compiling editor,
contract with three authors to contribute chapters and then
seek the chapters at deadline time, one will be months behind
on commitments that come before your book, one will be on
a year-long sabbatical in a remote village overseas, and one
will have forgotten about the project entirely.
You as the Initiator of an Edited Book
The initiator of an edited book should have certain character
istics: You should have a fair amount of experience as a book
chapter contributor. It would be good to have a name that is
well known among potential contributors, but this is not a
requirement if you have a very good idea and a signed contract
with a respected medical publisher. You must be willing to spend
nights and weekends on the project, especially when chapter
manuscripts arrive, since they are all going out of date as they
sit on your desk. You must be tactful, since you will be dealing
with some colossal egos, as a few contributors decide they know
better than you how the book should be compiled. And you must
be tenacious, since the worst thing you can do in an edited book
is let the project die. This death can occur when half the chap
ters are in hand, and the authors of the other half are behaving
like the apocryphal three authors described above.
Planning an Edited Book
There are major edited books (such as
Harrison’s Principles
of Internal Medicine
) and there are focused books (such as
Written Communication in Family Medicine,
cited above).
In most areas of medicine, there really is scant room for
another major edited book. The issue is not that you could
not produce a big book that is better than those available;
the truth is that the publisher cannot afford the financial risk
of failure inherent in adding a new expensive product to a
f my memory is correct,
read this tale of three authors in the preface to a book published
about 25
years ago.
cannot recall the name of the author or book and, to help me avoid
accidental plagiarism,
would be grateful if a reader could supply this information for the next
edition of Medical Writing.
crowded market. I find this risk especially pertinent today
when physicians first seek information online, and not in
heavy reference books.
If planning an edited book, think about a focused prod-
uct. The traditional approach is to marry a group of health
problems to an age group, gender, geographic location, or
medical specialty. Currently there are books on dermato-
logic diseases of children, medication use during pregnancy,
and geriatric neuropsychiatry. There have been books about
gynecologic, behavioral, neurologic and musculoskeletal
problems in
primary care.
An early, key decision in planning an edited book on health
problems is as follows: Do I want to present my chapters as
diagnoses (such as myocardial infarction) or as clinical presen
tations, that is, symptoms or signs (such as chest pain)? Most
medical books choose the former. It is handy and traditional.
However, patients present to clinicians with symptoms and
signs, not diagnoses, which speaks to the utility of presentation-
structured books like
Difficult Diagnosis
. As a hint to those
seeking contributors, it is much easier to recruit authors to
write on diseases than on signs or symptoms. Physicians like to
take ownership of a disease, and will write endlessly to hold on
to their turf. On the other hand, few clinicians claim expertise,
much less ownership, of clinical presentations such as cyanosis,
hemoptysis, or, as mentioned earlier, hyperhidrosis.
At a minimum, you will need to plan the following for your
new edited book:
A compelling need for the book
A good idea of who will buy the book
Overall length of the book
Number and titles of the chapters
Short description of what should be included in each
A list of potential authors
The time and commitment you will need to complete the
How much time commitment will be needed? Compiling
an edited medical book is a 2-year commitment—if all goes
well. The good news is that you will not be working overtime
for the full 24
months. Editing a book occurs in stages requir
ing intense effort, alternating with times when the editor has
little to do. Here are three major phases when evening and
weekend effort will be needed: Phase one is author recruit
ment. Contacting and reaching agreement with all the book’s
primary authors will take a lot of effort, as described below.
After all authors are recruited, things are quiet while authors
write; at least you
they are writing. Phase two comes
when all the manuscripts arrive. The manuscript editing
time is the busiest of all, because of the need to verify many
facts and to negotiate changes with contributors. Phase three
is proofreading, which cannot simply be delegated to oth
ers. Of course, each contributor should proofread his or her
own contribution. In my experience, however, most chapter
authors are dismal proofreaders and you, as editor, must take
responsibility for all errors by checking every word carefully.
The first step, after planning and committing yourself to
your edited book, is getting a contract with a publisher. This
is accomplished by submitting a proposal.
The Book Proposal and Contract
What follows regarding book proposals and contracts applies
to both edited and authored books.
Finding the Right Person
Not long after deciding upon the niche-filing edited book you
will compile, you must find a publisher. And at that publishing
company you must find the “acquisitions editor,” the person
who can actually offer you a contract (with approval from the
publisher, the person who controls the company budget). To
locate the right medical publishing firm, look for one that pro
duces books in your field. Some publishers bring out a number
of radiology and plastic surgery books, those with many illus
trations and requiring specialized production. Some medical
publishers prefer primary care books. Another may specialize,
to some degree, in psychiatry and psychology books. Check
the books on your own bookshelf or in your institution’s
medical library to see who is publishing in your specialty. Visit
individual publisher Web sites or, or go to the
Literary Market Place (
) to
see who publishes what type of books; there is a fee charged
for full access to the Literary Marketplace.
After you have identified one or two potential publishers
for your book, find the acquisitions editor in one of two ways.
If you are going to a major medical meeting in your specialty,
visit the exhibit booths of the publishers you are targeting. At
the booth, you will find salespeople, but also at the meeting
may be an acquisitions editor. Ask the salesperson whether
the acquisitions editor is at the meeting and, if so, when he
or she will return to the booth so that you can discuss your
idea. This approach takes some effort and a little serendipity,
but nothing replaces face-to-face contact.
Plan B, if you cannot meet in person, is to use the telephone
and network research to track down the acquisitions editor.
Let’s imagine that you are a radiologist, and that you have a
great idea for a new book in diagnostic imaging. Your research
has shown that 9Y; Publishing Company has a very good list of
radiology books. Call the company and ask to speak to the acqui
sitions editor for medical radiology books. With any luck, you
will soon be connected with the office of the person you seek.
Another good way to contact an acquisitions editor is
through the publisher’s website. For example, acquisitions
editors for this book’s publisher can be found by visiting, choosing the subject area of your potential
book, and clicking “Get in Contact.”
What’s Next in Getting a Book Contract?
Tell the acquisitions editor about your proposal, being sure
to cover the planning topics listed above. The acquisitions
editor may give you some immediate feedback: “We have a
book like this in production.” “I don’t think there is a market
for this book.” Or “Not a bad idea, but here is how I would
modify the concept.”
In most instances, your idea will be received with some
guarded interest, and you will be asked to submit a pro-
The Book Proposal
Your book proposal is a formal document. By the time it
is submitted, you and your acquisitions editor may be on a
first-name basis, and you have fully discussed the proposal.
You are both enthusiastic. Nevertheless, you should submit a
complete, polished proposal, covering all the points listed in
. A complete proposal portfolio, with all the pieces,
is important because the next task of your acquisitions editor
is to present the proposal at the regular meeting of the other
editors and the publisher. Here is where your new editor acts
as your advocate to get the project approved. At this meeting,
his or her most important ammunition is your proposal. In
fact, the proposal may be the most important bit of writing
you do in regard to your book.
The Contract
The proposal is approved! Hooray! The standard contract is
in the mail. Wonderful. But wait. Even though you receive
a preprinted contract, it may be useful to know that the
publisher has several “standard” contracts that can be used,
according to circumstances. Some contract terms may
be negotiable, and additions to the contract are possible.
A review by your attorney may be helpful, but going over the
contract with an experienced book author/editor is likely to
be more helpful (and will cost less). These standard contracts
What to include in a book proposal
nticipated length of the manuscript, expressed in double-spaced
umber of tables and figures that will be in the book
he book’s audience, that is, who will buy the book
are usually written in plain English, and there are typically
not any trick clauses. With that said, there are some key items
to review carefully:
The standard was once 10 of gross sales at
the U.S. retail price, and less for foreign sales. Recently,
publishers have learned how to cut author/editor royalties
without being too obvious. The device was to change the
contract to read percent of
net sales
. Since net sales figures
are a black box impenetrable to authors, the author/editor
who receives 10 of net sales may not realize that this is
probably less than 8 of gross sales.
Advance against royalties:
Seasoned authors/volume edi-
tors should request an advance, as a warranty that the
book will actually be published, especially when the book
is a major project. Neophyte authors should ask, but are
often not in a strong bargaining position even though this
is really their money, and so it really isn’t a cost to the
publisher. You are merely getting some of your royalty
payment a little early.
Costs related to manuscript preparation:
I always ask that
the publisher pay for the cost of preparing figures and the
index. Without prior agreement to the contrary, these are
often charged to the author, and can be an unpleasant sur-
prise on the first royalty statement. If the book contains a
lot of art and the publisher cannot agree to pay for all, ask
for a grant or an allowance.
Author copies:
The contract will state that you get some
6–20 copies of the book. In the case of an edited book, be
sure that the contract also states that a copy will be sent to
each contributor, at no cost to you.
Costs related to excessive corrections on proofs:
There is
nothing to be negotiated here, but be very aware of this
clause. If you start rewriting on page proofs, the cost will
quickly exceed your allowance for corrections, and all
additional costs will be charged to your royalties.
Hold harmless clause:
You assume legal responsibility—
that is, you protect the publisher from liability—for any
damages caused by the book: libel, slander, and errors that
might result in patient injury or death.
There will be some royalty surprises. Some surprises will
be bad, some good. Royalties for foreign sales are generally
meager; I see no reason why this should be, but it is com
mon. Good surprises will be unexpected, although very mod
est, payments when your book is translated into Spanish or
Japanese. Another nice surprise is the small extra payment
showing up on your royalty statement, representing your
share of a fee paid by another author who has requested per
mission to use a table or figure in your book. Increasingly,
I receive a pleasant surprise, payment for online versions of
my books. I find these amounts a little hard to decipher—
it’s not like the number of hard copies sold, which I can
understand—but the payments are welcome. Royalty pay
ments for online use are an increasing percentage of what
book editors and authors receive.
As with book chapters, copyright to the book will be owned
by the publisher. Years from now, if and when the book is out
of print, you may request that the publisher return the copy-
right to you, or perhaps prepare a new edition of the book.
Working with Authors
Your contract is signed and in the file. Your outline lists all
the chapter titles. Now all you need to do is recruit a lead or
primary author for each chapter. I insist that I deal with one
lead author. That lead author may invite one or more coau-
thors, and he or she deals with the coauthors. Coauthors have
their names listed on chapters, but usually do not receive
copies of the book. The mantra for my edited books is: One
chapter, one book copy.
Author Recruitment
Selecting the best contributors and communicating clearly
with them can prevent hours of aggravation later. If given
the choice in authors, I choose reliability over brilliance
every time. Enthusiasm for the project is important, and if
an invitee begins to haggle over deadline dates and other
items, I am likely to break off the negotiation and go on to
someone else.
In extending invitations to write, I prefer to speak
directly to the potential author on the telephone, especially
if this is our first contact. The initial telephone discussion
is then followed by a letter with a written agreement (see
below). From then on, all interaction will probably be done
by e-mail.
Is it difficult to recruit authors to write chapters in books?
Not really. It is easiest to solicit contributors to established
books—new editions of the ones everyone knows, the ones
in their 6th or 10th editions. Recruiting for a new, untested
book is a little more difficult. That is why it is so important
to have a publication contract before beginning recruit
ment. My most problematic recruitment was for the books
Difficult Diagnosis
Difficult Medical Management
published by W.B. Saunders). These were new books and
they were interdisciplinary. Because of prior publications,
my name is fairly well known in my specialty. But radi
ologists and endocrinologists are very unlikely to know me.
However, I had a good concept and a signed contract with
Saunders. On my first round of invitations to prospective
authors in diverse specialties, my acceptance rate exceeded
60. Why? Because I invited authors to write on their top
ics, largely selected by seeing who was writing review arti
cles in controlled-circulation journals, and I believed that
these clinicians would want their imprint on their topics in
the new book.
Author Agreement
I have each lead author sign my own agreement form. It is
probably not a legal document, and later the publisher will
also send the more formal author agreement form that dis-
cusses copyright assignment. My agreement is useful when,
as sometimes happens, disagreements occur later. It antici-
pates some of the issues that may arise. My brief agreement
form covers six very important topics:
Chapter topic and title
Page allocation
Deadline for submission
Coauthors are acceptable, but only one complimentary
book is allocated per chapter.
An estimate of the royalty payment that authors receive.
I prefer to be realistic: “I hope that you will consider this
invitation a great honor, especially because there will not
be much cash payment for chapters.”
Full contact information, including e-mail address, mail-
ing address, and all telephone numbers, including home
number for the prospective author.
After the agreement is signed, I return a copy to the con-
tributor and keep a copy for my files. All my agreements are
with lead authors only, not with coauthors.
Author Reminders
Contributors to my edited books receive reminders about
their chapters about every 6
weeks. Some are sent by mail,
some by e-mail. They may discuss issues such as headings,
permissions, manuscript submission, provide a tally of how
many chapters have arrived to date, and so forth. Basically
they are all reminders so that my authors do not enter the
“forgot about the project entirely” category.
Development Editor
You may be assigned a development editor, who will help you
with issues regarding author communication and manuscript
management. Some development editors are very good. In
the end, however, the quality of the book will depend on your
efforts and commitment.
Compiling the Book
Months ago you contracted with a number of colleagues to
write chapters for your edited book. You have sent periodic
reminders. Now the deadline has arrived. Will the book really
come together? Will the chapters actually arrive? Will they be
as good as you hope?
Fundamentally, there will be two types of problem at man-
uscript deadline time: One is chapters that arrive and need
improvement; and the second problem is those chapters that
do not arrive at all.
Editing Chapters That Arrive
Some chapter manuscripts will be better than others. Some
will be practically perfect. After all, you have been in fre-
quent contact with all the authors, guiding them during the
writing phase. Other chapters will require editing. Here we
apply the revision principles described in Chap. 3, but with
a big
difference. Now you are editing someone else’s work,
not your own. You cannot just make substantive changes; all
modifications that might affect meaning must be negotiated
with the author. This often means sending the chapter back
and forth once or twice before you and the author agree that
it is the best that it can be.
Missing Chapters
The authors of missing chapters will offer a variety of excuses.
In Table
3.4 I listed some of the many reasons authors fail to
complete and submit their manuscripts on time (see page 88).
Of course, as volume editor, you are not really very interested
in the excuse, however inventive it may be. You need a chap-
ter manuscript.
When I plan an edited book, I create a set of three “late
manuscript” notices. The first begins, “This is a friendly
reminder that your chapter was due 2
weeks ago . . .” The
final notice states, “This is the third and final notice that
your chapter is late and is in danger of not being in the book.
I know you have worked hard on this project, but the book
must be submitted and published on time. Therefore, if your
chapter manuscript is not on my desk by (you select the
date), it will not be in the book. Packages arriving after this
date will be returned unopened.” By selecting authors care-
fully, reminding them often, and using late notices when
needed, I seldom have problems with missing chapters. But
occasionally it happens.
If a chapter actually does not arrive, you must face a
choice. One option is to create a chapter on short notice to
fill a needed gap in a book. Once while compiling a book
on health promotion, I encountered an author who fooled
me for weeks after the deadline. “The chapter is almost
done.” “You will have it next week.” Eventually I learned
that he had done nothing, and was in no hurry to do so. The
chapter was about weight control, a topic vital to a health
promotion book. To fill the gap, one of the associate editors
and I wrote a “weight control” chapter in about 10
filled the gap, and submitted an intact book manuscript.
The weight control chapter was probably not the best in the
book, but reviewers did not single it out for criticism (Taylor
RB, Ureda JR, Denham JW. Health promotion: principles
and clinical applications. Norwalk, CT: Appleton, Century
Crofts, 1982).
Missing chapters force the decision, “Is this chapter
expendable?” For the volume editor, the ideal edited books
are those such as
Difficult Diagnosis
, which present eclectic
topics. Books of this type can be, and often are, published
minus several chapters that were originally planned and
contracted, but that for some reason did not arrive. In fact,
in compiling such books, often with new authors in many
specialties, I count on attrition of about 7 of chapters and
authors. The more challenging books are those, such as a spe-
cialty textbook, that have a sequence of chapters in which no
one is expendable. In this case all chapters must be received
or created on short notice.
Publication of the Book
You have received all chapters, negotiated editing changes
with contributors, added any appendix material, and care-
fully submitted everything to the publisher. Of course, you
have kept a copy of everything, just in case.
Here are the steps that follow after the book is received by
the publisher:
An editorial assistant will check to see that
everything has been received. This person will take a hard
look at signed permission forms, and the publisher may
refuse to go further if any permission form is missing.
Assignment to a production editor:
The project will be
passed to a new person, the production editor. This person
has the important job of shepherding your manuscript
from submission to finished book.
Next the manuscript will have line-by-line
attention by a copyeditor who has basically two tasks.
One is to fix errors of grammar and syntax without chang-
ing meaning. The second is to mark up the book for the
printer, to communicate decisions about font, spacing and
similar issues.
Author review of copyediting:
In many instances, the manu-
script will be sent back to you and the contributors to
review copyediting changes. At this stage, you will prob-
ably see some questions posed by the copyeditor, asking if
this fact is true or if you really mean to say that.
Marketing questionnaire:
At about this stage, the pub-
lisher’s marketing department will probably send you a
long questionnaire to complete. 2uestions will concern
the key features of the book, the intended audience, the
best figures, and so forth. Take the time to do a good job
on this document, which will be the basis of the marketing
program for the book. Be aware that the marketing depart-
ment staff are generally salespeople, not writers, and are
very likely to use the language you submit. Thus you may
see your submitted description of the book over and over
on and on other sites.
Galley proofs:
Galley proofs are your work set in print, but
not divided into pages. You will review these proofs for
errors and return them to the publisher. In some instances,
the publisher will skip this step, especially if you have
submitted a manuscript with minimal problems and if the
copyeditor has asked few questions.
Page proofs:
Here is your book set in pages for your final
review. At this stage your job is to correct errors. That is
all. This is not the time to rewrite to improve phrases or
add new thoughts. Alterations at this stage are costly, and
will be charged to you.
Printing and binding:
This takes a while. During this time,
a cover may be created, and you should ask to review the
artwork. On several occasions I have picked up errors on
covers for my books. In the end, the publisher will create
several thousand copies of your book.
The book is released. Review copies are sent
to major journals by the publisher. Copies are sent to
leading book distributors.
After the Book Is Published
Now is the time to take a breather. You have your author’s
copy of the book in hand. It looks great. You show it to your
family and friends, who may actually be impressed. You
might even, as I have done for years, frame a copy of the book
cover to hang on the wall of your office. If you decide to do
this, request a loose copy of the cover so you don’t need to
tear up a copy of the book.
You will wait anxiously for reviews. These take a long time,
as might be expected. There is a time lag at each step of mail-
ing the review copies to the journals, assigning the book to
a reviewer, and then having the reviewer submit the review,
and finally experiencing the interval until publication of the
review. You hope for a favorable review, remembering from
Chap. 7 that a completely positive review lacks credibility.
At this time, create an errata file. As you use the book,
you will find small errors, which I hope do not involve drug
doses. Keep a file of these spelling glitches and minor fac
tual misstatements, which may be correctable with the next
Also, begin a file on ideas for the second edition of the
book, which will come up sooner than you think. Remember
that an edited book is a 2-year effort from outline to book-
store. A medical text or reference book has a useful life of
about 4
years, as new knowledge makes 5-year-old books
seem ancient. Your book has just been published. With a
4-year cycle, this means that you have 2
years to rest (and
collect ideas) before you start work on the second edition.
Finally, as volume editor, take good care of your contribu
tors. Send them a letter thanking them for participating.
If available, include a copy of the book’s reviews. Verify
that each lead author receives a copy of the book from the
Much of what I have presented above about edited books
also applies to authored books. The big difference with the
authored book, of course, is that an individual or a small
team undertakes to write it all.
Sir Winston Churchill, a prolific author who wrote alone,
once remarked: “Writing a long and substantial book is like
having a friend and companion at your side to whom you can
always turn for comfort and amusement and whose society
become more attractive as a new and widening field of
interest is lighted in the mind.” <
> I must say that, although
find revising and proofreading to be chores, I undertake
session with some relish. I want to find out what
I am going to say today. I work alone because I don’t want
to have to justify each golden phrase to a co-author who may
believe that his or her words are even better than mine.
Today not many medical reference books are written
entirely by sole authors, as Osler did. Certainly there are
no major, broad-based single-author medical books. On the
other hand, there are a number of possibilities for the aspir-
ing book author. Many of these will be enrichment medical
books. Here are some diverse examples of single-author,
focused enrichment books that have been written over the
Major RH. Disease and Destiny. New York: Appleton-
Century, 1936. Dr. Major writes of “a dominant role of
disease in the destiny of the human race.”
Marti-Ibanez F. A Prelude to Medical History. New York:
MD Publications, 1961. The author has compiled his lec-
tures on medical history given to medical students at the
New York Medical College.
Selzer R. Mortal Lessons: Notes on the Art of Surgery.
New York: Touchstone, 1974. Clinicians and laypersons
alike can read about the exact location of the soul and
other musings of this articulate surgeon.
Dirckx JH. The Language of Medicine. 2nd ed. New York:
Praeger, 1983. This physician presents a scholarly treatise
on the evolution, structure, and dynamics of the words
clinicians use.
Maynard DW. Bad News, Good News: Conversational
Order in Everyday Talk and Clinical Settings. Chicago:
University of Chicago Press, 2003. The author discusses
information, news, and communication in a variety of set-
Campo R. The Healing Art: A Doctor’s Black Bag of Poetry.
New York: Norton, 2003. The author discusses how poetry
can help comfort and heal.
Meyers MA. Happy Accidents: Serendipity in Modern
Medical Breakthroughs. New York: Arcade Publishing,
2007. I hoard curious facts, and hence this is just my sort
of book.
Loop FD. Leadership and Medicine. Gulf Breeze, Florida:
Fire Starter Publishing, 2009. Written by a surgeon who
was once the Cleveland Clinic’s chief executive office, this
is a book I wish I had written.
Taylor RB. Medical Writing: A Guide for Clinicians,
Educators and Researchers. 2nd Ed. New York: Springer-
Verlag, 2012. Okay, so I included my own book. It
authored, focused medical book.
What are the commonalities among the books listed
above? They are single-author books. They are focused, and
generally appeal to clinicians with special interests in medi-
cal history, epistemology, language, poetry, or other topics
outside the medical mainstream.
Notice also that many are not published by the big con
glomerate medical publishers. As an example above, I offer
Fire Starter Press in Gulf Beach, Florida. Such books are not
big money-makers, and proposals for meritorious projects are
often turned down by major publishers with the statement,
“This would be a great book, but we cannot project sufficient
sales to allow us to publish it.” Enrichment books are more
likely to be published by university presses, specialty societies,
or smaller publishers that can deal with modest print runs. If
you love your book and just want to see it in print, then con
tracting with a small publisher will not be a mistake.
If you decide to undertake an authored medical book,
you will follow the same path as described in the section on
edited books: Begin by clarifying your concept, and be real-
istic about potential sales. To be published, you must write
on something people will buy. Create a proposal packet, con-
taining all the elements described in Table
. Then find an
acquisitions editor, either in person or by telephone.
Do not
write the entire book
and then begin to hunt for a publisher.
Editors almost always want a role in developing a book’s
concept and style.
Contracts for authored books differ little from those for
edited books. The chief difference would be that there is no
provision for copies for contributors; all gratis copies go to
you, the author.
The contract will specify a date when the manuscript is
due. Be sure to give yourself enough time. Writing a book and
doing a good job of it takes time. I suggest allowing yourself
months from the date of the contract. If you deliver the
manuscript early, everyone will be happily surprised.
The big advantage of an authored book is that you are
not dealing with egoistic contributors, and you do not need
to negotiate changes with others. One disadvantage is that
you are on your own, and can go off track, beginning with a
good idea and then changing direction or style. While writing
your book, I urge that you show consecutive chapters to your
trusted colleague reviewer, asking for critical feedback.
In the end, writing a book can be exhilarating. One col-
league who wrote a book during a time of major administra-
tive challenges has said, “I wrote the book on evenings and
weekends, but at the time it was the only thing keeping me
sane.” As I write this book, I look forward to envisioning
what will come next in each chapter; then I write it. This is
the fun of writing, especially book writing, and I hope that all
readers experience the pleasure at least once in their lives.
Professional Books and Trade Books
Professional/textbooks and trade books live in two different
worlds. At a large book publisher’s offices, there may be
both text and trade divisions, but there seems to be a firewall
between them.
Trade books are what general-interest (read: nonmedical)
people read. Tom Clancy and J.K. Rowling write trade books.
Dr. Spock’s
Baby and Child Care
is a trade book. My first
books, in the 1970s, were trade books, until a Harper and
Row Publishers trade editor whom I never met did a remark-
able thing. I had submitted a manuscript (Yes, I had written
the book already, which I would not do today) about a book
on symptoms and what diseases they could represent. If an
individual had heartburn, might it be gastritis, peptic ulcer
disease, or stomach cancer? The trade book editor decided
that the book was too technical for a lay audience. Instead of
returning the manuscript to me with a form-letter rejection,
he sent the book to medical editor Charles Visokay, M.D.
Chuck read the manuscript, offered a contract, and Harper
and Row Medical Publishers published the book. I have been
doing professional medical books ever since that time.
There are tens of thousands of trade books published every
year. There are very few authors, like Clancy and Rowling,
who make vast sums from their royalties. Most trade authors
receive, at best, modest royalties for their efforts. For that
matter, neither do medical book authors earn much from
their books. For clinicians, the rewards come in professional
recognition, career advancement, and perhaps some patient
I believe that finding a medical publisher is much easier
than finding a trade publisher. It seems that everyone in
America is writing a book and seeking a publisher. Most trade
publishers protect their sanity by considering submissions
only through recognized literary agents. Agents, in turn, are
besieged by author wannabes, and turn away almost all pre-
viously unpublished authors.
In medical publishing, there are fewer publishing compa-
nies than in the past. The great medical publishing houses are
going out of business or consolidating. Lippincott, Williams
and Wilkins Medical Publishers represent only one such
merger. But there are also fewer prospective medical authors
competing for their contracts; aspiring academicians are
more likely devoting their energies to research studies, the
key to promotion and tenure. And to my knowledge, there
are, as yet, no literary agents in medical publishing.
I much prefer the professional medical publishing milieu
to the trade publishing process.
Do Not Underestimate the Effort
Editing or writing a book is a big effort. Yes, as I mentioned
earlier, the intense activity comes in cycles. Nevertheless,
preparing any type of book is committing your spare time
to the effort. Do not undertake the job lightly. To quote Sir
Winston again: “Writing a book is an adventure. To begin
with it is a toy, an amusement; then it becomes a mistress,
and then a master and then a tyrant.” <
> If you are planning
to commit to a medical book, you must want the project a
lot! I have seen clinicians come to hate the books they were
working on. A few have given up midway through the project.
Giving up on an authored book is bad enough. Abandoning
an edited book after colleagues have worked on chapters at
your request is devastating.
Respect Serendipity and Chance
Howard Conn, editor of
Conn’s Current Therapy
, was an
small-town Western Pennsylvania general practitioner with
an idea: an edited book in which experts told how they
treated various diseases. He trudged from one publisher to
another until a young editor at Saunders looked past Conn’s
lack of editorial experience and recognized the merits of the
proposal. This editor championed the idea with his company;
Conn’s Current Therapy
, first published in 1949, sold more
than 1
million copies by the time of Conn’s death in 1982 and
is still published annually <
Here is another story of serendipity: Leon Speroff was lead
editor of
Clinical Gynecologic Endocrinology and Infertility
when it was first published in 1973. Speroff was recently
interviewed by Marc A. Fritz, who described the book as “the
most widely read subspecialty book I the world.” In this inter-
view, Speroff tells how he came to be lead editor: “In 1972,
Bob Glass approached me in the hallway at Yale. He and Nate
Kase were writing a textbook on endocrinology, and Bob
asked me to join them, saying that they met every Thursday
evening to work on it. During our first meeting, I asked what
they had done so far—and the answer was nothing! Being a
compulsive organizer, I took the project over, which is how
my name got to be listed first on the textbook.” <
The Market Rules
You and your acquisitions editor must pay close attention to
the question, Who will buy this book? In today’s tight eco-
nomic times, publishers cannot afford to ignore the market.
Long ago, when I was still in private practice, I wrote a short
book entitled
Why Doctors Give Children Shots
. The book
told the stories of communicable diseases against which we
immunize children: smallpox vaccination (I said that this
was a long time ago), tetanus, diphtheria, polio, and so forth.
collected some wonderful historic illustrations. It was, in
my judgment, a well-written, vividly illustrated, innovative
book. There was only one small problem: Who would buy
the book? The kids getting the shots were too young to read
a book about medical history, however clearly written. The
parents weren’t especially interested in the topic, and the
book was too consumer-oriented for clinicians. I made many
unsuccessful efforts to find a publisher. Today the manuscript
is in a cardboard box in the attic. I know how to find it, in
case anyone wants to publish it.
Book Publishing and Personal Relationships
If you are interested in writing or editing medical books,
I urge you to remember what I am about to write. This may
be the most useful sentence in the entire chapter:
book publishing is about personal relationships.
As a book
editor, you work closely with your contributors. I have edited
six editions of the large reference book
Family Medicine:
Principles and Practice
(New York: Springer Publishers) over
years. Many of my authors contributed chapters over
multiple editions, and one loyal contributor has been in all
six editions.
During the past three decades, I have worked with more
than a dozen medical editors employed by five medical
publishing houses. Medical editors usually don’t fade away;
they move from one medical publishing job to another.
Relationships continue, and are highly valuable when you
need access to an editor to evaluate a project.
Nurture your relationships with contributors and with
your medical editors. Next to the exhilaration of actually
writing, these friendships can be the best part of working on
medical books.
Osler W. Dr. Osler to students. Oklahoma Med J. 1900;8:53.
Taylor RB. White coat tales: medicine’s heroes, heritage and mis-
adventures. New York: Springer; 2008, pages 191–192.
LaVigne P. Seeking publication. In: Taylor RB, Munning KA, eds.
Written communication in family medicine. New York: Springer-
Verlag; 1984:57.
Scherger JE, Taylor RB. Writing a medical article. In: Taylor RB,
Munning KA, eds. Written communication in family medicine.
New York: Springer-Verlag; 1984:33–42.
Churchill W. 2uoted in: Humes JC. The wit and wisdom of
Winston Churchill. New York: Harper Perennial; 1995.
Dusseau JL. An informal history of W. B. Saunders Company:
On the occasion of its hundredth anniversary. Philadelphia:
Saunders; 1988.
Speroff L, Fritz MA. A way with words: Leon Speroff, MD
describes the growth and evolution of reproductive endocrinology.
Sexuality, Reproduction & Menopause. 2008;6(2):6–7.
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_9,
© Springer Science+Business Media, LLC 2011
How to Write a Research Protocol
He who fails to plan, plans to fail.
No football coach would ever let his team take the field
without a “game plan.” The research protocol is the game plan
for your project, your vision of what you will accomplish when
you “take the field” with your research team. The document
describes the reasoning behind and the process of the research
project that you have in mind <
>. It tells what you hope to
accomplish and how you will get it done. It also imposes a dis
cipline, requiring you and your team to anticipate every step
of the project before the first subject is recruited. This body of
the research protocol more-or-less follows the IMRAD model,
an acronym for the words Introduction, Methods, Results, and
Discussion. We will return to this model in Chap. 11, which
discusses how to write a report of a research study.
For semantic clarity, I want to distinguish between a
research proposal and a research protocol. A research pro-
posal, which should be brief, describes a bright idea for a
project—with emphasis on the research question you hope to
answer. It tells how you might attempt to answer the question,
how you will obtain the data you need, a focused literature
search and perhaps the results of a pilot project. The research
proposal will help you crystallize your thoughts, and will be a
useful document when attempting to recruit co-investigators.
A research protocol is the next stage, representing a detailed
road map showing how you will successfully complete your
Many, perhaps most, research proposals and protocols will
be written as an early step in responding to a Request for
Proposal (RFP). Occasionally a brilliant free-range research
idea finds needed support (that is, dollars), but eventually
the serious investigator learns that one’s research livelihood
is dependent on successful responses to RFPs, whether from
government agencies such as the National Institutes of Health
(NIH) or private foundations. Because of this, it is vital that
the person writing a research protocol carefully read the RFP
instructions. Then reread them several times. Failure to follow
the instructions to the letter can result in a poison pill, an item
at odds with the instructions that permits the review panel to
dismiss consideration of your project and go on to the next.
What might be examples? A high risk item would be a section
that describes a generous stipend for teaching medical students
or for the services of a paid consultant in instances when these
expenditures are specifically prohibited in the RFP. I will return
to this issue in the next chapter on writing grant proposals.
I like to think of a research protocol as the framework for
the paper that will report the study’s findings. To this end,
sometimes a good early exercise is to prepare the format for
tables that will go in the final report to be submitted for publi-
cation. Let us, for example, think about a study looking at the
safety of giving live influenza virus vaccine to children with
asthma. In the final report you may have a table describing
subjects by age, gender, ethnicity, and other characteristics.
You might then have a table of adverse outcomes—asthma
attacks, bronchitis, or pneumonia in patients who did and
did not receive the vaccine. Then you may have another table
showing the incidence of influenza, with and without compli-
cations, in both the study group who received the vaccine and
those who did not. In this way, the tables are already concep-
tualized; they await only the data from the study.
The research protocol will almost certainly be submitted to
a “human subjects committee,” called an Institutional Review
Board (IRB) at many universities, and probably also to the
funding agency (aka grantor), if grant support is sought. Note
that some IRBs have a research protocol template that you will
be required to follow. You should spend a lot of time and energy
developing the protocol, not only because it is likely to be a key
in securing IRB approval and grant funding, but also because
this is the plan you will follow in the months to come.
The actual research protocol may not be submitted to a
potential funding agency. That document will be a Grant
Proposal, described in the next chapter. For you, the greatest
value of the research protocol will be in clarifying your think-
ing before you embark on your research journey.
Two steps precede writing a research protocol: The first is
identifying a researchable question, and the second is assem
bling your research team. You will note some similarities to
the writing team, described in Chap. 5; a research team dif
fers from a writing team, however, in that some specialized
skills are needed to plan the study. Based on the assumption
that you, as the person with the insightful research ques
tion will be the principal investigator (PI), I suggest that
you consider including one or more of the following team
A clinical epidemiologist. This team member will guide
planning of the study design, assuring the team uses the
best method to answer the research question.
A biostatistician. Although some will differ, I think that this
individual should be included from the very start. As an
example, the statistician can determine the sample sizes
needed and the statistical tests that will be best for the
project. Also, if you wish to make a biostatistician apoplec-
tic, dump a pile of data on his or her desk late in a study
and ask if there is a p-value somewhere.
A senior investigator with more experience than you. This
person will serve as respected arbitrator when and if dif-
ferences arise on the team, and can be a big help when
writing results of the study.
An aspiring investigator, someone with less experience
than you. This individual will bring energy, will learn from
the experience, and just may find some way to pay you
back some day.
A project manager. This vital team member will plan
and manage budgets, time commitments of various
investigators, and all the records that will eventually be
submitted to the funding agency.
There is no single, universally-accepted format for a research
protocol. What is presented in this chapter is expansive.
have listed every topic I can bring to mind, adapted from
the World Health Organization Recommended Format for a
Research Protocol <
lists the elements of a research protocol, although
not all research protocols will contain every item on this
list. Most research protocols will have fewer topics, or will
combine some of the items described. For example, separate
discussions of safety considerations, follow-up, and quality
Format for a research protocol
Project title
Primary investigator (P
) and co-investigators
Project summary:
short overview to orient the reader
ackground and rationale:
nalogous to the
ntroduction in a research report
tudy goals and objectives: What do you hope to accomplish?
tudy design: What type of study is proposed?
tudy description: Who will be the subjects and what you will do to them?
Quality assurance: How will you assure that what is done reflects high standards?
xpected outcomes: What do you think might be found, and why might it matter?
Dissemination of results: Who will be told about your findings?
Problems that may occur: What are potential difficulties and possible solutions?
Project management:
n this project, who is in charge of what?
assurance may not be relevant to your study. On the other
hand, you just might list every topic in the order
here and use “NA” to identify those not pertinent to your
study. The order of topics presented can be different in your
protocol, but I caution against too much creativity. The for-
mat presented here is, more or less, what IRB reviewers and
grant funding agencies expect to see. Table
can serve as
a handy way to check your protocol for completion before it
leaves your desk. Some comments on the various topics pre-
sented are found in the text that follows.
In presenting some tips about writing a research proto
col I propose that we—you and I—use a hypothetical study,
addressing the following question: Are patients who have
gastric surgery for weight control at risk of developing serum
copper deficiency? This seems a pertinent question, consid
ering the frequency with which such procedures are done
today. My choice of a theoretical research project is not a
totally random selection. In fact, Prodan et
al. did just this
sort of study, with results published in 2009 in the
Journal of Medical Science
>. I chose the question of the
risk of copper deficiency developing following gastric sur
gery because it presents a fairly straightforward approach
to a potentially important issue, and you will see that our
hypothetical study mirrors the Prodan et
al. study in various
Project Title
After deciding on a research topic/question/hypothesis, most
investigators turn their attention to the project title. This is
not a trivial consideration given that, when the final report
is eventually published, most readers will scan the titles in
the journal table of contents, and use this first impression to
decide whether or not to read the abstract, or even the entire
For our study, a reasonable draft title might be: “The
Incidence of Low Serum Copper Levels after Gastric Surgery.”
Or alternatively: “Hypocupremia after Gastric Surgery.” The
former title tells what I wish to study and is “outcome-neutral.”
The latter title presumes that the outcome will be lower copper
levels in gastric surgery patients and, while this may be the title
of the final paper, would be presumptive as a title of a research
protocol unless a question mark is added: “Hypocupremia
after Gastric Surgery?” To get started I
prefer the first title
described. For the record, Prodan et
al. titled their final, pub
lished report “Copper deficiency after gastric surgery: a reason
for caution.”
Acronym-named randomized trials are quite fashionable
today. Clinical investigators, whimsical imps that they are,
are fond of dreaming up colorful—if sometimes tortured—
acronyms, perhaps over a bottle of wine. Here is an exam
ple: the Carvedilol Prospective Randomized Cumulative
Survival (COPERNICUS) Study. (Packer M et
al. Circulation.
2002;106:2194). Stanbrook et
al. reviewed acronym-named
clinical research trials and what happened to the reports of
these studies <
>. They examined 173 consecutive randomized
trials reviewed by the Cochrane Heart Group. Of these 173
studies, 59 (34) had acronymic titles and exhibited the fol
lowing characteristics:
Of these 59 studies, 61 were published in just three jour-
nals: The
New England Journal of Medicine
The Lancet
. (Recall that these were heart-disease-
related studies).
Methodologic quality scores were higher than in studies
with non-acronymic titles.
These studies enrolled five times as many patients, but had
shorter follow-up periods.
They were no more likely than non-acronymic-titled stud-
ies to report positive results.
They were four times as likely to have pharmaceutical
financial support and eight times as likely to have industry-
employed authors.
I considered creating an acronym for our modest (and
hypothetical) study of serum copper levels in gastric surgery
patients. Thus the first title considered, “The Incidence of
Low Serum Copper Levels after Gastric Surgery,” would
yield the acronym ILSCLAGS. Not compelling. The second
choice title, “Hypocupremia after Gastric Surgery,” results
in HAGS. Even worse. I decided against the use of an
acronymic title.
When crafting a title, it is helpful to append a descrip-
tor telling the method used, such as randomized controlled
trial, case-control, cross-sectional study, or meta-analysis.
Our study compares two groups, those who had weight-loss
gastric surgery and those who did not. Thus our working title
will be “The Incidence of Low Serum Copper Levels after
Gastric Surgery: A Case Control Study.”
Primary Investigator (PI) and Co-investigators
Clearly identify the PI and all co-investigators. Be sure to
include—especially for the PI—titles, mailing addresses, tel-
ephone numbers, fax numbers, and e-mail addresses. Contact
information is important, because someone may want to get
in touch with you about collaboration in this study or the
next, or may even want to send you grant support.
Project Summary
Here is where you should explicitly state your research
question or hypothesis. Be sure that anyone reading this
paragraph has a clear idea of what you hope to learn. A good
research question is short, focused, and unequivocal. Most
research questions describe something that can be answered
with quantitative data, although there is an increasingly
number of reports of qualitative research, related to topics
that defy quantification.
A useful model for stating a research question is the PICO
model <
>. Here is how it works and how it might apply to our
study of serum copper levels:
Population or patients: Patients who had weight-loss
gastric surgery
Indicator or intervention: Serum copper levels
Comparator or control: Patients who did not have gas-
tric surgery
Outcome: Differences in serum copper levels
Careful wordsmithing is vital here. Bordage and
Dawson describe the research question as the “keystone
of the entire enterprise,” adding that, “Everything hinges
on the quality of the research question, hence its crucial
importance <
Many RFPs specify the maximum number of pages per-
mitted, and even if length is not prescribed, keep the Project
Summary short—250 words or less, and not more than one
page in length. Start by using the study title, and follow by
briefly telling the rationale and objectives for the project, the
research question, the methods and subjects, the duration
of the study and the anticipated outcome. Use language that
would make sense to a reader who is not fully familiar with
your area of inquiry. This summary page, arguably the most
important page of the protocol, must give a crisp and memo-
rable overview, and it must stand on its own, without sending
the reader to search items, such as abbreviations, found later
in the document.
Background and Rationale
This section, not unlike the Introduction section in a research
report (See Chap. 11), tells why the proposed research is
pertinent in the context of current knowledge. This section
may cover:
The importance of the topic in the context of current
An overview of your approach to the question
Any results you have already obtained that indicate that
the question can be answered by your approach
How your study will advance medical practice and the
health of humankind.
Our serum copper level after gastric surgery study is
pertinent to medical knowledge and health care because
undetected and uncorrected hypocupremia can cause health
problems including anemia, neutropenia, optic neuropathy,
myopathy, and myelopathy with a spastic gait <
You may list current references here or, alternatively, in a
separate section (below).
Study Goals and Objectives
The WHO Recommended Format for a Research Proposal
recommends describing “broad statements of what the pro
posal hopes to accomplish,” which should logically emerge
from the research question(s) <
>. Singh et
al. advise that
these objectives should be Specific, Measurable, Achievable,
Relevant and Time based, offering the catchy acronym
SMART objectives <
>. The objective of our example study
might be: To determine if patients who have received weight
loss gastric surgery are more likely later to have lower
serum copper levels than persons who have not had gastric
Study Design
Describe your study design—randomized trial, case-control,
cohort study, cross-sectional study or other approach—and
why the study design proposed is the best way to answer
the research question. For my study of serum copper levels
in post-gastric-surgery patients, I chose a case control study
model. This and various other study design models are
described in Appendix
Study Description
Here I will begin with a few linguistic tips: First of all, I rec
ommend that you use active voice and future tense. Active
voice (“We will draw blood samples.” vs. “Blood samples will
be drawn.”) is simply stronger prose. And you should use the
future tense because you are describing something to be done,
not something being done now or accomplished in the past.
Secondly, describe persons in the study as subjects, not
patients. You are not typically in a traditional physician-
patient relationship with these individuals.
This section of the protocol often begins by describing
the subjects to be in the study and control groups. What will
be your sample size? Who will be included and who will be
excluded and why (Think about the possibility of exclusion
bias)? How did you decide on the number of subjects in each
group? A too-small sample size may not yield a statistically
satisfying answer to your research question, and your study
will be criticized as “under-powered.”
How will subjects be found? Will you use a newspaper
advertisement, search existing hospital records, or some
other method?
Then once you have your subjects, what will you do to
them? Describe each step of the study, beginning with enroll-
ment. If subjects are to be randomized, tell the method to be
used. Continue to describe what will happen, step by step, all
the way through the last follow-up event.
Name the specific statistical tests that will be used to
answer your research question(s) or test your hypotheses.
In the case of interventional studies, it may be useful here
to identify dependent and independent variables. There are
a number of statistical tests that can be used, according to
the design of your study. In their published study of copper
deficiency after gastric surgery, Prodan et
al. used independ-
ent t tests and Fisher exact tests for comparison of continuous
and categorical variables, respectively <
>. In my opinion, the
diversity and complexity of the statistical tests that might be
used just serve to emphasize the importance of a research
team member with statistical expertise. And here is a sober-
ing thought that will be pertinent when you write the final
report of your study: According to Bordage, the most com-
mon reason manuscripts are rejected by peer-reviewed scien-
tific journals is incomplete or inappropriate statistics <
Here is where you should present a time-line, which may
help you identify possible bottlenecks, such as the possibility
that you may not find as many qualifying subjects as antici-
pated. The timeline also may be useful later when writing a
grant application. Table
presents a sample timetable that
would be appropriate for my gastric surgery/serum copper
level study. Figure
presents the same information in tabu-
lar form.
Safety Considerations
This section is about risks to the subjects, especially pertinent
when patients will take drugs or undergo procedures. Tell the
risks, including possible drug side effects, allergic reactions,
ample timeline for a not-very-complicated 18-month project
Research Question:
Are patients who have bariatric gastric surgery at risk of developing serum copper
Year one:
onths 1–3
dentify potential subjects who have had a history of partial gastric resection
dentify potential control population with no history of partial gastric resection
ssure that controls match study subjects relative to age, gender, and concur-
rent illnesses
onths 4–6
Recruit study and control subjects
onths 7–9
ollect serum samples from study and control subjects
onths 10–12

control subjects
and contro
control subjects
Plan report of study
Submit final report for publication
ample timeline presented as a figure. Research question:
Are patients
who have bariatric gastric surgery at risk of developing serum copper deficiency?
or procedural complications. Then describe what you will do
to reduce risk and what will happen if adverse events occur.
Rid et
al. have proposed a framework for assessing the
risks associated with a research project <
>. They call this
method the Systematic Evaluation of Research Risks (SERR),
and base the method on four steps:
Identifying potential harms associated with the project
Categorizing the magnitude of the potential harms
Quantifying or estimating the likelihood of each potential
harm occurring
Comparing the likelihood of each potential intervention-
related harm with what might occur with a comparable
For my study involving determining serum copper levels in
study and control group subjects, I believe that the chief risks
are those associated with obtaining blood samples.
Here you should tell what, if anything, will happen to subjects
after the research study is completed. In my study, patients
found to have significant hypocupremia will be referred to their
personal physicians for further evaluation and management.
Data Management
As things move along, you will accumulate data—informa-
tion about subjects, consent forms, laboratory reports, tables
of results, and so forth. How will these data be coded and
entered into computer files? How will you assure that data
are both accurate and complete? Especially when your study
involves human subjects, it is a good idea to tell how you will
maintain security of these data. Identify who will do these
tasks, ideally the project manager on your team.
2uality Assurance
Especially important when human subjects are involved, you
should tell how you will pay attention to the fundamentals of
good clinical practice. How will you determine best practice
in the conduct of the study? Will there be an independent
oversight committee, described by the WHO report as a Data
& Safety Monitoring Board? <
Expected Outcomes
The ideal clinical study will have an impact on some segment
of the population. In the case of my small study on the risks
of copper deficiency following gastric surgery, the results will
either be helpful in alerting physicians to a potential adverse
outcome of increasingly common surgery, or serve to be
cautionary to patients considering gastric surgery for weight
control or for other reasons.
Dissemination of Results
Who will be told of your findings? Are you targeting a specific
journal or a clinical specialty as the eventual reader of your
study report? Do you plan to present to a specific specialty
group or at a future scientific meeting? Will study partici-
pants be informed of the outcome of the study? Under this
heading, the WHO research protocol advises discussing “who
will take the lead in publication and who will be acknowl-
edged in publications, etc.” <
In the case of our hypothetical study of the possible occur-
rence of low serum copper levels following gastric surgery,
I think that the information would be especially pertinent to
certain groups of physicians: surgeons, notably bariatric sur-
geons, and also generalists, including general internists and
family physicians, who will see these post-operative patients
in their continuity practices. Whether to aim for publication
in a surgery or a generalist specialty journal will be a deci-
sion for the research team to ponder.
Problems That May Occur
Research trials are not exempt from Murphy’s Law: If some-
thing can go wrong, it will. Use your imagination to think of
possible problems, and what you would do to remedy them.
Here is an example: In our hypothetical study, a potential
problem might discovering that my surgery subjects turn out
to have a much higher incidence of a concurrent disease,
such as inflammatory bowel disease, than my control sub-
jects. What would I do about this?
Project Management
In this section, tell the specific role and duties of each
research team member, including the all-important project
manager. Reaching consensus on these issues can prove vital
to success, and misunderstandings about the assignment of
responsibilities can spell trouble. For these reasons alone,
this section of the protocol should be the subject of informed
agreement by all on the team.
Ethical Considerations
Ethical issues are among the chief concerns of the IRB.
The IRB’s scope of interest includes hospital chart reviews,
questionnaire studies, and anything that involves human
bodies, tissues or fluids, or information. They will ponder
any discomfort or even pain associated with a study inter
vention. For example, in my study, there will be blood sam
ples drawn. Does the potential outcome of the study justify
the admittedly small discomfort that will be experienced by
In any study involving drugs, there is the risk of adverse
reactions. Are there any hazards to subjects that might not
be readily apparent, such as the long-term risk involved in
studies involving radiographic imaging? Does the potential
benefit of the study justify such risks?
Will participants be paid to participate in the study? If so, is
the amount being offered “correct,” that is, enough to compen
sate for their time without being such a large sum that persons
step forward as volunteers who really should not do so?
Do subjects have the right to withdraw from the study with
out physical risk and without the threat of being punished—
that is, of having subsequent care withdrawn?
All of these issues, and perhaps more, should be discussed
in a carefully worded Informed Consent document, which is
appended to the Research Protocol.
This will be a list of published reports that serve as back-
ground to your proposal.
For my hypothetical study, I would certainly list the 2009
Prodan et
al. report and others.
In this section, describe the funding that will be needed to
complete your project, including justification of how every
dollar will be spent. If there is an RFP involved, you need
to read the RFP carefully to see what expenditures are
allowed and what are not. Can you, for example, budget
administrative assistance, student research workers, or
travel to present findings at a scientific meeting? Although
the budget section of your Research Protocol may be of only
passing interest to the IRB, it will be a key part of your even-
tual Grant Proposal, described in the following chapter.
Be sure you budget figures are realistic and accurate. An
underpowered budget—not nearly enough money to do the
job—is as bad as an underpowered study. Budget preparation
is not time for guesswork.
Other Support
Here is where you should reveal any funding—such as a
pharmaceutical company grant—that might not otherwise be
apparent in your protocol.
Collaborations Planned
Is your project being done in concert with investigators out-
side your research team, perhaps even in other institutions?
If so, you will eventually need letters of agreement from these
Links to Other Projects
Is the proposed project somehow related to some other
research project? Because academicians tend to develop
“career topics,” such links are not uncommon <
>. Statements
here may document compelling evidence of your leadership
in this topic. Or they may raise suspicion that this is a “chain
letter” project (See Chap. 12).
Curriculum Vitae of Investigators
Append the curriculum vitae of each member of the research
team. Follow any RFP instructions as to format and number
of pages desired.
Other Research Activity of Investigators
The principal investigator and co-investigators should briefly
describe their current research projects, the amount of time
devoted to each, how long each project will last, and the
sources of funding.
Clinical Trial Registration
International Committee of Medical Journal Editors (ICMJE)
member journals now require, as a consideration for pub-
lication, registration of the study in a public trials registry
before the enrollment of the first patient <
>. This rule was
implemented to counter the practice of selective reporting
of trials—if the drug had desired result, the results were
published, but if the drug tested seemed no better than pla-
cebo, the study data languished in someone’s desk drawer.
Furthermore, the US Food and Drug Administration requires
clinical trial registration 21
days after the first patient is
enrolled. I recommend that your Research Protocol mention
the status of your clinical trial registration. Full information
is available at:
This section should contain a copy of the informed consent
form. You may also list here the literature reviewed, if not
presented above, as well as other items that do not logically
fit in the outline above.
Fundamentally, a good research protocol provides enough
detail that could allow another investigator to do the study
and arrive at comparable conclusions <
The best research protocols have some characteristics in
Early overview, described above as the “Project Summary:”
Begin with a brief synopsis of the project that helps orient
the reader to what is coming later.
Logical progression of ideas: Use the outline described
here to lead the reader, point by point, to a clear under-
standing of what you plan to do and how you will do it.
Carefully constructed headings: The research protocol is
really an essay. Use headings to announce how ideas are
Clear prose: Remember that the person reading your
protocol, such as a member of your Institutional Review
Board, may not be familiar with your field at all.
Completeness: Anticipate the questions a reader might
have, and try to provide answers.
This section describes mistakes we make in research plan-
ning and protocol writing (or perhaps in writing, in general).
Some of the common ones are:
Inadequate literature review, conducting a quick survey
when a systematic review is needed.
Vague research question: Often this means the question is
too broad or unanswerable, and needs to be focused.
Flawed research design: Do not select a study type that
will not answer the question. Much time and effort will be
wasted. Most research failures can be traced to the early
planning stages.
A project too ambitious for your research skills or for the
institutional resources available to your team.
Too many research questions: I think a study can answer
up to three related research questions. More than that
suggests a lack of focus. I once encountered data from a
study that had listed 57 research questions. Although the
investigators succeeded in collecting some data, when
ultimately preparing a paper, they struggled to find just a
few questions whose answers had statistical significance.
(“Isn’t there a meaningful p-value anywhere is the mess?”)
They never succeeded in writing a publishable paper.
Inadequate number of subjects to answer the question: Do
not count on the IRB to alert you to this problem, which
poses no risk to subjects, even though it wastes the time of
willing volunteers.
Inappropriate plan for statistical analysis: The statistician
is planning to use the wrong tests to look at the data.
Poorly written consent form: Your IRB will send the con-
sent form back for rewriting if not comprehensive and
legally sound.
A budget inadequate for the project, or even too high.
Failure to reach consensus on all aspects of the protocol.
The discipline of preparing—and struggling to group
agreement about—a research plan will prove invaluable if
there are later disagreements within the research team.
Underestimating the time needed to complete all the
steps—including peer review and institutional review—
needed to get the grant out the door on time.
After the Research Protocol is written (and re-written a
few times), what then? As with all writing products, I rec
ommend that you next have it reviewed by your “critical-
reader” colleague, described in Chap. 3. This person will
help you identify problems with organization, syntax and
grammar that may detract from the merits of your idea. If
the “critical-reader” colleague is not research-savvy, espe
cially in your area of investigation, I suggest that you next
have the document reviewed by an experienced investiga
tor. (Following my own advice, I am having the manuscript
for this chapter reviewed by our department’s most skilled
Then your research protocol is ready for consideration—
and, we hope, prompt approval—by the Human Subjects
Committee. With that approval in hand, you are ready to
work on your Application for Grant Funding.
O’Brien K, Wright J. How to write a protocol. J Orthodontics.
World Health Organization Recommended Format for
a Research Protocol. Available at:
[email protected]/[email protected]/en/index.html
Prodan CI, Bottomley SS, Vincent SS, et
al. Copper deficiency
after gastric surgery: a reason for caution. Am J Med Sci.
Stanbrook MB, Austin PC, Redelmeier DA. Acronym-named
randomized trials in medicine—the ART in medicine. N Engl J
Med. 2006;355(1):101–102.
Glasziou P, Del Mar C, Salisbury J. Evidence-based medicine
workbook. London: BMJ Books; 2003, Page 40.
Bordage G, Dawson B. Experimental study design and
grant writing in eight steps and 28 questions. Med Educ.
Singh S, Suganthi P, Ahmed J, Chadha VK. Formulation of
health research protocol—a step by step description. National
Tuberculosis Institute (India) Bulletin. 2005;41(1&2):5–10.
Bordage G. Reasons reviewers reject and accept manuscripts:
the strengths and weaknesses in medical education reports.
Acad Med. 2001;76(9):889–896.
Rid A, Emanuel EJ, Wendler D. Evaluating the risks of clinical
research. JAMA. 2010;304(13):1472–1479.
Taylor RB. Academic medicine: a guide for clinicians. New
York: Springer, 2006;136.
DeAngelis CD, Drazen JM, Frizelle FA, et
al. Clinical trial
registration: a statement from the International Committee of
Medical Journal Editors. JAMA. 2004;292(11):1363–1364.
Kendall MJ, Hawkins C. Planning and protocol writing. In:
Hawkins C, Sorgi M, eds. Research: How to plan, speak and
write about. New York: Springer, 1985;65.
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_10,
© Springer Science+Business Media, LLC 2011
How to Write a Grant Proposal
The relatively young woman stood up from her computer
and replied while sipping her coffee: “It is hard work and it
requires a lot of dedication. I know it’s going to be many hours
before I finish this grant and I know the chances of getting
funded aren’t in my favor. But, it’s a labor of love because I’m
discovering a cure for cancer.”
From an article by American physician and educator Chip
Souba <
The engine of America’s clinical investigation enterprise is
fueled by grants. In fact, so is some of medical education, by
virtue of government and foundation grant funding for educa
tional programs. One of the big surprises I encountered upon
leaving rural practice and entering academic medicine in 1978
was the discovery that there was no pool of money to fund
my salary. Is short, I was expected to bring in almost all my
support. Although there were other sources, such as private
philanthropy and endowments, for most of us in the United
States, funding the salary that supports our teaching efforts
meant seeing patients or writing successful grant proposals.
Things have not changed over the past 3+ decades. An aca
demic appointment is not a meal ticket; it is a hunting license.
Fortunately, there is a lot of money available: The U.
National Institutes of Health (NIH) invests more than
28 billion annually in medical research, largely awarded
through approximately 50,000 competitive grants to more
than 325,000 investigators in some 3,000 institutions in the
United States and around the world <
>. In addition, tons of
private money, donated to nonprofit organizations as tax-
deductible gifts, is available as grant funding. While all this
funding could easily cover your salary and mine for many
years, getting access to the money requires knowledge, effort
and perseverance.
Grant getting in the USA uses a “tournament” model that
involves competition, recruitment of star players, and both
winners and losers <
>. In regard to recruitment, would you
believe that if your academic department has a nationally
recognized, highly productive grant-getter, that other institu-
tions are constantly wooing this person? These “rainmakers”
are the all-stars of the grantsmanship competition. As to
winners and losers, failing to acquire grant funding can be a
major problem for a faculty member, one that could lead to
job loss, not only for the investigator, but for everyone on his
or her research team.
The purpose of writing a grant proposal/application is to
get an award—money that will support your project over a
few years. At this point it may be instructive to be clear about
the words we use. You and I write
grant proposals
; in doing
so we hope to get
grant awards
. Thus, saying that I am hard at
work “writing a grant” is semantically incorrect, even though
this is the common parlance we use today.
There are actually two types of awards. We most com-
monly think of the
, often funding basic science or clini-
cal research. Classically, the research idea is generated by the
applicant, and the grant recipient has reasonable flexibility
in using the money to complete the project. On the other
hand, the
award, often used for applied research, is
an agreement to do something the funding agency—such as
a state agency or pharmaceutical firm--wants done. A state
agency, for example, may award a contract to survey general-
ist physicians regarding their ability and willingness to pro-
vide mental health services in the face of reduced availability
of psychiatric referrals for Medicaid patients. In the case of
a contract, expect greater control by the funding agency and
strict accountability for the money spent.
In some ways, a grant application will resemble a research
protocol, described in the previous chapter, but there are
important differences. Fundamentally, the research protocol
is a document created for you and your team, even though it
may be shared with the Institutional Review Board and per-
haps others. To reprise the sports metaphor, it is your “game
plan,” a series of steps to which you all agree. In contrast, the
grant application is written for an outside audience—specif-
ically for the panel of experts who will review your request
for funding. As I have written grants, I have occasionally
reflected that the dozens of pages being written will actually
be read completely by only a handful of people—perhaps only
two—who will then describe the proposal, as they understand
it, to the review committee. I’ll return to this below.
To begin at ground level, there are two major funding
sources: government and private. Government sources may
be federal, state, or local. Private grant and contract funding
sources include foundations, corporations, or professional
Government Funding Sources
State and local grant funding agencies are often politically
grounded and funding may be awarded as contracts that
advance favored agendas such as care of the homeless, rather
than based on the likelihood of providing new knowledge. If
you or your department has a contact in state, county or city
government, you may have a chance of receiving state/local
funding for a project. An example of such a project might be
a needed statewide survey of the impact of high professional
liability rates on procedure-oriented specialists in regard
to their willingness to accept indigent patients for care. Or
county leaders might need a survey of physicians as they
assess the need for more or less hospital beds in the future.
If offered such a contract, you must consider your need for
salary support as well as the direction this might take your
personal research agenda.
There are a number of granting agencies in the federal
government, offering opportunities of various types. For
example, there are primary care training grants avail
able through the Bureau of Health Professions (BHP) of the
Health Resources and Services Administration (HRSA). For
the academic clinician and researcher, the important funding
source is the NIH, whose mission is “to seek fundamental
knowledge about the nature and behavior of living systems
and the application of that knowledge to enhance health,
lengthen life, and reduce the burdens of illness and disabil-
ity.” <
> I urge you to learn about NIH grants and funding
early in your career. A good beginning web site is The NIH
Guide to Grants and Contracts, available at
Because the NIH is the source of so many funding oppor-
tunities, its policies and attitudes are especially important
to the academic clinician who aspires to do serious clinical
research. According to Kotchen et
al., “A perception exists
among clinical investigators that the NIH peer review proc-
ess may discriminate against clinical research.” With that
as a background, these authors studied outcomes of grant
applications submitted to the NIH by MDs vs. non-MDs, and
those involving human subjects vs. those that did not. They
conclude: “Although physicians compete favorably in the peer
review process, review outcomes are modestly less favorable
for grant applications for clinical research than for labora-
tory research.” <
> Table
lists selected grant and contract
databases. The sites here may include both government and
private funding opportunities.
elected funding databases and web sites
gency for Healthcare
esearch and Quality (
Q) Grants
ine Database
Community of
cience (C
comprehensive source of funding information
that lists more than 400,000 possibilities.
P (Computer
Non-Governmental Grant Sources
Foundations, societies, corporations and associations can be
a rich source of funding support, and are a good place for
the new faculty member to get started. There are independ-
ent, sometimes regional, foundations, such as the Northwest
Health Foundation or the Paul G. Allen Foundation for
Medical Research, serving the Pacific Northwest area of
the United States. There are health-company-related foun-
dations, such as the Aetna Foundation or the Robert Wood
Johnson Foundation, and charitable family foundations, such
as the Ford Family Foundation. Almost any major organ or
chronic disease you can name has a foundation; examples
include the American Heart Foundation, the American Lung
Association, The National Stroke Association, the American
Cancer Society, the American Diabetes Association, the
Alzheimer’s Association and several foundations focused on
autism. Funding for research projects may also be available
from your specialty society, which may have its own founda-
tion, such as the American Academy of Family Physicians
Foundation. In addition, there are many grants available
from business and industry; some of these are available to cli-
nicians and academicians, and others are for projects outside
the realm of medicine and science.
If you are a faculty member considering sending a grant
proposal to a private or corporate foundation in your state,
urge that you contact your academic medical center (AMC)
grant office. That office is charged to coordinate grant
requests submitted to various agencies, especially those that
are “local.” Their reasoning is as follows: The institution
looks foolish if a local foundation receives several proposals
from your institution, with one investigator not even aware
of the other’s submission. Even worse, your heartwarming
grant award of 10,000 today may be blamed for a later
rejection of a million dollar proposal if the grantor chooses
to make only one award to a single institution.
Another type of private funding is related to research
conducted by pharmaceutical companies or corporations
making medical or surgical equipment. One of the big
surprises of young faculty members may be the amount of
corporate-sponsored research in AMCs. Such research might
be part of a larger collaborative study with you as a listed
co-investigator. It is much more likely, however, that your
role will be to submit research data, based on a company-
generated protocol that is being used in a number of institu-
tions. You may have no control over what goes into the final
paper, and, in fact, are unlikely to see your name in print
when the results are published in the medical literature. Of
course, without being listed as a co-author on a published
report, the effort is valueless when you become a candidate
for promotion. “Then why do this research?” you ask. The
answer is money, and the monetary rewards for providing
pharmaceutical research services are quite high. Many medi-
cal school departments and divisions depend heavily on this
income to support the salaries of faculty and staff.
Here I will present some generalities that apply to various
types of funding proposals. A noteworthy exception to what
follows is pharmaceutical company contract research, in
which you simply agree to abide by the terms of their con-
tract offer—or decline to participate.
The Request for Proposal
Grant awards often begin with a Request for Proposal (RFP),
an invitation by a granting agency—government or private—
to submit an application. There will be a description of the
type of projects that will be considered, specific instructions,
a cap on the amount that may be requested and a submission
deadline. In some instances, there will be a funding priority—
an items that, if included in the grant proposal and approved,
add points to the final funding score, moving the application
higher in the funding queue. As a hypothetical example, the
American Diabetes Association might seek proposals that
study the impact of homelessness on the management of
diabetes mellitus, with a maximum award of 100,000 over
3 years, a deadline for submission about 4
months in the
future, and a funding priority for proposals that target Native
American homeless subjects.
Study the RFP carefully before taking the fateful step of
beginning to outline a grant proposal. Be very sure that your
idea for a project fits exactly with what the funding agency is
seeking; in the hypothetical study above, writing a proposal
examining the impact on homeless Native American subjects
of having an
family member in the household will
probably be a waste of effort.
Reviewing What Has Worked in the Past
In a world as competitive as grant getting, it is almost
anomalous that successful grant applications to govern-
ment agencies are available for your review. Revealing such
information would be unheard of in industry. In some cases,
when there are repeated cycles for similar initiatives, past
award-winning applications can serve as helpful models for
your grant. Even if you do not read every word of every grant,
a quick review can tell you who are writing the grants (the
principal investigators) and what is contained in the sum-
maries. To view information of successful NIH grants, access
the Research Portfolio Online Reporting Tools (RePORT) at:
In fact, if you are especially keen on seeing the entire
text of a specific grant, you can do so under the Freedom of
Information Act (FOIA). You will need to contact the NIH
Freedom of Information Office Coordinator for the Institute
in question; begin by accessing:
. Expect to pay a fee for processing and
Foundations and other private sources will generally sup-
ply you with a list of projects they have funded recently, but
beyond this, you may need to talk to the authors of the grant
The Program Officer
Most federal and private grant funding agencies will have
a designated program officer (aka project officer) for each
grant solicitation. This person is a very valuable contact.
I advise early contact by telephone. A face-to-face meeting
would even better, but is usually not possible because of
distance reasons. Be ready to give a brief description of your
project. Then ask open-ended questions:
How well do you think my ideas match the intent of the
What might be the problems with the idea?
What else would you suggest be included?
What would you do differently? Do you see a fault in my
What other suggestions would you have?
What else should I know?
The program officer is likely to know a great deal about the
project and the agency. It is his or her job to help you present
the best proposal possible. Contact the program officer early
and often as you work on your proposal.
Do not call the program officer with foolish questions that
are readily answered in the RFP or on the grantor’s web site.
Also, don’t call to ask questions such as, “What types of pro-
posals are likely to be funded this year?” Or “Should I send a
copy of my curriculum vitae with the proposal?” Be sure your
questions are thoughtful and carefully constructed.
Just one word of caution: The role of the Program Officer
is to be helpful and supportive. However, this person is not a
decision-maker when it comes time to review your proposal.
Encouragement by your Program Officer does not predict
or connote approval.
The Letter of Intent
Many foundations request a letter of intent briefly describ-
ing your project. Some federal and state funding sources are
adopting this concept, and you may see the terms “proposal
concept paper” or “white paper.” This concise overview of
your idea allows both the funding source and you to decide
early if more effort is warranted. If a letter of intent is
requested, think your project through carefully, pay atten-
tion to the length of letter requested (one page, two pages,
or some other length), and be sure to answer all questions
included in the instructions.
If you are provided no prescribed format for a letter of
intent or proposal concept paper, use the following as topics
for the paragraphs in your letter:
Project summary: This is a two or three sentence overview
of your idea, and why the project is appropriate for the
agency you are contacting.
Significance of the project: Tell the problem you intend to
Approach to the problem: Tell how you will address the
problem and how your approach is different from others.
Request for funds: Describe why you will need money to
complete the project, with a brief overview of how funds
will be used.
A sentence thanking the potential grantor for considering
your proposal, followed by your signature and full contact
I like letters of intent, because they provide a preview of
potential success or failure, without the full effort of prepar-
ing a long grant proposal. With that said, however, I would
not submit a letter of intent without having had a conversa-
tion with the program officer.
Planning the Budget
Some say that this is the second task, right after deciding on
the concept for your proposal.
It is often prepared by working with a project manager. The
budget is certainly important because asking for too much
may sink your proposal; requesting and getting a too-small
grant award can cause you to be underfunded. Whatever
you put in your budget, be sure to justify every item in your
application. If you ask for travel funds, tell why travel is
needed to make your project a success. If you request money
for photocopying or postage, describe what you plan to copy
and mail. Also, you must master the somewhat arcane terms
used in grant budgets, including direct and indirect costs,
the latter now called (at the NIH) “facilities and administra-
tive costs,” and TBA, which stands for “to be added,” and
may refer to faculty, staff or equipment—all dependent on
successful funding.
A Title for Your Project
In the end, your proposal will be presented to a review
committee who will pass judgment of its merits. I am an
advocate of making the topic and the outline of the project
easy for the reviewers to remember. Sometimes the key is a
catchy acronym, as discussed in Chap. 9. A few years ago,
our department submitted a federal training grant to support
a 3-year program to teach our residents about Advocacy (for
their patients), Cultural competence, and Ethical issues in
medicine. It became the ACE program; the acronym made
little sense in an academic setting, but the three-letter word
represented a memory device to help the review committee
recall the three main components of the project. The project
was, in fact, approved and funded.
Another training grant proposal consisting of what was,
frankly, a jumble of unrelated projects was approved and
funded in part, I believe, because we linked them together
with the memorable title, “The New Physician’s Black Bag
for the 21st Century.” Today I can’t recall what we stuffed in
the “black bag,” but I do remember the title of the project.
A good idea for a project is important as is early contact
with the program office, but success ultimately depends on
a professionally prepared grant proposal. In many instances,
and especially with non-governmental funding agencies, your
grant proposal can be crafted to address the mission and
goals of a grant funder, emphasizing how you will address
their published objectives. Table
tells basic components
of a grant proposal, written assuming that you are the prin-
cipal investigator (PI) and grant proposal author. Some of
these items are similar to headings in the Research Protocol,
but others are not, because grant proposals may describe
projects other than research. If in doubt about discussing a
topic, I suggest including the information.
Basic outline of a grant proposal
xecutive summary (abstract): Briefly describe the proposal
verview of institution: Describe your institution and project team
he problem and rationale for what you plan, typically
based on a literature review and/or preliminary studies
Project objectives:
our hypothesis or the aim of the project
have and have not had gastric surgery in the past. The outcome
of this study can help determine if post-gastric surgery patients
might be at risk for hypocupremia, which would have implica-
tions for long-term post-operative management.
In the case of foundations that may have lay donors who
take an interest in what is funded, you may consider sub-
mitting two types of summaries: The first is the scientific
abstract, intelligible to scientists with training and experi-
ence in the area of the proposal. The second is the layman’s
abstract, written in terms intelligible to the general reader.
I suggest that you write the executive summary early, and
then return to it from time to time, making sure that it is as
good as it can be.
Overview of Institution
This section, generally only a few paragraphs long, should
describe your organization in a way that suggests that it has
the wherewithal—experience, trustworthiness, reliability—to
support your project and to manage funds properly. Describe
important institutional accomplishments. Important evi
dence of all of this is a past record of research success, espe-
cially with big-budget projects. If you are part of a very large
institution, be sure to identify your role, perhaps including an
organizational chart.
This section should be included even if you and your team
have a past track record with the funding agency. Remember
that funding agency personnel can change and institutional
memory is short.
In this section, you will explain the problem and why it is
important, based on a selective literature review or some-
times, in the case of a major research endeavor, a systematic
review (see Appendix
5). In the case of copper deficiency fol-
lowing gastric surgery, I would point out that hypocupremia
in adults can cause neurologic manifestations including pro-
gressive sensory ataxia and weakness in the extremities, as
well as anemia and neutropenia <
If you have done preliminary work or pilot studies, describe
them here, especially if this work has resulted in publications.
If you are citing just a few references, they may be listed
here, at the end of this section. If the list of citations is longer,
and/or citations also occur elsewhere in your document,
they should all be listed below under a separate heading
“References” in the Appendix. In most cases you need cite
only very pertinent studies that are integral to your proposal.
Do not append a long list of references intended chiefly to
impress reviewers.
Project Objectives/Research 2uestion
Here, in the case of a request for research support, you tell
your specific aims and hypotheses. This section is described
by Inouye and Feillin as “the most important section of the
grant.” <
Not all requests are for hypothesis-based research support
and, if this is the case, the project objective should be stated
clearly. Here are some examples:
We propose to develop, teach and evaluate a course for
second-year medical students presenting the recognition,
management and prevention of domestic violence.
We propose to plan, conduct and evaluate a 1-year leader-
ship fellowship for primary care physicians who have com-
pleted residency training and at least 3
years of practice.
Following the initial statement of the project’s objectives,
you should spend a paragraph or two presenting the elements
involved, including primary and secondary hypotheses, if any.
Your writing here may seem to repeat what was said in the
Executive Summary. This reiteration is acceptable, even desir
able, because you want the reader to have your aim clearly in
mind while he or she is reading the rest of the document.
Project Methods
How you will achieve your objectives is going to be vital
to success, both in attaining grant funding and in car-
rying out your project. Writing this section is easier if
you have previously prepared a comprehensive Research
Protocol. Topics to be included in proposals related to clini-
cal research include:
study design, availability of subjects,
inclusion and exclusion criteria, the intervention strategy,
considerations, data collection methods, how data will
be analyzed, and the outcomes to be measured. I recommend
using subheadings when writing this section, to be sure that
each topic is fully described.
Inouye and Feillin emphasize the importance of the Project
Methods section: “The most common general issue (in grants
reviewed) is that the methods were underdeveloped.” <
> They
recommend that grant application writers devote at least half
of their total page allowance to the Methods section.
Include a timetable for completion, such as the one devel-
oped when writing your Research Protocol (see Table
9.2 or
9.1). Be careful that your timeline is consistent with the
grant funding available. Or if the project is to be continue
beyond the period of grant funding available, tell how this
ongoing activity will be funded.
Budget and Budget Justification
If there is a major difference between the research protocol
and the grant proposal, it is here. Because the chief objective
of writing a grant application is to convince someone to give
you money to support your project, you need to submit a care
fully crafted budget complete with prose that explains every
planned expenditure, practically down to the last paper clip.
What might you ask for in your budget? The answer to
this question depends on the rules of the funding agency and,
often, the stipulations in the RFP. Follow guidelines carefully,
so that you do not compromise your credibility and perhaps
even your application’s approval, by requesting forbidden
funding. Examples of items that may be subject to funding
rules are equipment such as computers and administrative
expenses such as secretarial support. Here is a list of items
that you should consider when crafting you budget:
Personnel, including salary support for the PI, co-investi-
gators and research associates
Independent contractor expenses
Consultant costs
Supplies, including paper, envelopes, and printer ink
Clinical items, such as needles, syringes and laboratory
Equipment, including hardware, software, and sometimes
even furniture
Fees paid to subjects
Space or equipment rental
Travel expenses to project sites
Conference expenses to present results of the project
Miscellaneous costs such as advertising, copying, printing,
insurance, and postage
Indirect administrative expenses
You may wish to cluster your requests under three head-
ings: personnel expenses, direct project expenses, and admin-
istrative/overhead expenses. At this point, it is often helpful
to review the structure of past successful grants submitted to
your target agency.
Bordage and Dawson recommend presenting the budget
in three sections: (1) funds needed for year 1; (2) funds
requested for the remaining period of support; and (3) the
budget justification <
>. The budget justification is the sec-
tion that tells the need for each item in the budget, and when
the money will be spent. Although some agencies ask only for
global budgets, most require detailed justification of every
item requested in the budget. For major expenses, include
how you determined the anticipated costs, perhaps even
appending estimates from vendors.
Other Funding
This can be a good thing. Agencies, especially private foun-
dations, favor projects that have been able to attract support
from various sources. Such support can add credibility to
your proposal.
Plans for Future Funding
Funding agencies generally like to look to new projects
don’t favor funding the same endeavors over and over.
For this reason, if your project is to continue beyond the
period of initial grant funding, you should state how this will
occur. A clinical trial, such as my post-gastric surgery/copper
deficiency study, may be projected to be complete on the very
day grant funding ceases. On the other hand, in the case of
training grants, which typically fund 3-year programs, the
recipient is often asked to describe how the educational pro-
gram will continue after grant funding runs out. Our medical
school department currently has several programs that we
now self-fund years after grant support ended.
Appendix/Supplementary Items
This is the “attic” of a grant proposal—where you put stuff
that may be needed, sometime. Inouye and Fiellin caution
never to put anything in the Appendix that you actually
want the reviewer to read. “The grant should stand alone,
and appendices should only provide supporting materials.
The reviewers may not receive or read the appendices.” <
With that admonition, I submit that there are some items
that have
to go somewhere, and this is usually it. These may
include support letters, affiliation agreements, consent forms,
and more.
Support Letters
Support letters, including letters of recommendation, are
often requested by agencies. For example, in a medical
school, you may need a support letter from your dean or from
the chair of a department whose cooperation will be vital
to the project’s success. If such a letter is needed, ask for it
early; your letter-writer has things that are higher on his or
her personal to-do list. I have found that I get the prompt-
est response when my request for a support letter includes a
draft of what I want in the letter.
Affiliation Agreement
Some of these are already in the institution’s files. If a new
document is needed, follow the advice given just above under
“Support Letters.”
Consent Form
If there is a consent form that participants will sign, include
a copy in the appendix.
Biographical Summaries of Investigators
When biosketches are requested, there is often a prescribed
format—often as regards what to include and a limit on
pages. Follow instructions.
If your proposal calls for a long list of reference citation, put
it here.
Other Items
Here you may append requested items such as a list of your
board of directors, a copy of your Internal Revenue Tax-
exempt Letter, or a current financial statement.
Fundamentally, the grant proposal applicant most likely to be
funded is the one who seems to be thoughtful, capable and
professional. The grant application document should reflect
these attributes. The following are a few principles that apply
to grant proposals of all types:
Tell your idea early in the proposal. Do not make the reader
wade through three pages of “rationale” and “obstacles to be
overcome” before finding the project overview on page 4.
Use the language in the RFP. If the RFP states that the
foundation seeks grant proposals to “determine ways to
improve the nutritional status of homeless women in large
cities,” you should use exactly that language to describe
your project. You will also need to determine what is meant
by “nutritional status,” “homeless,” “large cities,” and even
“women.” Are 13
year-old homeless females “women?”
Craft your project description carefully, and then use
the same words in the same manner over and over. This
assures that, after reading the document, the reviewer will
recall the key words. Thus, in the ACE program described
above, I used the words
Cultural competence
Ethical issues in medicine
repeatedly, in exactly the
same way each time.
Make the document visually interesting. The reviewer will
probably receive a number of grants to read, and you want
to capture his or her attention. Try to avoid using very long
paragraphs. Use tables to present data, when possible.
If you see a section of prose extending to several pages,
consider inserting headings to break up the long string
of paragraphs. Notice on this page that I have used bullet
points to avoid large blocks of prose.
The document should use the font and margin size recom-
mended in the RFP. If none is recommended, use size 12
font. Margins should be 1 inch or more on sides, top and
bottom. Don’t try to gain a few more words by crowding
your pages. This can annoy your reader, and you do not
want an angry reviewer.
Document assertions with data and sources. Cite the lit-
erature if appropriate, but don’t let your grant proposal
become a literature review with 90 citations.
Peer review is an important part of grant-proposal-writ-
ing. Just when you think you are done and everything
is perfect, submit the grant to one or more experienced
and trusted grant-getting veteran colleagues, asking for
criticism. Where are the errors? Can you detect cognitive
dissonance? Is something important missing? Do not rush
this volunteer peer reviewer, who is likely to be as busy as
you. Allow up to 2
weeks for the peer review, just one more
reason to start early and stay on schedule.
Follow all instructions regarding submission. Such instruc-
tions historically included how to clip your carefully writ-
ten pages together, how many copies of the grant to mail,
and where to mail it all. Today most grants, just like article
manuscripts submitted for publication, are transmitted on-
line. Although this reduces paper use and shipping costs, it
can be challenging for grant-writers. Think of it this way:
The granting agency staff is very comfortable with the
on-line submission program; but each of us grant-writers
needs to master the quirks of each agency’s program.
patient with the process and take the time to climb the
learning curve.
Start early and finish early. I like to begin projects early
and finish them well ahead of deadlines. I hate last-
minute, frantic rushes. Your institutional research serv
ices office—which must read and approve your project
before it can be submitted—probably dislikes last-minute
problems even more than I do. Grant deadlines for vari
agencies come in cycles, and all grants must be vetted
by your
institutional office of research services (or some
office with a similar title). Hence, if you have a grant
headed for the NIH, it is likely that there are a number
of other grants from other departments at your AMC that
have the same deadline. For this reason, it is best to be
at the head of the line by completing your grant proposal
early. A late submission will not get the attention from
the offices of research services that it deserves, a problem
that becomes even worse if there is an issue with your
Your grant proposal has been approved by your department
chair and the institutional research services office. The pro-
spective grantor has received it. You are in the tournament.
Next it goes to a review panel. In a typical grant review panel,
all reviewers will have access to your grant. Some may read it
completely; others will scan it. At the table, one of the review-
ers will be selected to present it to the group. What are the
implications of this method?
First, be sure that your proposal is appropriately titled in a
way that accurately describes the project and that the reader
can recall a day later.
Next most read is the executive summary. The reviewer
who presents your proposal to the review panel is likely to
begin his or her presentation here, perhaps reading it word-
by-word, and this paragraph is likely to be in front of the oth-
ers around the table. Be sure to tell the readers your concept,
the key words and the approach you will use throughout the
In various grant application review settings there will be
a “score,” based on the total or the average of scores submit-
ted by the reviewers present. The scores of all proposals will
become a continuum when it comes to deciding funding.
What you will eventually hear is that your proposal is:
Approved without modification to the project or budget.
Approved, with modification to the project and/or budget.
This is usually also considered good news.
Approved. but not funded. Your grant received a good
score, but the agency ran out of money as they funded
proposals with even higher scores. Here is where fund-
ing preferences may sometimes be the key to success or
Rejected. This means that your proposal’s score fell below
the level needed for approval and funding.
If your proposal was rejected or approved but not funded,
you should request a copy of the reviewers’ written com-
ments, which can guide your decision as to whether or not
to resubmit the grant in the next submission cycle. If you do
decide to resubmit, the reviewers’ comments will be valuable
as you modify the proposal.
As you read the reviewers’ comments, you might find
a remarkable diversity of opinion among members of the
panel. You might even conclude that one or two members
of the review panel did not understand the proposal, if they
read it at all. Recognize that, although review panel members
are selected based on expertise in some key area, there may
be considerable differences in their individual knowledge of
your project topic.
As you consider modifying and resubmitting the proposal
in the next cycle, ask the program officer for any suggestions
that might be helpful. Does the program officer think you
might have a reasonable chance of acceptance if you resub-
mit? Are there any parts of the grant proposal that the pro-
gram officer thinks especially merit change? Perhaps there is
a problem that was not covered in the reviewers’ comments.
To learn more about the NIH review process, go to What
Happens to Your Grant Application at:
If and When Your Grant Is Rejected
Yes, you will have a proposal rejected, probably more that
one, during your career. Just as an example, the 2009 National
Institute of Allergy and Infectious Diseases RO1 success rate
for new investigators was 18.5, actually a little higher than
the 17.5 rate for established PIs <
>. Grant-getting seems
to the inverse of Pareto’s 80:20 “rule,” which holds that 80
of your efforts will succeed and 20 will fail. (If you are not
familiar with Pareto’s Rule, check it out through Google). In
the instance of grant application submissions, 80 of our
efforts may be unsuccessful. What should you do when you
receive the notice of rejection, which will often be in the form
of an aggravating form letter?
Let me begin with what you do not do. You do not blame
your grant program officer; this person has tried to help you,
had no vote in the review committee’s decision, and stands
ready to help you in the future. Do not risk losing a friend.
Do not act while angry. Do not call the agency and accuse
the review committee of being a clan of Neanderthals who
would not recognize the merits of the wheel. Do not impugn
their motives or their honesty.
What should you do? First, consult with your co-investi-
gators and plan your telephone inquiry to the agency. Write
out a script with your questions. Begin by biting your tongue
and thanking the agency for their thoughtful review. Then
inquire, “What could I do that would improve the proposal?”
“What can you can suggest to help us in the future?”
You want to find out what sort of rejection was received.
Was it an “oh, so close” no? Or was it a “this-was-really-
awful-proposal” no? Did you almost make the cut, and fall
short by just a few points? Or did the review committee truly
loathe your application, and wish never to see it again?
I mentioned earlier that one of the attributes of the suc-
cessful grant-getter is persistence. After your anger and dis-
appointment subside, and after getting all the information
you can from the rejection-letter agency, you and your team
should have a strategy meeting. If your proposal was not
truly terrible, but just not good enough, and if you still think
it might match with the mission of your targeted funding
source, then dust it off, make revisions based on feedback
received, and re-submit at a later time. Many grant propos-
als, especially NIH grant applications, succeed only on the
second or third submission.
If you still think you have a great, and fundable, idea but
conclude that resubmission to the initial target agency is
not going to succeed, then your initial application can prob
ably be revised to meet the requirements of another agency.
And the reworked and improved application may well be
Beginning grant proposal writers make some classic errors;
experienced academicians also sometimes make missteps:
Ignoring the instructions. When agencies have a surplus
of grant applications, the first cut may be those who did
not follow instructions precisely. Here is an example that
is extreme, but true. In 2003, a drug-and-alcohol treat-
ment center in Oregon had two grants rejected by a federal
agency because of the width of page margins. The center
had submitted funding requests totaling 703,000, but
“missed out because the application margins were two-
tenths of an inch too small.” <
Failing to recognize signals in the RFP. If the RFP seems
somehow peculiar, as though one needs to have very spe-
cial attributes in order to carry out the project, it is just
possible that it is “wired.” This means that a specific insti-
tution already has an inside track, may even have a hand
in writing the RFP, and your proposal will fight an uphill
Not listening carefully to the program officer. You have
just described your idea to the program officer, who
replies, “What you are describing is not exactly what we
usually fund.” Of course, you can ignore this comment,
spend weeks preparing a grant application, and receive
sympathetic reviewer comments (“I wish we could have
approved this well-written proposal, but d”) along with
your rejection notice.
Carelessness. Do not submit a grant with grammatical or
typographical errors. Avoid excessive use of abbreviations
or abbreviations that send the reader scrambling back 20
pages earlier to figure out meaning. Do not submit a grant
with misstatements or outdated information. Avoid topic-
specific jargon. Such errors can only harm your chances
of success.
Injecting guaranteed failure into the proposal. One exam-
ple is targeting the wrong population. I once sat in a
review panel for HRSA training grants. These specific
grants involved training medical students and residents.
One of the most comprehensive and articulate grants we
considered during the 2-day meeting involved a longitu-
dinal educational program in an integrated continuum
from college through residency. But the grant funding
was intended only for medical students and residents, not
college students. We turned to the program officer, who
stated that this grant could not qualify for funding. Fatal
error. Next grant.
Submitting to the wrong agency. Some grantors fund
research; some fund education and training. Do not waste
your time by mixing these up. If you intend to combine
research and training in a grant, discuss this early with
the program officer.
Overestimating your capability. Grantors always consider
if the PI has the experience and resources to get the job
done. Begin with modest achievable projects with reasona-
ble budgets. Then, after a few successes, think about more
ambitious projects with larger budgets. Eventually you
may qualify to write the grant for the BIG PROJECT, but
this must be earned by a track record of earlier successes.
A step-by-step, patient approach offers the best chance of
being a winner in the tournament of grants.
nformation sources about grant seeking
Articles and Books
Bauer DG.
he “how to” grants manual: successful grant seeking techniques for
obtaining public and private grants. 6th ed. Westport, C
: Praeger; 2010.
Browning B. Perfect phrases for writing grant proposals.
. Winning grants: step by step. 3rd ed.
an Francisco: Jossey-Bass; 2008.
cheinbert C
. Proposal writing: efficient grantsmanship. 3rd ed.
aks, California:
age; 2008.
H peer review of grant applica-
tions for clinical research. J
. 2004;291:836–843.
, Goldberg
esearch proposals: a guide to success. 3rd ed.
cademic Press; 2002.
. Grant application writer’s handbook. 4th ed. Boston: Jones &
Freeman R, Weinstein E, Marincola E, Rosenbaum J, Solomon
E. Competition and careers in bioscience. Science. 2001;294:
About the National Institutes of Health. Available at:
Kotchen TA, Lindquist T, Ehrenfeld E. NIH peer review of grant
applications for clinical research. JAMA. 2004;291:836–843.
Prodan CI, Bottomley SS, Vincent AS, et
al. Copper deficiency
after gastric surgery: a reason for caution. Am J Med Sci.
Tan IY, de Tilly LN, Gray TA. Hypocupremia: an under recog-
nized cause of acute combined degeneration. Can J Neurol Sci.
Halfdanarson TR, Kumar N, Li CY, Phyliky RL, Hogan WJ.
Hematologic manifestations of copper deficiency: a retrospec-
tive review. Eur J Haematol. 2008;80(6):523–531.
Inouye SK, Feillin DA. An evidence-based guide to
grant proposals for clinical research. Ann Intern Med. 2005;
Bordage G, Dawson B. Experimental study design and
grant writing in eight steps and 28 questions. Med Educ.
National Institute of Allergy and Infectious Diseases: Funding
News. Available at:
Center loses grant by slimmest of margins. Oregonian. December
3, 2003. Page D2.
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_11,
© Springer Science+Business Media, LLC 2011
How to Write a Report of a Clinical
In questions of science, the authority of a thousand is not
worth the humble reasoning of a single individual.
Italian physicist and philosopher Galileo Galilei (1564–1642)
Galileo, a leader in the Scientific Revolution that followed the
hyper-religiosity and doctrinaire thinking of the Middle Ages,
was a champion of reasoning. Ideally, of course, reasoning is
based on observed facts—data—and medicine science’s best
format for data presentation and analysis today is the report
of a clinical study.
is the report of a study that examined
the risk of fatal myocardial infarction in persons exposed
to aircraft noise. (Huss et
al. Epidemiology. 2010;21:829).
Following analysis of 4.6 million individuals over 5
years, the
authors concluded that there is, indeed, a dose-related asso-
ciation between aircraft noise and death from myocardial
infarction, independent of possible confounding factors such
as particulate matter air pollution and socioeconomic status
of the municipality.
According to a report published in
, the use of
probiotics, specifically
Lactobacillus reuteri
, can reduce daily
crying episodes in colicky babies, a conclusion based on a
randomized, double-blind, placebo-controlled trial involving
50 infants (Savino et
al. Pediatrics. 2011;126;e526).
Are there actually more fatal medication errors in July,
when new medical residents arrive on hospital floors, or is
this simply an “urban legend?” Actually there is some truth to
the belief, according to a study of 62 million death certificates
recorded over 27
years, with a July mortality spike that Phillips
and Barker conclude “results at least partly from changes
associated with the arrival of new medical residents” (Phillips
al. J Gen Intern Med. 2010;25:774).
A report in
The Lancet
describing a 20
year follow-up of
five randomized trials to assess the long-term effect of aspi-
rin on colorectal cancer incidence and mortality presents
this conclusion: “Aspirin taken for several years at doses of
at least 75
mg daily reduced long-term incidence and mor-
tality due to colorectal cancer” (Rothwell et
al. The Lancet.
In the
Journal of the American Medical Association
is a report of a study intended “to determine whether integrat-
ing smoking cessation treatment into mental health care for
veterans with posttraumatic stress disorder (PTSD) improves
long-term abstinence rates.” A randomized controlled trial
involving 943 smokers with military-related PTSD revealed
that the answer to the research question is: Yes (McFall et
JAMA. 2010;304:2485).
Preparing the report of original research is arguably the
most challenging undertaking in medical writing. It is not
necessarily that writing the report is so complicated, because
the model is prescribed. In a sense, you need only fill in the
blanks. The challenging part is that one needs to have com-
pleted a research study and have the resulting data available.
What follows assumes that you have completed that task, and
are composing your report for publication.
Because there is a prescribed model, writing the report
of original research has one advantage over other types of
medical writing. You will not need to dream up a concept
and structure for the article. In previous chapters I dis-
cussed diverse ways to approach the review article, edito-
rial, book chapter, and other models of medical publication.
For the report of original research, there is only one model,
called IMRAD. This acronym stands for the major parts
of a research report:
iscussion. The IMRAD format is what editors are accus-
tomed to reviewing. It is what clinicians and scientists are
used to reading. Deviating from this format risks summary
rejection. I describe the IMRAD format below.
The rigid format for the report of original research
highlights the fact that research reports are written to be
published and cited, more than they are written to be read.
They are intended to be repositories of scientific data rather
than literary gems. They just happen to be in prose. Day <
has summarized this viewpoint very well: “Some of my old-
fashioned colleagues think that scientific papers should be lit-
erature, that the style and flair of an author should be clearly
evident, and that variations in style encourage the interest
of the reader. I disagree. I think scientists should indeed be
interested in reading literature, and perhaps even in writing
literature, but the communication of research results is a
more prosaic procedure.”
With that said, I still plead with authors, even those com-
posing research papers, to construct paragraphs thoughtfully,
avoid long and convoluted sentences, select words carefully,
avoid the use of jargon, and express their ideas as clearly as
For the clinical investigator, getting research results pub-
lished can be the difference between professional success
and failure in the academic medicine arena. It can deter-
mine whether or not one gets the big grant, or if one receives
tenure. Entire academic careers have been built on a single
groundbreaking research study, carefully reported in a pres-
tigious journal. Whether you are a patient care physician or
a research-track academic faculty member, whether you have
done a practice-based research project or a randomized clini-
cal trial, remember that your research is not completed until
the results are reported in print.
The five papers I cited above all had research questions
that provoked my interest, and perhaps yours. Although I
had never thought much about the issue before I read the
title, I wanted to know if aircraft noise might be associated
with death from myocardial infarction. I was intrigued by the
well-designed study of the use of probiotics in colicky babies.
The finding of a July morality spike confirms one of my long-
held, but previously evidence-deficient, beliefs regarding
the risks of unseasoned residents caring for unsuspecting
patients. We clinicians need to know if it is worthwhile to
advise the use of low dose aspirin for the primary prevention
of colorectal cancer in our patients. And as one who teaches
residents seeing smokers with mental health issues, I was
intrigued by the possibility of combining therapy for these
problems. For this reason, I briefly summarized the study
outcomes, even though this is a book about writing and not
clinical science.
I mention the above—about my interest in the research
questions that prompted the studies—because you may be
tempted to stretch the definition of research too far. As a
surgeon, you may consider reporting the findings of your last
200 cases of lumbar laminectomy or laparoscopic cholecys-
tectomy. If you are an internist, you may believe that your
colleagues are keenly interested in how you treated 100 con-
secutive patients with congestive heart failure. Such studies
do not set out to answer a clinical question and generally
do not have anything important to say. They may qualify as
quality improvement efforts, but are not likely to result in a
publishable research paper.
A research report describes your research, whether it
involves humans, rats or a meta-analysis of previously pub-
lished studies. In general: You generate a research question,
and then collect data to answer the question. “Mining” tons
of data to find something,
that has statistical signifi-
cance is not good research, and a paper describing such a
method will be evident to the informed reviewer.
When planning a research report, be aware that com-
petition for publication space in leading refereed journals
is intense, and research papers are typically rewritten sev-
eral times before final acceptance. Ultimately, your clinical
research paper will be judged by its impact on your specialty
and on the greater body of medical knowledge, as evidenced
by its citation in other research articles, review papers, and
Just before launching into a discussion of the how to write
a report of hypothesis-based research based on the quantita-
tive scientific model, I want to acknowledge another branch
of research that also is reported in the literature—qualitative
research. This type of research, which medical science has
borrowed from our colleagues in sociology and anthropology
does not generate piles of data. Instead, we find terms such as
focus groups, studying stories, and mixed methods research <
The IMRAD model, describe below, does not readily lend
itself to reports of qualitative research, which tend to use
more innovative styles, prompted by the nature of the results
being reported. Perhaps that will be a good chapter for the
next edition of this book. For now, we will examine how to
report the results of traditional quantitative research.
The IMRAD model of research reports has evolved over
generations of scientific publications. It has at its core four
Introduction: Why is the topic important, what prior
research has been done, and what question did you set out
to answer?
Methods: Who were your subjects and what did you do to
them? How did you analyze the data?
Results: What did you find out?
Discussion: What do your findings mean?
These four items are the foundation of IMRAD. Research
papers, however, have more than just the four main compo
nents, and I am going to present an expanded IMRAD model.
Keep in mind the four key elements as we explore the IMRAD
and more, beginning with selection of the title for the report.
The title is the “label” for the paper. The title must tell, more
or less, what was studied. An early question the writer must
answer is this: Should I reveal my conclusion in the title?
One of the studies cited at the beginning of the chapter is
titled “Long-term effect of aspirin on colorectal cancer inci-
dence and mortality: 20-year follow-up of five randomized
trials.” If I read only the title and had no other background
knowledge, I might misunderstand the authors’ intent and
take away the message that aspirin actually
risk of colorectal cancer incidence and mortality. In fact,
the study showed just the opposite. Therefore, I believe that
a better title would be “Long-term use of aspirin reduces
colorectal cancer incidence and mortality: 20-year follow-up
of five randomized trials.” Might the title of the JAMA arti-
cle about tobacco cessation have been more helpfully titled:
“Integrating tobacco cessation into mental health care for
posttraumatic stress disorder: a randomized controlled trial
showing greater prolonged abstinence?”
Whimster <
> writes: “I believe that readers need a verb
in the title, such as a newspaper headline usually has, and
that to be meaningful it should convey the message, as in:
lRickettsial endocarditis is not a rare complication of congen-
ital heart disease in dental practice: a report of five cases.’”
Sometimes we authors dream up witty titles. Consider the
following title: “It’s b-a-a-a-a-a-a-ck again, or how to live with
the new APA manual: reprise for Edition 6” (Baggs et
al. Res
Nurs Health. 2009;32:477). Generally, editors counsel against
using clever phrases in titles, and rightfully so.
Note how often colons show up in article titles. They allow
progression from the general to the specific, all in an inte-
grated title phrase. See the papers cited above. One example,
cited above as one of the chapter’s five index papers, is the
title “A July spike in fatal medication errors: a possible effect
of new medical residents.” The authors discuss the general
problem and then the data sources. The reader has a better
idea of the article’s contents than if only the first phrase were
On a technical basis, the instructions for authors may pre
scribe a word or character limit for the title. Also, I believe that
titles should not contain acronyms or abbreviations, no matter
how widespread the author and editor consider their use.
The chief issues in authorship of a research report are gener-
ally twofold: (1) Who is an author? (2) How shall the authors
be listed?
As discussed in Chap. 5, everyone who contributed sub-
stantially to a research project and preparation of the report
should be listed as author. Furthermore, each author should
have participated sufficiently in the work to take public
responsibility for appropriate portions of the content <
What about adding author names of those who have con-
tributed very little? Strasburger <
> described the problem:
“Fiction is written by one individual; medical articles may be
written by committee. There is no such thing as lauthor infla-
tion’ in fiction, simply because there is no need for it. Medical
writers must publish or perish, academically. Fiction writers
must publish or perish, existentially.” Despite the need to
avoid perishing, it is inappropriate to have your name listed if
you have not met the criteria listed in the previous paragraph.
You must not become an “author inflation” perpetrator.
No department chair or research director should insist on
being named as an author unless there has been a significant
contribution to the study and to writing the paper. Authorship
listing by administrative fiat is academic malpractice. Adding
the name of a prestigious senior faculty member as the final
entry on a long author list might help get the paper a better
review, but including the well-known name implies that per-
son’s active participation in the project. Gratuitous addition
of an author name is ethically inappropriate.
The order in which authors are listed on a research report
should be decided very early in the process, generally during
one of the first meetings of the research group planning the
study. Changes in the rank order can be made later if con-
tributions of individuals to the project do not turn out to be
what was originally planned.
The first author should logically be the one who has done
most of the work on the study being reported. Generally this
is the person who led the research team and who has created
the early drafts of the paper. From then on, authors should
be listed according to how much they contributed to the
study and the report. As one whose last name begins with a
letter toward the end of the alphabet, I have never consid-
ered alphabetical listings of names to be fair to the Taylors,
Washingtons, and ;ells of the world.
A quirk of citation listing holds that when the paper is used
as a reference in other studies, if your paper has seven or
more authors, only the first three are named and the rest will
join the et
al. army of obscurity.
The abstract is an author-generated synopsis of the paper.
Many believe that the final version of the abstract should be
the last item written, since only then will you know exactly
what is in the paper that you are summarizing. When writing
an abstract, select each word as if your paper’s being read
depended on it, and jettison verbal clutter ruthlessly.
In general I have always taught that the abstract should
mirror the IMRAD structure of the paper. That is, the paper’s
introduction, methods, results, and discussion (conclusions)
should each be presented in a sentence or two, and many
good abstracts have exactly four short paragraphs. According
to the Uniform Requirements, “The abstract should provide
the context or background for the study and should state the
study’s purpose, basic procedures (selection of study subjects
or laboratory animals, observational and analytical methods),
main findings (giving specific effect sizes and their statistical
significance, if possible), principal conclusions, and funding
sources. It should emphasize new and important aspects of
the study or observations.” <
The current trend is for journals to require structured
abstracts <
>. This means that information in the abstract is
presented according to specific headings that differ a little
with each journal. All structured abstracts will include the four
key components of the IMRAD model, although synonyms for
these headings may be used, including some variations such as
“Context,” and “Main Outcome Measures.” Some journals pre
fer abstracts with full sentences; others encourage the use of
phrases. Here, from the
Archives of Surgery
, is what we might
find in a well-written structured abstract for a paper titled:
“Risk Factors for Lymphedema in a Prospective Breast Cancer
Survivorship Study” (Kwan et
al. Arch Surg. 2010;145:1055 ):
To determine the incidence of breast cancer-
related lymphedema (BCRL) during the early survivorship
period as well as demographic, lifestyle, and clinical fac-
tors associated with BCRL development.
The Pathways Study, a prospective cohort study
of breast cancer survivors with a mean follow-up time of
Kaiser Permanente Northern California medical
care program.
We studied 997 women diagnosed from
January 9, 2006 through October 15, 2007, with primary
invasive breast cancer and who were at least 21
years of
age at diagnosis, had no history of any cancer, and spoke
English, Spanish, Cantonese, or Mandarin.
Main Outcome Measure
Clinical indication for BCRL as
determined from outpatient or hospitalization diagnostic
codes, outpatient procedural codes, and durable medical
equipment orders.
Note that so far, only one section—
a complete sentence. Later in the abstract, under
, paragraphs become longer and the style
changes from phrases to complete sentences.
The instructions to authors for the Journal of the American
Medical Association state, “Reports of original data should
include an abstract of no more than 300 words using
following headings: Context, Objective, Design, Setting,
Patients (or Participants), Interventions (include only if there
are any), Main Outcome Measure(s), Results, and Conclusions.
For brevity, parts of the abstract may be written as phrases
rather than complete sentences.” <
> The JAMA Instruction for
Authors goes on to tell what should be presented in each section
of the abstract.
The tight word limitation and the many topics to be
covered serve to get the important data into tightly writ-
ten abstracts, but at the expense of some very complicated,
number-laden, and almost incomprehensible sentences in the
Results section.
On a technical basis, descriptions of work that has been
done (
) should be written in the past
tense. An explanation of what you think (
) is writ-
ten in present tense, often with a phrase such as, “We con-
clude. . . .” In the spirit of intellectual honesty, the abstract
must never contain a conclusion that is not supported by
what is in the body of the paper.
Clinical Trial Registration
For all clinical trials, the name of the trial registry, registration
number, and URL of the registry must be included <
Key Words
In some instances you will be asked to identify Key Words.
Key words can be what keep your report from being lost in
the information jungle. They are part of the retrievability
process that can contribute to the number of times your
paper will be cited. In the instructions to authors, many jour-
nals request that you submit three to ten key words or short
phrases. These will “assist indexers in cross-indexing the
article and may be published with the abstract. Terms from
the Medical Subject Headings (MeSH) list of Index Medicus
should be used; if suitable MeSH terms are not available for
recently introduced terms, present terms may be used” <
(see Chap. 1 and Appendix
Finally we arrive at the “I” in IMRAD. The introduction
should identify the problem you set out to solve. In a sense,
it describes the context of the study. In general terms, the
introduction should cover three areas:
Problem statement
: What is the general nature of the prob-
lem that merits valuable journal space and the reader’s
Background and work to date
: What are the most pertinent,
timely published studies that relate to the problem?
The research question
: What is the specific, focused ques-
tion that you set out to answer? If you have a formally
stated hypothesis, here is where it should be presented.
The Problem
The Introduction classically opens with a broadly stated and
virtually unassailable generalization about the problem. The
Introduction to the paper on aspirin and colorectal cancer
begins, “Colorectal cancer is the second most common can-
cer in developed countries. . . ”
Good Introductions are often written as a three-level
“inverted pyramid.” The broadest statement comes first.
Here is an example: Primary care clinicians encounter many
patients with headaches. Next comes a more narrows state-
ment, e.g., The clinician treating a headache patient is always
aware that, in a few individuals, the cephalgia might be the
tip-off to a life-threatening disease. This might be followed
by an even more specific statement setting out the purpose
of the study: This study examines patient records to identify
symptoms and signs that might identify persons most at
risk for life-threatening causes of head pain who should be
referred for diagnostic imaging.
Describe the key work that has been done on the topic to date.
Do not present an exhaustive literature review dating back to
the Renaissance. Be very selective and include only articles
that have a direct bearing on your research question.
Research 2uestion
State clearly the question you are trying to answer. One
focused question is usually better than many. The question
may be stated as a query or perhaps as a hypothesis, but
often is phrased as a statement of intent: In the study of air-
craft noise and fatal heart attacks, the research question is
stated: “We examined residential exposure to aircraft noise
and mortality from myocardial infarction, taking air pollu-
tion into account.”
To inform the reader as to what your study is all about,
it is vital that you articulate the research question clearly
in the introduction. I wish that writers of research reports
would all do so and would frame their research questions
as direct queries or even as hypotheses. For example, the
authors of the paper on integrating tobacco cessation into
mental health care for posttraumatic stress disorder state
an explicit hypothesis: “Our multisite randomized controlled
effectiveness trial hypothesized that integrating smoking
cessation treatment into mental health care would improve
long-term smoking abstinence rates in veterans with PSTD
compared with referral for specialized cessation treatment.”
However, most authors are less explicit, and I have learned
to be content with somewhat vaguely stated research ques
tions stated as: “The purpose of this study was to investigate
both early and late dumping syndromes after gastrectomy
for gastric cancer in 2 high-volume centers in Japan” (Mine
al. J Am Coll Surg. 2010;211:628).
Technical Issues in Writing the Introduction
When writing your introduction, use the present tense
when describing the general nature of the problem and the
background work. Then the research question, if presented
as a statement, is usually in past tense, as in the examples
The uniform requirements advise, “Do not include data or
conclusions from the work being reported.” <
> Not every-
one agrees with this stance. Both Day <
> and Whimster <
advocate stating the conclusions early in the article, and not
the reader in suspense, as you would with a whodunit
mystery novel. The best spot for the important implication for
translation of your findings to clinical practice may be in the
introduction. In this area where controversy exists, use your
best judgment, based on the data you are presenting.
The Methods section, sometimes called Participants and
Methods or perhaps Methods and Materials, should describe
a logical experimental approach. Because this section
presents a number of topics, subheadings are often used. In
the Methods section of the article mentioned above about
probiotics and infant colic, the authors used the following
headings: Subjects, Study Objectives and Outcomes, Study
Design and Sample Collection, Analysis of Bacterial Groups
by FISH, Analysis of Fecal
DSM 17 938, Analysis
of Fecal Ammonia, and Statistical Analysis. The Methods
section of the study on aircraft noise and fatal MI has five
headings: Study Population, Outcomes, Exposure to Aircraft
Noise, Exposure to Air Pollution, and Statistical Analysis.
Fundamentally, this section needs to describe the subjects,
what you did to them, and what statistical methods you used.
After writing the first draft of the Methods section, ask your-
self whether what you are presenting allows
That is, could a trained investigator in your field replicate
your study, given the information you have provided?
Methods should not include numerical data, which should
be presented in the Results section.
Describe the subjects studied, including age, gender, and
other important characteristics that may be pertinent to
the study. Uniform Requirements recommends that when
authors use such variables as race or ethnicity, they “should
define how they measured these variables and justify their
relevance.” <
State also whether any potential subjects were excluded
and why they were excluded, if there is a meaningful reason.
For example, in the study of probiotics and infant colic, sub-
jects with chronic illness or gastrointestinal disorders were
Here you describe what was actually done to the subjects.
Also, if appropriate, describe any data collection tools, such
as survey instruments. If apparatus was used, identify the
item and manufacturer. Be sure to identify all drugs by
generic name; adding the trade name is optional, but is use-
ful for the practicing clinician. Be sure to include medication
doses and routes of administration.
Describe the statistical methods used, “with enough detail
to enable a knowledgeable reader with access to the original
data to verify the reported results.” <
> This generally means
identifying specific tests used. In the study of aircraft noise
and fatal MI, the description of the statistics used begins,
“We analyzed the association between aircraft noise and car-
diovascular mortality using Cox proportional hazard models,
with age as the underlying timescale. . . ”
In an effort to make this book more useful for those
involved in research studies, I have added a lexicon explaining
Commonly Encountered Methodologic and Statistical Terms.
(See Appendix
5) In the meantime, here are some thoughts,
several taken directly from the International Committee of
Medical Journal Editors (ICMJE) Instruction for Authors <
about the use of statistics in presenting reports of clinical
research studies:
Avoid relying solely on statistical hypotheses testing such
values, which fail to convey important information
about effect size <
When data allow, present quantifiable findings with appro-
priate indicators of measurement error or uncertainty,
such as confidence intervals <
When describing the statistics you employed in analyzing
data, specify the computer software used <
Don’t hesitate to seek help with statistics. It is easy to get
lost in the unfamiliar forest of statistical analysis. A study
by Strasak et
al. found, “Five of 31 papers for the New
England Journal of Medicine (NEJM) (16.1) contained
usage of wrong or suboptimal statistical tests, either
because of incompatibility of test with examined data,
inappropriate use of parametric methods, or use of an
inappropriate statistical test for the scientific hypothesis
under investigation.” <
Finally, as I was reminded by a reviewer commenting on
the first edition of this book, you should never allow a
pharmaceutical company or other research sponsor to do
the statistical analysis of your data <
lists some publications that may be helpful for the
statistically challenged.
Stick with the approach that the informed reader should
be able to replicate your research methods used and the
statistical analysis. Provide all data that were analyzed,
and show the outcomes of the statistical methods that you
described under Methods.
What did you discover? Describe your findings in a logical
sequence and do so fully, yet succinctly. To support my plea
for readability in research reports, I like the image created
by Alexandrov <
>: “Make data presentation so clear and
simple that a tired person riding late on an airplane can take
your manuscript and get the message at first reading.” (As a
physician, I find this a formidable challenge, given that with
the imperfect pressurization of aircraft cabins, there is a
measureable decrement blood oxygen saturation, and hence
in cerebral oxygenation, at 35,000
ft elevation).
I have sometimes said, only partly in jest, that the ideal
Results section has a single sentence, “The results are pre-
sented in Table
,” followed by a single carefully constructed
table. In reality, presenting research results is never this
simple, but the use of tables and figures can help organize
numbers in ways that cannot be accomplished in words. Also,
the Results section should begin with some explanatory prose
before sending the reader to the first table. Keep in mind that
tables and figures are expensive for the journal to produce
and are a leading source of error. On balance, however, most
Results sections benefit from one or more tables or figures.
The paper on the July spike in deaths, for example, has four
figures, all bar graphs.
Tables and figures for all types of publication models are
discussed in detail in Chap. 4. Here I will only emphasize
the importance of creating a legend for each that explains
the table so that it can be reasonably understood without the
Sources of statistical information for medical writers
, Colton
. (eds)
ncyclopedia of biostatistics. 2nd ed. Hoboken,
Wiley; 2005.
ntroduction to medical statistics. 3rd ed.
ress; 2000.
J. Statistics at square two. 2nd ed.
ooks; 2006.
edical statistics from
to Z: a guide for clinicians and medical students.
2nd ed.
ondon: Cambridge
ress; 2006.
, Hardin JW. Common errors in statistics (and how to avoid them) 2nd
d. Hoboken,
J: Wiley; 2003.
, Sterne J.
ssential medical statistics. 2nd ed. Hoboken,
J: Wiley-
lackwell; 2003.
, Secic
. How to report statistics in medicine:
nnotated guidelines for
authors, editors and reviewers (medical writing and communication). 2nd ed.
merican College of
hysicians; 2006.
nderstanding uncertainty. Hoboken,
J: Wiley; 2006.
eacock J,
erry S.
resenting medical statistics from proposal to publication.
ress, 2007.
accompanying text. That is, a lecturer can incorporate your
table with its legend into a PowerPoint presentation (with
credit to you, of course) without adding explanatory prose.
Tables and figures should not duplicate data presented in
the text. Select only one location to present the numbers.
In Chap. 1, I stated that each article must face the “So what?”
question. The Discussion section should answer that question
by stating the relationships among facts discovered, relating
them to prior studies (the ones you mentioned earlier in the
introduction), and postulating what it may all mean—the
conclusions. Discuss the results, but do not restate what has
already been said under Results. A good way to begin this
section is with the phrase: “Our study showed. . . ” <
The Discussion section is where you might describe your
opinion of the novelty of your findings, or how they may
affirm or contradict previous research in the field. For
example, in the study of breast cancer-related lymphedema
described above, the authors write: “Our results confirm and
contrast with findings from 2 recent studies of BCRL.” Here
is also where you describe any study limitations, or even any
disagreement among co-authors regarding the interpretation
of results.
The Holy Grail in all of this is
, a neologism
that is not in my Microsoft Word spell checker or
Medical Dictionary
, but that all researchers recognize. Does
what you have found apply only to your group of subjects, a
weakness of the small sample or the single-institution study?
Or do the results found have implications for similar patients
elsewhere, the obvious advantage of the large trial involving
thousands of subjects in various sites, such as the aircraft
noise vs. fatal myocardial infarction study mentioned at the
beginning of the chapter.
State any weaknesses of the study design, or these will
surely be described enthusiastically by reviewers or in let-
ters to the editor. The Discussion section is also where you
should tell about any factors that may have biased collection
of the data, such as unexpected events, attrition of subjects,
mid-study changes in methods, such as terminating one
of the study groups. The aircraft noise study, for instance,
describes the possibility of bias in the coding of deaths.
In the last paragraph (where the grazing reader may go
right after reading the abstract), present a summary of your
conclusions and what your team thinks they mean. State the
implications for others in your field, the generalizability of
your work, and perhaps how they might translate to patient
care in the office or hospital. Write this paragraph very care-
fully. It represents the outcome of months of effort.
Your references are where you have obtained background
information and indicate your awareness of prior work in
the area of your research. A focused list of citations is more
valuable to your reader—and to you, as author—than a very
long list of unselected papers.
References serve other purposes. Readers often use them
as part of their own research on topics. For these individuals,
your list is already a little out of date by the time it is pub-
lished, but it can be useful at times. Your reference list also
represents a sort of “merit badge” for the authors, indicating
that you valued their papers enough to cite them as credible
When using a reference citation to support a statement, be
sure that you are conveying the actual meaning of the author.
I have seen too many references used to support statements
when the paper cited says something entirely different. Today,
the ready availability of PubMed and other sites makes it easy
to match author assertions and the actual words of authors.
The technical considerations of presenting references are
similar for all publication models, and are presented in Chap. 4,
along with the most familiar models (Table
4.2). Here I will
list just a few additional suggestions and comments:
The ideal reference citation is the original research
Uniform Requirements recommend that you avoid citing
abstracts, such as “grey literature” conference abstracts,
as references <
If in doubt in listing the name of a journal, write it out,
because, for example, “Psych” could mean psychiatry or
By custom, a journal with a single word title, such as
, is written in full and is not abbrevi-
A paper accepted for publication, but not yet published,
can be cited as “in press” or “forthcoming.” <
> If the paper
is published before your article goes to press, the citation
can be updated in page proofs to provide the details of
Try to avoid using websites as references in a scientific
report; these sites contain a lot of specious data and out-
right fiction.
If you must cite a website: Because the site of electronic
citations can change or disappear altogether, the author
citing a Web site should print out a copy of the online
material, in case it is requested later.
Never cite a source you have not read and copied for your
electronic or paper files.
Some papers have a final section listing those who assisted
with the work. This includes “all contributors who do not meet
the criteria for authorship, such as a person who provided
purely technical help, writing assistance, or a department
chair who provided only general support.” <
> For example:
At the end of his article “How to Write a Research Paper,” <
Alexandrov states: “The author is not a native English speaker.
I am indebted to John Norris, MD, FRCP, for—among many
things during fellowship training—his patience with my la’s’
and lthe’s’ and the first lessons in study design, analysis and
presentation.” If financial or material support has not been
disclosed elsewhere, it should be included here.
There is one important caveat: Be sure that all the people
who you thank are pleased to be acknowledged and that
they actually agree with the substance of the paper. Being
mentioned allows readers to infer that those acknowledged
support the data and conclusions, whether this is true or not.
For this reason, you must have written permission from all
persons listed in the acknowledgments. Some journals have
specific online forms for this purpose; others will accept a
signed note on a letterhead.
What are the common mistakes seen in reports of clinical stud
ies? Despite the many hours of labor that go into scientific man
uscripts, there are a few errors that occur even with the most
experienced medical researchers and writers. Maybe some
creep in as unhappy compromises during group wordsmith
ing. Others may be the result of midnight editing, when not all
the mental light bulbs are on. Whatever the reason, we make
mistakes in following the recipe for writing research reports. To
help you avoid these missteps, I offer the following to act as a
checklist to use when you think your manuscript is done.
Be sure to prepare a Title Page listing the article title, the
names and affiliations of all authors, sources of support
such as grants, the number of tables and figures, a word
count, and anything else requested in your target journal’s
Instructions for Authors.
Remember that the title page should specify the “cor-
responding author”—the author who will represent the
research team in conversations with the editor—along
with this individual’s full contact information.
Check once again to assure that your title accurately
describes your study, and that it just might prompt the
casual reader to learn more.
Ask yourself: Have I stated the problem clearly?
Perform a last-minute review of the literature to assure
that you have not overlooked a recent key report.
Review the Results section of your research report to be
sure that it does not contain background information
(which should be in the Introduction).
Ask yourself: Have I tried to put too much in my tables
and figures?
Also check to be sure that you have not repeated the same
data in tables, figures and text.
Verify that interpretation of what you found is in the
Discussion section and not in Results.
Remember that the Discussion section is not the place to
introduce new information.
The ICMJE Uniform Requirements advises: “Avoid non-
technical uses of technical term in statistics, such as
lrandom’ (which implies a randomizing device), lnormal,’
lsignificant,’ lcorrelations,’ and lsample.’” <
Eliminate overly-clever phrases and clichÂs.
Consider ruthless removal of anything that causes you to
think, “I just want to get this fact in print.”
Reconsider acknowledgements: Remember that leaving
someone out can lead to hard feelings.
Assure that you have clearly identified any potential con-
flict of interest.
Have a last meeting of the research/writing team to assure
that everyone knows exactly what is being submitted and
that all agree, once again, on the initial target journal.
2uality Writing and Research Design
Medical composition is a laudable skill, one that we should all
work to improve. Wager, in an article telling “What Medical
Writing Means to Me,” <
> observes that medical writing
“inhabits a strange boundary zone between science and art.”
When it comes to writing a report of a clinical research study,
however, the art of medical writing skill must take a back
seat to research design. Have you ever read a research report
and wondered whether the skillful prose—perhaps composed
chiefly by an editorial assistant—masks questionable methods
or unjustified conclusions? As Dirckx <
> has written, one
should guard “against the temptation to cover his lack of
information with a rhetorical snow job, to palm off muddy
thinking under a veneer of smooth writing.” Medical writing,
especially in the case of research reports, is chiefly about
medical science, and here art cannot trump science.
Stating What You Really Think
Reports of clinical research studies are often written by com-
mittee; the members seek consensus on what will appear in
print. Perhaps this is why the final version of the paper does
not always include the heartfelt opinions of some researchers
on the team and often does not reflect the diversity of author
opinions. Richard Horton, editor of
The Lancet
, surveyed
contributors to ten research articles published in
The Lancet
Thirty-six of 54 contributors to the ten articles responded to
questions in a qualitative analysis. The research question in
the study was: “To determine whether the views expressed in
a research paper are accurate representations of contribu-
tors’ opinions about the research being reported.” <
> The
study found unreported concerns about study weaknesses,
and disagreements among authors about findings and their
significance. The study concludes that one remedy for the
problem of suppressed opinions may be structured Discussion
sections in research papers, as we now see in Abstracts.
Research Mentors
Research is best undertaken in teams, and members of the
team bring different skills, one of which may just be men-
toring. Research mentors can be especially important team
members, who provide nurturing and guidance to the less
experienced. They help keep young researchers on track,
which can yield surprisingly good outcomes. Hoff <
> writes:
“When I finished medical school, I did not intend to do
research as part of my life in surgery. That all changed when
I met a mentor who inspired me during my training days.
had some protected time, assembled space and equipment,
developed a hypothesis, and went to it. I’ll never forget my
first experiment and publication. Frankly, it was my best.”
Getting Your Research Report in Print
General Douglas MacArthur once said, “There is no substitute
for victory.” In academic medicine, there is no substitute for
publication. You can have a brilliant idea, perform ground
breaking research, and write the results with great proficiency,
but if the paper is not published—so that it can be cited, criti
cized, or praised—then the effort has been largely wasted. The
advancement of science depends on sharing of knowledge in
print. Chapter 12 discusses how to achieve publication, for
your research report or other publication models.
Day RA. How to write and publish a scientific paper. Westport,
CT: Oryx, 1998;12, 34.
Cohen DJ, Crabtree BF. Evaluative criteria for qualitative
research in health care: controversies and recommendations.
Ann Fam Med. 2008;6(4):331–339.
Whimster WF. Biomedical research: how to plan, publish and
present it. New York: Springer, 1997;101, 105.
International Committee of Medical Journal Editors. Uniform
requirements for manuscripts submitted to biomedical journals.
Available at:
Strasburger VC. Righting medical writing. JAMA. 1985;
Nakayama T, Hirai N, Yamazaki S, Naito M: Adoption of struc
tured abstracts by general medical journals and format for a
structured abstract. J Med Libr Assoc. 2005 Apr;93(2):237–242.
Journal of the American Medical Association. Instructions
for authors. Available at:
Strasak AM, ;aman 2, Marinel G, Pfeiffer KP, Ulmer H. The
use of statistics in medical research: a comparison of The New
England Medical Journal and Nature Medicine. American
Statistician. 2007;61(1):47–55.
Gotta AW. Review of Taylor RB. The clinician’s guide to medi-
cal writing. Ed. 1. New York: Springer-Verlag, 2005. In: JAMA.
Alexandrov AV. How to write a research paper. Cerebrovascular
diseases. 2004;18(2):135–138.
Wager E. What medical writing means to me. Mens Sana
Monographs. 2007;5(1):169–178.
Dirckx J. Dx
Rx: a physician’s guide to medical writing.
Boston: G.K. Hall; 1977:99.
Horton R. The hidden research paper. JAMA. 2002;287:
Hoff JT. Research by academic surgeons. Am J Surg. 2003;
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6_12,
© Springer Science+Business Media, LLC 2011
been able to write it up. These are all important steps; the
next is getting your work in print. Notice that I say, “Next
step,” because, as I will explain at the end of the chapter,
there are things to consider even after publication. What
follows are hints as to how to get your work published. The
advice is general, and applies to all the publication models
discussed in the book, not only to research reports.
Fundamentally, publication follows an invitation by an edi-
tor that is accepted by the author following submission and
consideration of a manuscript. Of course, along the way there
will be peer review, editing changes, and sometimes a major
revision or two. But, following negotiated changes, author
and editor must both say, “Yes.”
In fact, you and the journal editor have consistent goals.
You, as author, want your work in print as soon as possible.
The editor needs high-quality articles for publication, in most
cases each month. You and the editor need one another. As
King <
> writes, “Authors and publishers thus live in symbio-
sis. The unpublished manuscript accomplishes nothing for its
author, and a journal without manuscripts speedily dies.”
Submitting Your Article to the Right Journal
Planning the journal for first submission is an important
step that should begin as you conceptualize the paper, as
discussed in Chap. 1. In many cases, you will call or send
an e-mail query to the editor to see whether there is some
interest in the topic. If so, this publication then becomes your
“target journal.”
Pay attention to how often the journal publishes papers
similar to yours. What topics are generally presented in the
journal? If you have a paper on a general medical topic, such
as irritable bowel syndrome, depression, or chest pain, your
range of journal possibilities is wide. If your paper describes
a urologic surgical procedure or a method of teaching psy-
chologic assessment of the geriatric patient, your choices are
more limited.
Sometimes you will sense an unmet need. If your research
shows that the
Annals of Internal Medicine
has published no
articles on gynecologic topics over the past few years, that
finding can mean one of two things: either the journal editor
considers gynecologic articles outside the scope of the jour-
nal, or the editor has received no useful submissions in this
area, and would welcome your paper on current approach to
the female patient with pelvic pain.
In selecting your target journal, consider the following
The Variety of Article Formats
Some journals accept almost no articles that are not research
reports. Others limit themselves to review articles. Some pub
lish case reports; other journals never do so. In some journals
you will find invited editorials—that is, written by persons
who are not the editor of the journal. In other journals, only
the editor writes the editorials. Here are two ways to check on
the variety of article formats published: (1) scan several recent
issues of the journal, which is also helpful in determining the
scope of topics, the usual writing style, and what authors are
publishing in the journal; and (2) review the instructions for
authors, which will probably describe the types of articles
published, with some guidelines for the preparation of each.
Fortunately, both the tables of contents for recent issues and
instructions for authors for almost all journals are available
on line, with no need to make a trip to the library.
The Journal’s Impact Factor
For the author submitting a research report, the impact fac-
tor becomes a two-edged sword. On one hand, the impact
factor of the journal in which your article is published is the
key to having your findings widely cited <
>. On the other
hand, and this is why I bring up the impact factor again, a
journal’s high impact factor reduces your chances of accept-
ance. The most prestigious journals receive huge numbers of
submissions. The most submissions of all are likely to go the
major broad-based journals with high impact factors, with
acceptance rates often below 10.
Aiming High: The Controversy
Some investigators submit their papers first to one of the
most prestigious journals. Of course there is only a slim
chance of acceptance, but the authors generally recognize
this fact. What they seek is a critical review of the paper by
experts. In recommending rejection, the peer reviewers will
identify the weaknesses of the paper. This allows the author
to fix the problems before submitting the paper to what was
always the true target journal.
One disadvantage to such a practice is that it delays pub-
lication. The turnaround time in peer review and editorial
decision-making can be measured in months. For a paper
that has very timely data, this delay may actually work
against publication.
The larger question is the ethical issue of seeking what is
really a free consultation regarding your paper, when you
know that your chances of acceptance approach zero. Yet one
goal of volunteer peer reviewers must be to help investigators
and authors prepare the best papers possible.
Working with Journal Editors
Working with editors means recognizing and respecting what
they want from you. Norton <
>, an assistant editor of the
Journal of the American Academy of Dermatology
, writes, “I
would be proud if every article published in the Journal were
novel, interesting and important—in other words, if every
article were both readable and worth reading. (I’d also like
it if every article were eloquent, funny, and short). The edi-
tors would love to receive manuscripts that are perfect when
first submitted, but these papers rarely exist. The peer review
system is intended to select the most worthwhile papers and
nudge them along toward that elusive perfection.”
“Read the instructions, Grandpa.” This was my then-5-
year-old granddaughter’s directive when mixing ingredients
to make pancakes, starting a board game, or trying to operate
a new electronic gadget. My granddaughter was on the right
track. Journal editors earnestly wish that more authors would
actually read—and follow—the instructions for authors.
Failure to do so results in extra work for both editor and
author. It can cause delays, as the manuscript is returned for
the missing pieces. Sometimes failure to
follow directions
can result in summary rejection (see below),
simply because
it was egregiously nonconforming.
If you read Author Instructions carefully, you may learn
some very useful facts. One of these has to do with getting an
early opinion from the editorial staff. For example, the
England Journal of Medicine
(NEJM) offers a Presubmission
Inquiries/Fast Track: “Send your summary via our Rapid
Review request form. You should hear back from us within
36 hours. Rapid Review allows a manuscript to be reviewed
by the Journal, and a decision on publication will be reached
within two to three weeks. A Rapid Review does not in any
way guarantee acceptance of the manuscript nor does it
promise rapid release if the paper is accepted. Each of these
decisions will be made separately.” <
Good Manuscripts and Bad: What Editors Think
Here is what one editor thinks about good and bad articles:
Wonderful articles are alike in so many ways. They have a con-
cise introduction that proposes a testable hypothesis, a meth-
ods section with a good study design, a results section in which
the statistical analysis addresses clinical relevance as well as
statistical signiêcance, and a discussion in which points are
made succinctly and are based on evidence, not conjecture. In
wonderful articles, the prose is clear, ëuent, and direct. On the
other hand, unhappy articles are often uniquely bad, each with
In an insightful, but humorous editorial in
JAMA, Grouse
> identifies a “rogue’s gallery of medical manuscripts.” The
following describes a few of the perpetrators.
The Clone
The clone is born as a researcher attempts to publish two or
more papers based on data in a single study. The act of sub
mitting clone articles is sometimes called fractionated publi
cation, salami science, or duplicate publication. Von Elm et
>. reviewed 56 systematic literature reviews that included
1,131 main articles. They report, “Sixty articles were pub
lished twice, 13 three times, 3 four times, and 2 five times.”
Academic institutions must bear some responsibility for
this behavior, as promotion and tenure committees
count the number of publications listed on a candidate’s
curriculum vitae (CV). Journals contribute to the
problem with
a reluctance to publish long research reports. Nevertheless,
the clone wastes valuable journal space in repeating back-
ground material, methodology and often-similar conclusions
in several papers.
The Chain Letter
The chain letter is a variation on the clone. In a chain letter,
a research group lets each member be first author by submit-
ting an ongoing series of papers that present just a little more
data from an ongoing study plus a great deal of previously
published results. Each version of the chain letter varies a
little in the list of authors and in the title of the article.
The Attention Grabber
In this manuscript the authors may have conducted perfectly
good research, but they postulate sometimes-outrageous
conclusions that go beyond their data. In many cases, the
discussion suggests some breakthrough in the diagnosis or
treatment of disease that is sure to be reported in the media.
An egregious variation on this behavior is when the authors
release their findings to the media just as their scientific
article goes to press.
The Shell Game
A shell game occurs when an author submits the identical
paper to more than one journal at a time. Playing the shell
game is risky and some say unethical. The player “wins”
when one journal accepts the paper, and it is rejected by
all the others. The player loses when two or more journals
accept the article, and all but one must be told (or learn) of
the ruse. The shell game wastes reviewers’ and editors’ time.
It can make for duplicate publication if the author doesn’t
withdraw the paper from all but one publication. Journal edi-
tors hate shell game players.
The Ambush
In his paper, the author launches a missile aimed at a
in the field. The Background or Discussion section of the
paper contains a cleverly crafted criticism of the colleague’s
work, perhaps including an attack on the individual.
The ;ombie
This describes a manuscript that never dies. When a
rejects an article in no uncertain terms, it means that the editor
does not want to see the manuscript again. The
author’s job
is to make any needed changes, and then submit the
elsewhere. Do not let your manuscript become a zombie by
resubmitting it to the editor who rejected it without an invita-
tion to do so.
By now you have selected the best journal for first submis-
sion, contacted the editor or decided why you should not do
so, and made sure your manuscript will not be considered
one the “rogue’s gallery” described above. It is time to take
care of the last technical details of manuscript submission.
Submission Letter
A submission letter should accompany every manuscript
from research report to letter to the editor. Also sometimes
called the “cover letter,” the submission letter provides infor-
mation about your paper and about you as the author(s). The
letter should be addressed to the journal editor, by name.
Identify the title of the paper just before the salutation in the
letter. Table
describes the contents of a comprehensive
submission letter.
Title Page
The title page gives important data about the paper and the
authors. The title page should include the following items,
which are consistent with the recommendations of the
International Committee of Medical Journal Editors (ICMJE)
> and the instructions for submission to the
New England
Journal of Medicine
The article’s title
Each author’s name, academic degree(s), and institutional
The name of the department(s) and institution(s) where the
work was done
Disclaimers, if any are appropriate
The corresponding author’s name and full contact infor-
The name and address of the person to whom reprint
requests should be addressed, or a statement that no
reprints will be available
Sources of support, such as grants
A running head (a short version of the title) that will
appear on each manuscript page
Literature Review Update
Just before submitting the manuscript, repeat your litera-
ture review. Important papers may have touched on your
topic since you did your original literature search. Be sure
that there has been no “breakthrough” study that should be
acknowledged in your article. Assure yourself also that no
one has recently published a paper just like yours. Having
someone beat you to publication on a topic should not dis-
courage you from submitting, but you should know that the
playing field has changed.
What to Submit and in What Order
When you finally have collected all the pieces, it is time to
assemble your submission file. Unless specifically instructed
otherwise, assemble your materials as follows:
Submission letter
Title page
Key words
Body of the text
Tables with legends, each on a separate page
Figures with legends, each on a separate page
Check the Instructions to Authors carefully if you are submit
ting artwork that is not appropriate for on-line submission.
When you are all ready to submit, review the checklist in
to help assure that you are not forgetting anything.
Electronic Submission of Manuscripts
Today almost all journals accept electronic submission of
manuscripts, whether as an email attachment, on a compact
disk, or by downloading onto the journal’s web site. This
saves time and money for the journal, and facilitates the
peer review process; no paper, no delay in the mail. Different
journals have different requirements. For example, the NEJM
states <
>: “All text, references, figure legends, and tables
should be in one double-spaced electronic document (Word
Doc or PDF). You may either insert figures in the text file or
upload your figures separately. We prefer the former, but this
may not work well for complicated graphics, which should
be sent separately.”
As one who has made the transition from carefully
manuscripts to submitting electronically, I can attest that the
online way is not necessarily easier than the old method. To
check my belief, I spoke with my colleague Rick Deyo, MD,
MPH, who has published scores of highly regarded papers in
top journals. Loosely quoted, here is what Rick told me: “I allow
2–3 hours for an electronic submission. This is even for journals
anuscript checklist for journal article or book chapter submission
ouble-space the entire manuscript, including references unless
otherwise instructed
se 12-point font unless the instructions specify otherwise
eave the right margin of the manuscript unjustified (i.e., ragged)
dentify all abbreviations when first used in the text
with which I am familiar. Some want all parts of the manuscript
bundled; some want them submitted
separately. I may have to
look up co-authors’ addresses and email addresses. Or they
will request an extra document. There is always something.
It takes time.”
The “always something” can be unique to the journal. For
instance, the British Medical Journal asks authors to com-
plete a “What This Paper Adds” box, providing a thumbnail
sketch of what the article contributes to the literature, an aid
for readers seeking a quick overview <
Here is a special caution when downloading to a journal
site. Never attempt to compose on line. You are likely to be
timed out and lose what you created—very frustrating. Instead,
compose everything on your computer so that you can “copy
and paste” to appropriate locations on the journal’s site.
Other than the above, submitting online is a lot like mail-
in submission used to be. You still need all the manuscript
“pieces,” and the checklist above is still pertinent. What’s
different is that there is no envelope, no postage, no lost pack-
ages, and, once the system is mastered, things move much
faster. And reviewers no longer receive manuscripts with
smudges and coffee stains.
Some Mistakes Made in Submitting Manuscripts
The discussion above will help you avoid most technical
manuscript submission errors. Here are some additional
ways authors go wrong.
Relying on Your Spell Checker
Your Microsoft Word spelling and grammar utility is excel-
lent, but it will not detect all errors. For example, type in the
Eye no hat correct spellings is important, and sew eye was
care full to us the spell checker.
My Microsoft spellchecker accepted this sentence as correct.
Also, proofread to be sure words are left out, especially if the
Whoops, again! In reading, did you notice the omission of the
word “no” from the example sentence, an omission that my
spellchecker also approved?
Touting Your Paper
Do not use your submission letter to tell the editor that yours
is a VERY IMPORTANT paper. Editors look at many articles,
and can recognize those that are important, especially with
the advice of peer reviewers. Your paper is not a used car to be
“sold,” claiming to report the greatest advance since Wilhelm
Conrad Roentgen took a snapshot of his wife’s hand in 1895.
Seeking Perfection
Earlier in this chapter, I quoted Norton about the quest for “elu
sive perfection.” In fact, your paper will never be perfect, either
as to content or manuscript preparation. Do not undertake
multiple, but trivial, revisions. At some time you must say, as all
writers and artists must eventually do, that this is as good as I
can reasonably make it, and I am going to declare it done.
Journal editors want pertinent, timely and well-written
articles, and will make allowance for small deviations from
minor technical requirements so long as they do not interfere
with reading, reviewing, or editing the manuscript. That is
not to say that the editor may not require corrections before
the manuscript is published. The point is that you should
do your very best when writing a paper. However, do not
fret about whether the terminal page numbers in references
should be written in full or truncated. Such minor variations
will not cause rejection, and perseveration over trivia can
only interfere with your writing success.
Your manuscript has been received by the journal and has
been sent for review. Your article was not summarily rejected,
sent back immediately by the editor as being “not appropri-
ate for consideration by the journal.” That would have meant
that the editor believed the work to be outside the journal’s
field or that it is libelous, blasphemous, or totally irrational
>. You have passed the first hurdle. Things are now in the
hands of the peer reviewers.
Peer Review
The Role and Duties of the Peer Reviewer
The journal editor considers the peer reviewers who will read
and comment on your paper to be familiar with your topic.
Many are senior academicians and investigators. All are
volunteers, and they do a lot of work for no pay. Peer review-
ers, sometimes called referees, can be a very big help to you,
even if your paper is ultimately rejected.
How are peer reviewers chosen? Each journal has a panel
of peer reviewers who have been recruited by the editor. If
you wish to be a peer reviewer, send a letter and your curricu-
lum vitae to the journal editor and volunteer to serve. State
the areas in which you have some expertise and are willing
to review papers. The editor will reply, and perhaps add you
to the review team. Editors want their peer reviewers to have
certain traits. Peer reviewers should be knowledgeable in the
topic under consideration, intellectually honest, and time-
sensitive. The author and editor cannot wait 6
months for a
paper to be reviewed. In reviewing reports of clinical stud-
ies, a peer reviewer should know research methodology and
basic statistical analysis. In the end, the peer reviewer helps
to improve the paper, making it clearer, more informative,
and often shorter—even if the paper is ultimately rejected by
the journal. (Remember that the paper will then be revised
and submitted to the next journal on the list.) These are
exactly the traits you hope for in the reviewer who evaluates
your paper.
The duties of a peer reviewer can be summarized as
Accept a paper to review only if the job can be completed
within the time specified in the editor’s request.
Agree to referee papers only in areas of the reviewer’s
Maintain confidentiality about the paper.
Disclose any possible conflict of interest, and decline a
review if there is any potential difficulty.
Write a thoughtful review that is honest and free of bias.
Aim to make the paper the best it can be, balancing criti-
cism with suggestions for improvement.
Avoid excessively harsh comments, especially those that
could be interpreted as a personal attack on the author(s).
The opportunity to comment anonymously on unpublished
papers can bring to the surface heretofore-submerged
sadistic traits, which must be recognized and stifled.
Submit the review promptly. The authors of the paper are
anxiously awaiting a verdict.
The peer reviewer never contacts the author directly. In most
cases, but not all, the name of the author is not present on the
paper being reviewed. Remember that the author’s name goes
only on the title page, which is not sent to the peer reviewers.
There are exceptions. The last paper I reviewed contained the
names of the authors and there had been no effort to “blind”
the review. Even when the names of authors and institutions
are absent in blinded reviews, the peer reviewer who is work-
ing actively in the field can often deduce the source of the
paper based on the topic, methods, and even writing style.
I think of the roles of a peer reviewer and a practicing
clinician as somewhat similar. Both are expected to exhibit
ethical behavior and to be committed to providing high-
quality service. Both the reviewer and clinician should be
knowledgeable, capable, and thorough in what they do. Both
have the ability to examine details while keeping a broad
perspective. Both are reliable and trustworthy, and believe
that they serve a worthy purpose. And, if careless, both can
cause a lot of harm.
The Role and Duties of the Editor
The editor makes the final decision about acceptance or
rejection of an article. Of course, an editor’s decision is based
strongly on the recommendations of the peer reviewers.
Although it is significant that most papers seem to go to three
reviewers, not two or four, the final decision is not a “vote.”
Editors are paid to make judgments, and they do so.
Editors, like peer reviewers, must be honest, ethical,
unbiased, responsible, and detail-oriented. They must also
be literate, knowledgeable, and compulsive as to deadlines.
After all, most journals must be published every month, some
more often.
The editor serves as the buffer between the author and the
peer reviewers. As such the editor must be able to deal with
authors who are disappointed or angry. In other cases, the
problem is tardy or sloppy authors. A good editor can handle
all these problems with tact and grace.
What Actually Happens
Here is a quick summary of what occurs when you submit an
article to a medical journal. You will establish an identity on
their manuscript tracking system, following which you will
send your manuscript on line. Your article will be assigned
an identification number, and you may be asked for some
additional data, such as release forms or identification of an
“archival author,” who will be responsible for maintaining
records of the study.
Next the editor or assistant editor looks over the article
quickly to see whether it merits peer review. As discussed
above, articles with topics outside the journal’s scope or those
that are carelessly prepared will be immediately rejected and
returned to the author. Those that survive the initial screen are
sent to referees for peer review, a process that has changed little
in decades. The editor’s choice of reviewers is probably more
intuitive than scientific, something along the lines of: “I think
so-and-so would be a good person to look at this report.”
After (what we hope is) a careful reading, each referee
prepares an evaluation. Most evaluations have two parts; one
part is for the editor’s eyes only, and one part is sent to you,
the author. The part sent to you can be quite valuable—or
not—as discussed below.
When all reviews are received, the editor makes a deci-
sion and lets you know the outcome of the process. If you
have not heard about a decision in a reasonable time, let’s
say 6–8
weeks from the time of submission, it is a good idea
to contact the journal. For example, your paper may be in
a pending file while the assistant awaits receipt of a third
review, due from a referee who has left for a 4-month trek in
Nepal. Some journals offer a way to keep track of the proc-
ess. For example, the
New England Journal of Medicine
authors to track the status of manuscripts through the Author
Dashboard of their Scholar One manuscript system <
Possible Responses from the Journal Editor
The journal editor’s decision will come as a letter that indi-
cates one the following: rejection, revision, or acceptance.
Rejection Letter
The rejection letter is the one you really don’t want to receive.
The editor will probably avoid the word “reject,” and instead
will euphemistically state that it “does not meet the Journal’s
needs” (Note that editors always refer to their publication as
“the Journal,” with a capital “J”). The editor is not only saying
that, after careful review, your paper will not be published in
their Journal. This response also connotes that it cannot be
improved to make it consistent with their standards. The edi-
tor simply does not want to see your paper again.
Unless you have had the bad luck to compete with an
article in press that is very similar to yours, the rejection will
be attributed chiefly to the evaluations of the referees. These
comments will usually be sent to you, and you should read
them very carefully. The decision to reject will be based on
one or more of the reasons listed in Table
Your first reaction will probably be denial. Could this edi-
tor really have rejected my paper? Could there be a mistake?
Maybe this rejection notice was meant for someone else.
Then you read the reviewer comments and become annoyed,
actually furious. How could they miss the point of my paper?
Did the referees read the paper at all?
Next you settle down and consider appealing the decision.
Should you request reconsideration? Actually, this sometimes
lassic causes of article rejection
opic considered unimportant or outside the area of interest of the journal’s
utdated or inaccurate information
nadequate literature review
works. Whimster <
> estimates success “in perhaps 15 of
cases.” Your appeal must be rational and civilized. Describing
the referees as troglodytes will not advance your cause.
reasonable appeal letter should politely refute the review-
ers’ criticisms point by point, citing evidence. Show how your
paper will be especially important to the journal’s readers
and how this point may have been overlooked. Indicate any
recent publications that validate your findings and conclu-
sions. Type your brief, let it sit for a day or two to cool off,
and then revise to expunge any hint of anger. Then mail the
appeal letter, and prepare to be rejected again.
Then sadness sets in. Maybe I am not cut out to be a medi-
cal writer. Perhaps I should spend my spare time working in
the yard or traveling to Europe. How could I have ever had
the hubris to think that I could get my work in print?
By this time have you recognized our progress through the
classical stages of bereavement—denial, anger, bargaining,
depression, and acceptance—described by Elisabeth KÕbler-
Ross? <
The final step is to accept the judgment of journal number
one. At this point, you should use this opportunity to improve
the paper. Seek the nuggets of truth in the reviewers’
remarks. Yes, I know that at least one of the reviewers seems
to have totally misunderstood the paper, and maybe there is
message there. Make the appropriate revisions and update
the literature search and references, especially if a few
months have passed. Then submit the paper to another jour-
nal. Do this soon to help prevent becoming discouraged. As
a hint, subsequent submissions are sometimes more success-
ful when sent to more specialized journals, especially those
with lower rejection rates than the
Journal of the American
Medical Association
(JAMA) or the
British Medical Journal
(BMJ), both of which reject more than 90 of submissions.
When preparing the second submission, read the journal’s
instructions and make sure your manuscript complies with
its technical requirements, which are sure to differ from
those of the previous journal. Basically, the second submis-
sion should have no indication that this is not the first time
the paper has left your desk. There is, of course, the chance
that one of the reviewers for the second journal may be the
very same person who was a referee for the first publication,
an occurrence most likely in limited scientific fields.
Even the best writers suffer rebuff at times. Bryson describes
the comments of a journal editor upon receiving an advance
copy of Charles Darwin’s
On the Origin of Species
in 1859.
He counseled Darwin that the book, although meritorious,
would never appeal to a wide audience. The editor, in a help-
ful mood, undoubtedly noting the many pages about birds in
the book, suggested that Darwin write a book about pigeons.
“lEveryone is interested in pigeons,’ he observed helpfully.”
> I recommend that you save all rejection letters. Put them
in a folder in the back of your file. Medical writers all receive
many such letters, and the file may eventually overflow. Years
from now you will read them and chuckle.
As I leave the grim topic of rejection letters, allow me to
indulge my sense of humor by describing what I consider
some amusing examples.
“Dear Contributor. We are returning your dumb story.
Note that we have not included our return address. We
have moved to a new office, and we don’t want you to
know where we are” (Source: Peanuts cartoon in
, March 5, 2004).
“Your work was good and original. Unfortunately the
good bits were not original and the original bits were not
good.” Richard S. Smith, former editor of BMJ tells that
this was a rejection letter actually used at the BMJ during
his tenure <
“I am returning this otherwise good typing paper to you
because someone has printed gibberish all over it and put
your name at the top” (Source: Writing quotes. Available
And my favorite, a letter sent to a writer by a Chinese pub
lication: “We have read your manuscript with boundless
delight. If we were to publish your paper it would be impos
sible for us to publish any work of a lower standard. And as
it is unthinkable that, in the next 1,000
years, we shall see its
equal, we are, to our regret, compelled to return your divine
composition and beg you a thousand times to overlook our
short sight and timidity” (Source:
Nemy E. Must you, if
you’d really rather not? References and other
tortures. The
New York Times, February 24, 1994, page C8).
Revision Letter
This is a much better letter to receive than the rejection
letter. Be aware that the revision letter, sometimes called the
modification letter, can be misleading. It can begin with the
cunning phrase, “I regret to inform you that your paper does
not meet the Journal’s requirements in its present form.” Oh,
sadness and gloom! But read on. The next sentence may be,
“However, if you make revisions as suggested by the peer
reviewers, we will be pleased to reconsider your submission.”
Hooray! This is actually a conditional acceptance letter. If you
agree with the suggestions offered by the referees, you should
make the recommended changes and thank the reviewers
in your resubmission letter. Your resubmission cover letter
should also indicate where changes were made and how they
relate to the comments of the referees and editor.
In a descriptive analysis of manuscripts submitted to and
eventually published by the
Annals of Internal Medicine
Purcell et
al <
>. identified five leading types of problems
prompting manuscript changes during peer review and revi-
sion. These were: “too much information, too little informa-
tion, inaccurate information, misplaced information, and
structural problems.” They further state, “Changes most often
occurred because information was missing or extraneous.”
In modifying your paper, focus your effort on the suggested
changes. Consider the language offered by your reviewers,
which should be used in any letter responding to reviewer com
ments. Does some of this language also belong in your paper?
Do not add new data or conclusions, which can only give the
editor and referees something new to criticize. Make surgical
repairs and resubmit before the editor has a change of mind.
One dilemma you may face is the revision letter that
invites you to cut your paper to 500 words for a brief report
or shorten to a letter to the editor (see Chap. 7). This calls
for some soul-searching, discussion with coauthors, and per-
haps consultation with a trusted senior advisor. On one hand,
such an invitation suggests virtually certain publication in a
journal high on your list. On the other hand, you have to give
up on full presentation of your data and conclusions. I can
only recommend that your writing team struggle to a unani-
mous decision.
Acceptance Letter
Someday you might receive the following letter:
The three referees and I have all read your paper.
We agree that your methods are ëawless, your results are bril-
liantly stated, and the conclusions are logical and important.
We have no suggestions to make and wish to publish the paper
Yours truly,
But I don’t think that letter will ever come. If you submit an
article to a major refereed clinical journal and it is accepted
upon first submission without a single revision, let me
know and I will take you to dinner the next time you are in
Portland, Oregon.
Most acceptance letters follow one or more revisions.
This is probably a good idea, because the revisions, based on
reviewer comments, usually result in better papers in print.
Whose Papers Are Published and Why?
In the next few paragraphs, I share some of the dark secrets
of medical publication, especially in regard to research
reports. Tell no one what you read next!
About Peer Review
Peer review may not be the pristine process we imagine.
Conflicts of interest are rampant, especially in focused
research communities. There are only so many investigators
who are experts on, as a fanciful example, the new vaccine
against male-pattern baldness. Few people would have the
expertise to review papers in this area, and all may be at
different stages along the same path to a very lucrative dis-
covery. Is it possible that the reviewer might make use of the
information in the paper being reviewed? Such use would
be unethical, but I suspect that it might happen. Or might a
reviewer unfairly criticize a paper that seems a few months
ahead of his own submission of parallel findings?
Occasionally review decisions lack the integrity and quality
we authors hope for. Strasburger <
> describes a somewhat
jaundiced view of the peer-review system in medical journals:
“There, one’s peers may have a decided self-interest in not
seeing a particular article published, may simply not know
very much about the subject, or may be inexperienced writers
themselves. Reports may be criticized by someone who is an
linferior,’ rather than a lpeer.’”
Few studies have examined the peer review process, I
found a recent one that is quite revealing. The research
question had to do with positive-outcome bias by reviewers.
Emerson et
al <
>. fabricated two versions of a well-designed
randomized controlled trial, differing only in the principal
end point—positive outcome vs. no difference. The papers
were submitted to 238 reviewers for two prestigious ortho-
pedic journals; 210 reviews were returned. The investigators
report: “Reviewers were more likely to recommend the posi-
tive version of the test manuscript for publication than the
no-difference version (97.3 vs. 80.0,
Smith considers peer review to be slow, expensive and
ful <
>. Yet today we have nothing better to offer, and medical
writers need to cope with its inefficiencies and caprice.
Your Native Language Matters
When we consider the worldwide scientific community, it
becomes apparent that more than half of all published research
reports are written by authors whose first language is some
thing other than English. If you speak English as your native
language, you have an advantage over others around the
world. A study by Coates et
al <
>. found, “The acceptance
rate of non-mother English tongue authors is generally a lot
lower than that for native English tongue authors.” A survey
of Korean authors submitting papers in English-language jour
nals revealed that the respondents perceived the “linguistic ele
ments of journal papers” to be the most problematic area <
The fundamental issue seems to concern language
problems in manuscripts, rather than discrimination against
international contributors. Imagine yourself as someone
struggling to master a language in which we drive our cars
on parkways and park in driveways. Our patients describe
feet that smell, noses that run, and heartburn doesn’t relate
to any type of cardiac disease. In this book, I am guilty of
using idiomatic metaphors such as “game plan,” “sweep-
stakes,” and “shell game.” Consider yourself, as one who
speaks English daily and other languages infrequently or
not at all, being required to submit your scientific paper in
Russian or Japanese language. My manuscript would surely
be full of grammatical errors. This helps explain the study
findings by Coates et
al <
>. that, in submissions to the jour-
Cardiovascular Research
, “The US/UK acceptance rate
of 30.4 was higher than for all other countries. The lowest
acceptance rate of 9 (Italian) also had the highest error
rate.” Simply stated, the authors conclude that with articles
of equal scientific merit, a poorly written, grammatically
challenged article is more likely to be rejected.
About Authors and Affiliations
An eye-opening article all medical writers should read was
published in 1982 in
Behavioral and Brain Sciences
. Authors
Peters and Ceci <
> wondered about the adequacy and
fairness of peer-review practices. Here is what they did:
The authors selected 12 articles by researchers in highly
respected United States psychology departments like Yale
and Harvard. Each of these articles had been published in
a different, prestigious American psychology journal with
high rejection rates (80) and non-blinded peer reviewers.
The authors substituted fictitious author names and institu-
tions (something like the Mountain View Center for Human
Potential) for what had been listed on the original papers.
The manuscripts, with only author names and institutions
changed, were then retyped and formally resubmitted to the
same journals that had peer reviewed and published them
months earlier.
What happened to the 12 papers? Thirty-eight editors and
reviewers evaluated the altered articles; only three detected
the ruse. Nine of the 12 articles were earnestly reviewed,
resulting in an editorial decision. In the end, eight of the
nine were rejected. Sixteen of 18 referees had recommended
against publication. In many cases, the referees described
“serious methodological flaws.”
The authors ponder the possibility “that systematic bias
was operating to produce the discrepant reviews. The most
obvious candidates as sources of bias in this case would be
the authors’ status and institutional affiliation.” <
In getting published, who you are, where you work, what
language you speak daily, and who reviews your paper may pro
foundly influence whether your paper is accepted or rejected.
Competition for Journal Space, Industry-Sponsored Studies
and Editorial Conflict of Interest
Here is another little-recognized truth about medical publi-
cation. You and your writing team seeking publication are
up against a formidable opponent—the industry sponsored
study. Seventy percent of studies published in the five leading
medical journals are funded by industry <
We begin with the fact that publication space is precious,
especially in the top-rated journals (Read: those with the high
Impact Factor). Then consider the money, research know-
how, and writing skills available to pharmaceutical firms—
those companies that have a vested interest in clinicians like
me prescribing their products. Is it any wonder that industry-
sponsored studies achieve better journal “placement” than
non-industry-sponsored studies? Here is an example: In a
Cochrane Database Systematic Review of 274 published
influenza vaccine studies, Jefferson et
al <
>. “found industry
funded studies were published in more prestigious journals
and cited more than other studies independently from meth-
odological quality and size.” In this review there was also a
difference in positive outcomes that, as noted above, helps
assure publication: “Studies funded from public sources were
significantly less likely to report conclusions favorable to the
Then there is the issue of multiple publication. In a study
of published trials of selective serotonin reuptake inhibitors
submitted to support a bid for marketing approval in Sweden,
Melander et
al <
>. found that “21 studies contributed to at
least two publications each, and three studies contributed
to five publications.” All of these clones and chain letters
increase the number of papers competing with your paper
and mine for publication.
All the above is bad enough, but there is one additional
concern—editorial conflict of interest. Here I am going to
quote Smith <
>, whom I remind the reader is former editor
of the BMJ: “This is a very important point: there are journals
which are making millions of dollars out of reprints of these
The Lancet
makes more money out of selling reprints
of drug company sponsored trials than it does from subscrip-
tions or straight advertising. Take the Vigor study, which
was published in the
New England Journal of Medicine
the information was released—the manufactures bought a
million dollars’ of reprints, by no means uncommon and of
course the profit margin is huge. If you sell a million dollars’
worth of reprints the profit is about 700,000 dollars, maybe
800,000, and that goes straight through to your bottom line,
so more and more editors and publishers are under tremen-
dous financial pressure. Think of the conflicts of interest for
an editor. You know which trials will make that kind of money.
If you publish it you have 800,000 profit; if you don’t publish
it you might have to find that 800,000 in some other way,
which is of course extremely difficult. I think it is a very, very
stark conflict of interest, more stark than many researchers
experience.” And it is a handicap for the researcher seeking
publication of a report that will not inspire a pharmaceutical
company to purchase thousands of reprints.
Finally, the acceptance letter arrives. No more worrying, and
no more revisions. Your article is on its way into print. There
are now three items to consider: proofreading, preventing
errors, and what to do after publication.
Upon acceptance of your article, a copyeditor will buff it for
publication, tidying up errors of grammar and syntax. The
copyeditor is your friend. With a degree in English literature,
the copyeditor is there to help you and the editor publish
the finest article possible. There may be minor alterations to
improve clarity and eliminate ambiguity, and you may find
very long sentences divided into two, and even some sub-
headings added in long expanses of text. The changes made
will reflect standing orders from the editor about style, and
should not affect meaning.
Although you may or may not see the “marked-up”
manuscript, you will definitely receive proofs to review.
Occasionally you will be sent
galley proofs
—your manuscript
set in print but not yet formatted to the journal page. Some
journals always send galley proofs, while others send galleys
only when they anticipate that the author will want to make
some more changes. Prior to publication, you will definitely
page proofs
, with your article formatted to the journal
page, perhaps even with the page numbers in place.
Read every word in the proofs carefully. Beware the
Printer’s Devil, which can change words like “antenatal” to
“antinatal.” Begin by checking the page proofs against the
manuscript. Has anything been omitted or jumbled? This
happens. Do all the reference citations appear in the text, and
do the numbers match the reference list? Pay special atten-
tion to tables and figures. If there are numbers and totals in
the paper, get out your calculator to recheck math.
In the proofs, there may be queries to “Au.” You must
answer these questions precisely. Do not waffle, give both
sides to an answer, or respond with a long explanatory para-
graph. The editor is asking you for a decision about an issue
in your paper. Make the decision and incorporate it in the text
in an efficient, workmanlike manner.
Keep in mind that proofreading is intended to correct
errors. You may be tempted to add new material during
proofreading. A new study was published since your paper
was submitted, or a new drug has been introduced. If you
propose to add to the paper, I advise that you call the edito-
rial office and discuss what you have in mind. Some editors
will approve a adding sentence or two, or perhaps a refer-
ence. In the case of books, I can attest that too many changes
can result in a charge against royalties.
If adding a reference, ask about numbering. In some jour
nals, the author need not renumber all 90 references when add
ing one more in proofs. Instead, go to the appropriate location
in the text and in the reference list and add the new number
with an “a.” Thus, if the new reference follows
reference 45,
the new addition will be reference 45a as a text citation and
also in the reference list. This convenience saves time and cost,
and avoids many subsequent numbering errors.
There are proofreader’s marks used as shorthand to iden-
tify corrections and changes in proofs in those instances
when you receive a marked-up paper manuscript or galley
proofs. These are found in Appendix
Return the manuscript promptly; the journal probably has
already reserved space in an upcoming edition. If your work
is a book chapter, there is probably a date scheduled with
the printer for the entire book. Keep a copy of the corrected
proofs. You spent valuable time and mental energy on the
changes. Assume that the version you are returning to the
journal will get lost in the ether of hyperspace.
Good writing is hard. Good proofreading may seem even
harder because it is not creative. Proofreading can be mind-
numbingly dull, and this is a danger, because it is very easy
to have errors escape into print.
About Errors
Whenever I have published a book and have the first copy in
my hand, I can unfailingly open the book to the exact page
with a misspelled word. It may be the only error in a 1200-
page book, but it seems to jump out at me.
Sometimes mistakes in print are called
, as though the
Latin word makes them seem less serious. Errors find their
way into print in many ways. Some begin with the author and
some with copyediting, and some seem to appear for mysteri-
ous reasons. It really doesn’t matter how they occur, it is the
author’s job to discover and crush errors. If you think errors
won’t occur, examine Fig.
12.1A, B
carefully. They are from
) has an error in labeling. (
) is correctly labeled.
an you
spot the error in (
)? (
he original captions were: (
verage apparent quality
of publications versus career age for the 4-year sample. (
verage yearly
publication rate versus career age for the 4-year sample. (
rom Krumland
and Gorry. [
sed with permission))
ote to reader:
he original legends
have been included, to explain what the graphs are meant to show
Average Apparent Quality of Publications
Career Age
a published article about medical
publications. Do you see
the error? Hint: The lines in Fig.
correctly labeled.
Now look at the two
pointing to the single line and the
other “
” line in Fig.
One hundred years ago,
The Lancet
apologized for using
the words “a sour correspondent,” insisting that it should
have been “as our correspondent” (JAMA 100 Years Ago.
JAMA. 2001; 286:140). The University of New South Wales
has advertised for a mathematics research assistant who
would work in a “3/4 research and 1/3 teaching position.”
Today some major medical journals seem to have a monthly
column correcting errors in recently published papers. Most
errata are of minor significance, other than the damage to
the self-esteem of the authors. Much more egregious, even
dangerous, are errors involving drug doses. I received a copy
of the 16th edition of the
Handbook of Antimicrobial Therapy
published by the Medical Letter on Drugs and Therapeutics.
The handbook came with an attached warning label:
On page 130 the pediatric dosage of doxycycline (combined
with quinine sulfate) for treatment of chloroquine-resistant
In fact, on page 130 of the handbook, the dose is listed as
mg/kg/d 9 7d. This is much more worrisome than incor-
rect fractions in a job advertisement.
After Publication
Saving Your Files
Some people save empty boxes, lengths of ribbon, odd pieces
of wood, and half-empty cans of paint. They will tell you,
might use this someday.” Saving stuff is a very good idea
for writers. I tend to file by project. I have a file with all the
notes and quotes used for this book. If I plan to use some-
thing from this book in another project, I will make a copy
for the new book or article. Items you liked, but didn’t actu-
ally use, might be just what you need for your next article or
book. For example, my last book was titled
Essential Medical
Facts Every Clinician Should Know
. (Taylor R. Springer;
2010), and I have an idea for a new book that will be along
the same lines. When I come across papers or anecdotes that
may be useful, I drop them in a file, unsorted for now. My
files include metaphors, similes, and examples that might
support my pet theories. I also keep a computer file of topic
ideas that may become chapter titles or section headings.
Some of these items languish for years, and then turn out to
be useful. That is how I
happen to have this chapter’s refer-
ence 6
from 1980.
Sometime during the production process, you will probably
be asked whether you would like to purchase reprints of your
paper. Reprints are a time-honored tradition in scientific writ
ing, and before the Internet they were an important way in
which investigators disseminated their findings. Today JAMA
advises authors as follows: “Reprints may be ordered when
the edited typescript is sent for approval to the corresponding
author. Reprints ship 2
weeks after publication. Corresponding
authors who provide an e-mail address for publication will
receive an electronic link that provides 25
free online accesses
to the PDF view of their article.” <
A century ago, C. D. Spivak <
>, the editor of
, reported, “There is an inborn craving in the hearts
of medical men for reprints of their articles.” He attributed
this craving to “a psychological fact, namely, that every writer
wishes to give the stamp of individuality to his work.” Spivak
called for authors to let medical libraries be the first claimant
on reprints.
Today, reprints are going out of fashion, and I don’t buy
them anymore. They have become expensive. Journals use
them to generate income, and seem unable to sell me a rea-
sonably small number. Today most reprint requests arrive
online, and are answered by sending a PDF of the article.
Each year more and more journals go to open access, and
predict that in time journal reprints, like my file of journal
article clippings, will become a historical curiosity.
Criticism of Your Writing
There is an old aphorism about medical writing: He who
writes stands up to be shot at. After publication of your
chapter, or book, some readers may write letters to the editor
saying, “Great job.” (In fact, such letters are unlikely to be
published, because they do not generate controversy.) Some
book reviewers may praise your work. The first
edition of my
Family Medicine: Principles and Practice
was reviewed
in the
British Medical Journal
as “the Cecil & Loeb/Gray’s
Anatomy of family practice for the foreseeable future.” Wow!
Three decades later, I still feel good about this review. When
you and I receive such accolades, we should savor them—
because they are the exception.
Other book reviewers and letter writers have reported that
I misspelled words, “missed the mark,” and, in one instance,
was an example of why no single physician should be the sole
author of a medical book. I have endured my share of harsh
New England Journal of Medicine
published a paper
on sleep deprivation and elective surgery (Nurok et
al. NEJM.
2010;363:2577). A printed comment challenges the opin-
ion of the authors, stating “. . . we believe that the solution
the authors offer—mandatory disclosure—is unwarranted”
(Pelligrini et
al. NEJM. 2010;363:2673).
In response to an article titled “Candidate Performance
Measures for Screening for, Assessing, And Treating Unhealthy
Substance Use In Hospitals: Advocacy Or Evidence-Based
Practice?” (Saitz R. Ann Intern Med. 2010;153:40), a letter-
writer remarks: “We read Saitz’s recent article with great
interest. Saitz concluded that evidence is insufficient to
support screening and offering counseling to hospitalized
patients with substance abuse problems. He recommends
that clinicians treat 70 chronic acute and chronic illnesses
that are linked to unhealthy substance use and ignore the
underlying cause. That would be the death of medical com-
mon sense. It would be like treating a patient with myocardial
infarction without screening for hypercholesterolemia. . .”
(Gentilello et
al. Ann Intern Med. 2011;154:73).
In an extreme example of reader criticism and editorial
response, the publishers of
Human Immunology
retracted an
immunogenetics paper that some believed contained inappro
priate content. Statements in the paper concerning culture,
religion, and genetics were judged to be offensive. The jour
nal editors deleted the article from the online edition of the
journal and requested that medical librarians tear the article
pages from their printed, often bound, issues of the journal!
The conclusion must be that as a medical writer you must
be able to withstand criticism. All you can do is write your
article or book chapter, check everything carefully, have the
manuscript reviewed by a colleague, and then submit for
publication. When the paper (or book) appears in print, be
prepared to take the barbs, or perhaps the applause, that may
come from readers and reviewers. Take pride in the fact that
you have successfully navigated the review process and had
your work published, and that your critic has, in fact, been
one of your readers.
At the beginning of the chapter I hinted that there are
more steps after publication. Some of these possibilities are
presented next.
Writing Groups and Courses
writing group
is composed of individuals committed to
improving their writing skills. There may be a formal group
leader, or leadership may rotate. Generally one member
presents his or her work, followed by comments by others in
the group. Sometimes the group uses specific writing exer-
cises. Fundamentally these are support groups of persons
who provide one another with encouragement, while allow-
ing members to applaud one another’s successes and grieve
colleagues’ rejections.
Grzybowski et
al <
>. describe a writing group at a hospital
in Vancouver, Canada. The group met regularly over 3
Fifty writing projects were discussed, and 12 of those were
subsequently published in indexed journals. The seven group
members who attended most frequently saw an increase in
their publication rate over 3
years of more than 300.
In an academic setting, 18 assistant professors participated
in a writing and faculty development program with seven
monthly 75-minute sessions. By the end of the program, all
participants completed at least one scholarly manuscript
>. This activity seems to be both a writing course and a
writers’ support group.
Houfek et
al. describe the structure and function of a
group, and how such a group can lead to co-
mentoring and
increased scholarly productivity <
Fellowships offer opportunities for clinicians who want to go
further with their writing and editing. Today there are at least
seven medical editing fellowships, sponsored by the following
publications and organizations:
: The Morris Fishbein Fellowship
American Family Physician
: The John Rose Fellowship
New England Journal of Medicine
Annals of Emergency Medicine
Canadian Medical Association Journal
Canadian Family Physician
Radiological Society of North America
Several journals sponsor writing contests. An example is the
Creative Medical Writing Contest sponsored by the
Journal of
General Internal Medicine
(JGIM). There are “prizes for the
best submission in each of the categories of poetry or prose
about the experience of being a patient, a patient’s family
member, a healthcare provider, a medical researcher, or a
student.” The prize awards are modest, but most winning
submissions are published. If interested be sure to check with
the JGIM about submission requirements.
The practicing clinician with writing skills and a compel-
ling story based on personal experience—such as how to
solve a troubling practice problem or deal with a difficult
patient—should consider the
Medical Economics
contest. The current grand prize? 2,000 and a crystal award,
plus 500 to donate to the healthcare charity of your choice.
If interested, visit the journal Web site or contact: Editor,
Advanstar Medical Economics, 24950 Country Club Blvd.,
Suite 200, North Olmsted, Ohio, 44070, or forward e-mail
entries to [email protected]
Contests are announced periodically and then have
deadlines. Be sure to check for up-to-date information if
considering a submission.
American Medical Writers Association
The American Medical Writers Association (AMWA), with
5,000+ members, is the leading professional organization for
biomedical communicators. Membership is open to all who
write, edit, or teach about writing in areas such as medical
science, biotechnology, or the pharmaceutical industry.
AMWA offers continuing professional education, which
includes courses and workshops. The organization publishes the
AMWA Journal
, a source of information and opportunities in the
field of biomedical communication. Some recent article topics
in the journal were “Of Pirates, Ghosts, and the Fool: Stumbling
Toward a Unified Theory of Medical Writing” and “Creating
Effective Slides.” If interested in learning more about AMWA,
contact the organization’s website:
Self-publication of an article, poem, or cartoon is easy. Just type
the following at the bottom of the page: Copyright, your name,
and the current year. Then print out the document, give it to a
friend, and it is published. Legally no one can copy or otherwise
use this now-published document without your permission. But
what I just described is not the topic of this section.
Many of us write books, and then find that attaining publi-
cation is difficult. In fact, without an agent, it is almost impos-
sible for the beginning writer to find a publisher for a trade
book. Also, agents are busy and most won’t read your book
unless you are a previously-published trade book author. Do
you see the problem here? Clinical books, if timely and well
written, are more likely to be published but this process can
also be challenging. (See Chap. 8 and my advice never to
write a book without a signed contract with a publisher).
Nevertheless, let’s assume that you are a clinician or edu-
cator who has written a book. Perhaps your book is a tightly-
plotted medical mystery novel, your heart-felt
or “How I Learned Neurosurgery on the Internet in Five Easy
Lessons.” Sadly, no publisher has recognized the literary
merits and marketing potential of your book, and the manu-
script is beginning to turn a little yellow.
Then you come across the magazine advertisement that
reads, “AUTHORS WANTED, Leading subsidy book publisher
seeks manuscripts. Fiction, nonfiction, poetry, juvenile, reli-
gious, etc. New authors welcome.” Or web-surfing brings
you to Amazon, which offers
, offering to publish
copies of your book on demand, sparing you an investment
in inventory. You may want to visit the Barnes and Noble
Web site and learn about their
self-publishing portal.
Other possibilities such as Tate, Lulu and Trafford publishing
companies can be easily found on the web.
Be sure to differentiate between a so-called vanity and a
subsidy publisher: The vanity press accepts all works without
regard to quality and has the author assume all financial risk.
In short, the vanity press makes money from authors, not
book buyers. The subsidy press publishes the book under its
own imprint and assumes some of the financial risk.
I consider self-publication is the last refuge of the desper
ate author. The problem is distribution. There is no publish
ing company with a full financial investment in your effort
out there trying hard to sell your book, and you probably
do not personally have the time or resources to do so. You
will have copies to give your family members. You can show
your book to your friends. You will almost certainly not sell
many books through commercial channels or receive much
in royalties. Your satisfaction with the process will depend
on your feelings about seeing your name and your work in
Here is a personal story about self-publication and another
of my writing error tales: Years ago a friend and I acquired
the translation rights for a medical book written in Europe
for the lay public. We formed a corporation called Erbonia
Books and self-published the book. We then owned a garage
full of books. To our surprise, no one beat a path to our
garage door to buy our books. Several local book-stores
stocked a few copies, as a favor to us, but sales were sparse.
We ran magazine advertisements, but none brought enough
orders to cover the cost of the advertisements. Eventually we
were lucky; my partner had a friend who worked for a major
publishing firm in New York City. This company bought the
rights to our book and published a paperback edition that
finally had national distribution. When all was said and done,
we spent a lot of time and effort. Our original printing costs
and advertising costs exceeded the royalties received from
the real publisher. We had learned a lesson, and we disincor-
porated Erbonia Books. (Today, just for fun 40
years later,
looked up the title of this small paper-back. A very few used
copies are for sale online at prices between 79 and 144. If
only I had held on to that garage-load of books!)
As a professional, I am not a fan of self-publication.
However, self-publishing may be the best option in some cir-
cumstances, when the dream of huge sales is not a considera-
tion. In fact, self-publication is ideal when you have written
your life history or the story of your ancestors, information
your children and grandchildren will want to have in the
future. A friend recently self-published his genealogy titled
Norwegians, Swedes and More
; he and his extended family
have been quite pleased with the venture.
Medical publishing may seem staid, but it is certainly not
static. In fact, it seems to be undergoing a revolutionary
change at this time. With full recognition of the perils of
prognosticating, let’s try to envision tomorrow’s medical
“journal” through the eyes of today aspiring medical writer.
I recently read the announcement of the millionth word
in the English language: It is “web 2.0,” denoting the second
generation of the World Wide Web. The new word connotes
interactivity, collaboration, and net-working—all at great
speed. And this is what I see as the future of medical publish-
ing—for both journals and books.
Today, my scientific journals—those I get by virtue of paid
subscription or society membership—arrive in my mailbox
and are stacked in a pile until I have time to read them. But
I sense a change. Before my paper copy arrives, the NEJM
sends me the table of contents on line and I can open and
read articles. The same thing happens with my specialty pub-
lications, such as
American Family Physician
. In the case of
the NEJM, some items are only available online. How long
will it be before the paper copies just disappear?
The transformation we are seeing has a name. It is called
open access (OA) publishing, and it will bring some profound
changes to how we report research, read these reports, and
respond to what we read. First about the reporting: Over the
past few months I have received emails inviting me to submit
papers to several journals:
Medical Education Development
The Open Medical Informatics Journal
, and the
Journal of Family Medicine
. I had never previously heard
of any of these publications, and I was intrigued to receive
unsolicited invitations to contribute, flattering indeed after
decades of working very hard to find homes for articles I had
written. What these journals all have in common, of course,
is that they are open access journals.
Open access describes barrier-free scientific communi-
cation that is digital and available without cost to anyone
online. Articles published in an open access journal are typi-
cally subject to limited or no copyright restrictions, meaning
that clinicians, educators, and students can download, copy
and share the articles without the current restrictions we
face. How is this possible? The answer is that most open-
access publishing is funded by authors, their institutions or
the sponsors of research studies.
A good example of pure OA journals is the Public Library
of Science (PLoS) group of publications, which includes
, an interactive open-access journal for the com-
munication of peer-reviewed scientific and medical research,
with an impressive Impact Factor of 4.351. The current fee
charged to an author or author’s institution to publish a paper
is 1,350, used to cover the cost of peer review,
professional editing and electronic distribution. There is also
PLoS Medicine
with a per-paper fee of 2,900. PLoS journals
offer a complete or partial fee waiver if authors or sponsors
cannot pay the publication fees.
On the way to exclusively OA journals we currently have
hybrid journals, with BMJ as an example. In 2010, the BMJ
initiated a publication fee of |2,500 (about US 3,970) for
each published research article. These articles are then both
printed in a traditional journal format and distributed on line
in an OA mode. The fee applies only when the funder of the
research that is reported in the article has pledged to pay for
OA publication and when the authors can claim the full BMJ
fee from their funder <
>. Who knows, the funder might pos-
sibly be a pharmaceutical company.
In addition to speedy dissemination of information, online
OA offers some other advantages, although some of what
describe next may be yet to come. Illustrations can be pre
sented with a “Download to a PowerPoint Friendly Image”
option. Instead of the fixed-image, silent illustrations found in
print journals, OA has the potential to present graphics with
motion and sound. And can images with depth be far behind?
The citation list can provide hyperlinks to each paper cited.
We may even see a paradigm shift in how papers are
reviewed, moving much of the emphasis from pre-publication
review by so-called experts to post-publication review. This
idea is championed by Smith, who tells how posting of find
ings for the judgment of the research community is already
used in the fields of high-energy physics and astronomy <
Open access publishing may also help minimize the con-
flict of interest, described above, that journal editors face
when they consider a study they know might bring their
journal a huge profit in paper reprints—if published. Might
this ethical dilemma become a thing of the past when there
is open access online?
Here is another potential benefit for those of us who
search the medical literature often. As an example, I came
across an interesting paper in this month’s issue of
Annals of
Internal Medicine
(Kind AJH, Bartels C, Mell MW, Mullahy J,
Smith M. For-profit hospital status and rehospitalization at
different hospitals: an analysis of Medicare data. Ann Intern
Med. 2010;153(12):718–727). The study was funded by the
National Institutes of Health. I could access the abstract
but, as a non-subscriber to the journal, 1-day access to the
full article would cost me 15. I am aware that NIH-funded
studies must be available by OA after 1
year. Nevertheless,
since I paid for the study as a taxpayer, why must I pay again
to read the full results while data are timely? Open access
publishing may just solve this problem.
If online publishing is faster, cheaper and more user-friendly
than print, how could anyone speak against it? Authors have
had some reservations, aside from the
publication fees. Some
consider OA journals to be inferior caliber, an argument that
is partly countered by the respectable Impact Factors of the
PLoS journals. On the other hand, supporting the concern
is a study by Davis et
al <
>. involving 1,619 research arti-
cles and reviews in 11 journals published by the American
Physiological Society. They report: “No evidence was found
of a citation advantage for open access articles in the first
year after publication.” The future success of OA journals will
depend, in some measure, on convincing medical authors
that these publications are high quality and are respected by
their peers, which will include how articles in these publica-
tions are assessed in promotion and tenure decisions.
Not unexpectedly, both commercial and non-profit pub-
lishers are very wary of OA journals. Commercial publishers,
some with huge investments in hardware, high production
costs, and substantial profits tied to advertising and reprints,
feel threatened. They question the viability of the “author-
pay” model. So-called non-profit publishers, most linked
to specialty societies, often provide much of the financial
support of these societies, and I suspect that they fear their
demise if they must compete with OA journals.
On balance, we all know what happens to an idea whose
time has come. We are already seeing our traditional
10-pound medical reference books move online. Journals
will surely follow, in some way. JAMA now publishes more
articles online than ever before <
>. The future is electronic
publication, searchable storage of readable electrons in open
virtual libraries, and instant, free access to today’s scientific
information for all. As you read this, electronic publication is
replacing paper. Two questions remain: How will journal and
book publishers adapt? And how can today’s medical writer
prepare for the open access future?
esteem. I believe that sort of response happens when reading
an article or, in this instance, a book. In writing this book,
I have offered some facts, my best advice, and what I think
are engaging personal stories. In return you have given your
attention, especially if you have reached this page in your
reading. In doing so, you allow me to assume that I may be
some small help in your future writing successes. For me,
that is the real reward of the writing effort.
Remember that writing is a continuous process. The writer
does not think about the writing episodically. For a writer,
the current task, and maybe the next, will always be lurking
in the subconscious mind. You will be sensitive to the anal-
ogy, the anecdote, and the image that can make your work
sparkle just a little. Writing does not occur just when you
turn on your computer. The ongoing mining of your personal
experience and connectivity, cataloging ideas and images,
and organizing ideas are all part of writing.
In the 1987 movie titled
Throw Momma from the Train
Billy Crystal plays a down-on-his-luck English literature
teacher leading an adult night school course in creative writ-
ing. Danny DeVito plays a not-too-bright student aspiring to
be a writer. At several key points in the movie, Crystal empha-
sizes to DeVito, “A writer writes!” In the end, both success-
fully publish their books.
I urge you to join me and others in writing. See it as an
ongoing journey of education, self-discovery, and personal
growth. For me, writing this book has been part of such a
process. I hope that you have enjoyed reading it half as much
as I have enjoyed writing it. I am a little sorry to see it end.
But I have another project in mind to start next week.
My last offering in the book is a personal indulgence. We
have all heard of Robert’s Rules of Order. Here are
Taylor’s Rules for Medical Writers
Be smart enough
. Yet, be well aware that being intelligent
is only part of what you will need for success.
Be organized
. Keep files and notes, with full reference cita-
tions, whether on paper or computer. Know where things
are, and take the time needed to systematize all your
writing materials.
Be a reader
. Always be reading something, and seek a wide
range of topics. While reading, note both what is said and
how the author expresses the ideas.
Do not write until you have something to worthwhile to say.
Do not clutter the literature with pedantic drivel.
Be a good time-manager
. Clinical care, teaching, or research
is your day job, and it cannot be neglected. If you do so,
patients, students, or your professional colleagues will suf-
fer and you will lose your wellspring of writing ideas. But
you must also carve out regular, dependable time for writ-
ing if you are ever to finish a project.
Be an effective networker
. Get to know medical editors,
other writers, and—if planning to edit a multi-author
book—potential authors. Make the ongoing effort needed
to nurture these relationships.
Be bold
. Don’t hesitate to aim high or to propose the project
that seems a little beyond your abilities. Those who take on
too much, with too little time and too few resources, some-
times succeed.
Be persistent
. Writers endure rejection often. You must be
able to bounce back and revise and resubmit or even start
over. But you must not give up on your writing. A writer
Remember that you love to write.
If you are not finding
writing enjoyable, stop for a while, only a while. Go do
something less important but that may seem more enjoy-
able, such as eating, sleeping or watching a movie. Your
energy will be renewed, and you may just formulate a good
writing idea in the process.
Now it’s time to Write It Up. Have fun!
Holmes OW. Some of my early teachers. In: Medical essays,
edited by Holmes. Boston: The Boston Society for the Diffusion
of Useful Knowledge; 1842.
King LS. Why not say it clearly? Boston: Little, Brown;
Callaham M, Wears RL, Weber E. Journal prestige, publica-
tion bias, and other characteristics associated with citation of
published studies in peer-reviewed journals. JAMA. 2002;287:
Norton SA. Read this but skip that. J Am Acad Dermatol.
The New England Journal of Medicine. Instructions for sub-
mission. Available at:
Grouse LK. A rogue’s gallery of medical manuscripts. JAMA.
von Elm D, Poglia G, Walder B, Tramer MR. Different patterns
of duplicate publication: an analysis of articles used in system-
atic reviews. JAMA. 2004;291(8):974–980.
International Committee of Medical Journal Editors. Uniform
requirements for manuscripts submitted to biomedical journals.
Available at:
British Medical Journal Resources for Authors. Available at:
Whimster WF. Biomedical research; how to plan, publish and
present it. New York: Springer-Verlag; 1997:136, 149.
PaperTRAIL—Paper Tracking through Interactive Links for the
New England Journal of Medicine.
KÕbler-Ross E. On death and dying. New York: Macmillan; 1969.
Bryson B. A short history of nearly everything. New York:
Broadway Books, 2003;381.
Smith RS. The trouble with medical journals. Medico-Legal J.
Purcell GP, Donovan SL, Davidoff F. Changes to manuscripts
during the editorial process. JAMA. 1998;280(3):227–228.
Strasburger VC. Righting medical writing. JAMA. 1985;254:
Emerson GB, Warme WJ, Wolf FM, Heckman JD, Brand RA,
Leopold SS. Testing for the presence of positive-outcome bias
in peer review: a randomized controlled trial. Arch Intern Med.
Coates R, Sturgeon B, Bohannan J, Pasini E. Language and
publication in “Cardiovascular Research” articles. Cardiovasc
Res. 2002;53(2):279–285.
Cho DW. Science journal paper writing in an EFL context:
the case of Korea. English for Scientific Purposes. 2009;28(4):
Any single-author book, especially a “how to” work such
as this one, is the product of the writer’s life experiences,
the influence of professional colleagues, and the writings of
others whom I probably will never be meet in person.
In addition to my professional time in private practice
and later in academic medicine, my life experiences center
around my family: Anita D. Taylor, MA Ed, an accomplished
author and academician, honest critic, and sharp-eyed proof-
reader; our children Diana and Sharon; and our four grand-
children, Francesca (Frankie), Elizabeth (Masha), Jack, and
Anna (Annie).
I thank just some of the many physicians who, over the
years, have helped me better understand medicine, writ-
ing, and life. In no special order, these valued persons are:
Doctors Robin Hull, Bob Bomengen, Ray Friedman, Tom
Deutsch, John Saultz, Bill Toffler, Scott Fields, Eric Walsh,
Peter Goodwin, Ben Jones, Joe Scherger, Takashi Yamada,
Ryuki Kassai, John Kendall and Charles Visokay. Faculty
colleagues Rick Deyo and Matthew Thompson helped me
polish drafts of some parts of the book and, I earnestly hope,
avoid egregious errors. Such faults as there are—and there
surely are a few—are solely my doing.
I offer a special thanks to Coelleda O’Neil, who has assisted
with the manuscript preparation of my books for more than
two decades. In addition, I gratefully acknowledge the excel-
lent work of my Springer editor, Katharine Cacace.
Finally, I am grateful to the clinicians and scientists who
reported the case studies, systematic reviews, randomized
trials and other publications that provided the examples used
to support my advice about
Medical Writing
R.B. Taylor,
Medical Writing: A Guide for Clinicians, Educators,
and Researchers
, DOI 10.1007/978-1-4419-8234-6,
© Springer Science+Business Media, LLC 2011
1. Glossary of Medical
Writing Words and Phrases
archival author
Boolean logic
Camera-ready copy
Career topic
Cover letter
submission letter
Direct costs
indirect costs
Journal of the American College of Surgeons.
Duplicate or dual publication
Electronic journal
Funding preference
Galley proofs, galleys
Grey literature
Impact factor
Indirect costs
facilities and administrative costs
International Committee of Medical Journal Editors
New England Journal of Medicine
Croatian Medical
Uniform Requirements for
Manuscripts Submitted to Biomedical Journals,
Letter of intent
proposal concept
Line drawing, line art
Loansome Doc
MEDLINE (Medical Literature, Analysis, and Retrieval
System Online)
MeSH (Medical Subject Headings)
National Library of Medicine (NLM)
Network research
Open access
Page proofs
Peer review, peer reviewer
Positive outcome bias
Proofreader’s marks
Public Library of Science (PLoS)
Request for proposal (RFP)
Research report
Review article
Running head
Science Citation Index (SCI)

Target journal
ear sheets
Trade books
professional books
Uniform Requirements for Manuscripts Submitted to
Biomedical Journals
ommonly Used Medical
(per os)
alues for Adults
Absolute risk
Absolute risk reduction (ARR)
number needed to
treat (NNT)
Relative risk reduction
exclusion bias
attrition bias
recall bias
referral bias
selection bias
Case-control study
Cochrane Collaboration
The Cochrane
Database of Systematic Reviews
Cohort study
Confidence interval (CI)
Crossover trial
Incidence, incidence rate
Likelihood ratio (LR)
Mixed methods research
Null hypothesis (H
Number needed to treat (NNT)
number needed to harm (NNH)
Odds ratio
Post-test probability
Pre-test/post-test case series
Primary outcome
Prospective study
2ualitative research
convenience sample
Randomized controlled trial (RCT)
Recall bias
Referral bias
Retrospective cohort study
Selection bias
allocation bias
Sensitivity (Sn)
Specificity (Sp)
Statistical significance
Systematic review
Face validity
Internal validity
External validity
Academic medical center (AMC)
Acceptance letter, 306
Academic medical center
American Medical Writers
Association (AMWA), 319
Writers Association
rapid review, 291
grabber, 292
editor’s view, 291
factor, 289
Authored books
enrichment books, single-author,
“Benign brutality”, 86
exclusion, 346
checklist review, 197
clarity and book’s ability, 178
factual accuracy, 178
questions, reviewer, 180
summarize reviewer’s opinion,
excellent review
factual accuracy, 178
mid-twentieth century, 175
today’s reviews, 175
letters, editor, 169
(COPERNICUS) Study, 224
letter-style, 163
literature and article review, 162
crystal-clear, 79–80
MS Word Thesaurus, 80
“wrote of” and “referred to”, 81
epidemiology, 265
JAMA, 266
The Lancet
electronic medical dictionary,
determine topic and concept, 69
expand heading levels, 70
chapter, 206–207
compiling editor, 197–198
items, review, 203
acquisitions editor,
initiator, 197
publisher, financial risk,
development editor, 206
editor, 165
editor’s opinion, 166
journals publisher, 166
summary, 169
conflict-of-interest problem,
JAMA, 134
American Family Physician
attention, quality, 157
Fellowships, 318
computer, 100, 101
JAMA and NEJM, 99–100
medical illustrator, 100
First draft beginning
of Information Act
Formal tables, 92, 93
Freedom of Information Act (FOIA),
executive summary, 249–250
institution overview, 250
money, 239
intent letter, 246–247
program officer, 245–246
review, past, 245
RFP, 244–245
Administration (HRSA),
Services Administration
Information sources, grant
authors instructions, JAMA, 273
rank order, 271
generalizability, 280
summary, conclusions, 281
reproducibility, 276–277
JAMA article and phrases, 270
misunderstanding, author’s
graph and chart requirements, 102
Keytlaw, 109
clinical chemistry, 343, 344
The Lancet
editor of, 285
Impact Factor, 120
Attaboy, 170
“sounding off”, 172
identify paper, 173
successful letter, 173
think of, 173
medical writing, useful
modern technology, 153
spell checker, 297–298
broad-based peer-reviewed
NEJM, BMJ and JAMA, 116–117
indexing and impact factor,
“throw-aways”, 117–118
index databases, 119
overstatement and hubris, 128–129
specialty oriented
peer-reviewed, 117
Medical subject headings
case-control study, 346
cross-sectional study, 348
post-test probability, 349
pre-test probability, 350
prospective study, 351
retrospective cohort study, 352
systematic review, 353
Microsoft (MS) Word program, 7,
New England
New England Journal
JAMA and, 99–100
Paragraph development
exception, classic format, 39–40
small essay, 38–39
using concrete examples, 41–42
Peer review, 299–301
experience and resources, 262
Proofreader’s marks, 339
copyeditor’s role, 310–311
irony and humor, 186
medicine history, 184
poetry, 183
“Clinician’s Corner”, 145–146
Elsevier, 117
favor, new author, 146
Springer, 106, 216
supply, review papers, 146
history, 7–9
time-capsule items collection, 10
creativity, 11–12
clinicians, experts and attorneys,
examples, 304–305
curriculum vitae,
summary, 226
tools (RePORT), 245
“critical-reader” colleague, 236
reader’s perspective, 223
expected outcomes, 231
follow-up and data
hypothetical study, 223
activity, 234
PI and co-investigators, 225
quality, questions, 225–226
RFPs and language, 226
RFP, 219–220
inter-specialty reference, 16–17
electronic medical dictionary,
Google and Google Scholar,
UpToDate, 22–23
journal’s impact factor, 143
learning disorders, epilepsy, 145
consulting, journal editor,
review paper, 144
splenomegaly, 145
archival author
editor’s role, 298
journal editor’s decision
acceptance letter, 306
rejection letter, 302–305
revision letter, 305–306
editor, 300–301
peer reviewer, 299–300
peer review, 306–307
Revision letter, 305–306
crystal-clear, 79–80
MS Word Thesaurus, 80
“wrote of” and “referred to”, 81
critical reader, 86–87
critical reader, 86–87
removing stuff, 82–83
agent and publisher, 319–320
density, 46–47
(SMART), 227
over-prepare, 72
article concept and structure, 69
critical reader, 86–87
removing stuff, 82–83
style and clarity, 79–80
Stedman’s Electronic Medical
Submission letter, 293, 294
data-oriented, 154–155
safety and efficacy, 156
systematic review, 155–156
journal editor’s expectation
JAMA, 94–95
Taylor’s rules, medical writers,
Technical issues
author’s responsibility, 111
necessity, 108
Technical issues (
“public domain”, 108
sample letter, 109–110
text usage, 108–109
number, 112
Text table, 92, 93
Trade books, 190
Web sites
Google and Google Scholar, 19–20
UpToDate, 22–23
precise manner, 59–60
Anglo-Saxon tongues, 53
literature/mythology, 53
Words and phrases
author, 331
camera-ready copy, 331
compositor, 331
copyeditor, 332
proofreader’s marks, 336
science citation index (SCI), 337
Words per sentence, 45
Writer, key questions
author and editor, 24
Writing and publishing
goals, author and editor, 288
AMWA, 319
editor’s role, 298
journal editor’s decision,
peer review, 299–301
submission letter, 293, 294
Taylor’s rules, 325–326
Writing books
Writing groups and courses,
Writing motivation
research team and senior,
key questions, writer, 24–26
history, 7–9
World Wide Web usage, 7
Writing motivation (
writer, clinician/faculty, 1
Writing skills
type of, 55–59
Writing team
Written Communication
in Family Medicine

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