Crafting a Message for Publication
Graham McMahon MD MMSc
Editor for Medical Education, NEJM
Specific Goals

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To familiarize you with the “publishing biz”
and how it works
To help you think about how to convert your
scholarship into publishable papers
• Research
• Innovative curricula
• New teaching/learning methods
• Other projects
Help you strategize your work with editors
Overall Objective

To help you become a
• Better
• Smarter
• More successful
writer for publication as an educator
From the Author’s Perspective
“It’s publish or perish, and he hasn’t published.”
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Why Experiment?
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Evidence based education!
Rigor in educational approaches
Improved quality for learners
Personal and professional value
Elevate the field
6
Challenges in Educational Research

Participants are actively learning over time
• Interventions must demonstrate additional increments of
performance improvement

Comparison groups difficult to identify
• Placebo groups challenging in education

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Small sample sizes and short studies
Open-label
• Students may be vulnerable to experimental coercion
and to change behavior as a result of being in an
experiment
• Contamination between research groups is common

Time between learning and behavior can be long
• Dependence on intermediary endpoints
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Frequent changes in regulatory expectations
Learners increasingly have survey fatigue
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Challenges for Educational
Researchers
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Conflicting demands
Isolation
Lack of programmatic support
Constrained budget
Activities not valued
Why Write?
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To share your ideas, programs, research
To get feedback from others
To incrementally advance the knowledge
base
To get appropriate recognition
Top Issues in MedEd Research
Todres M, Rogers R. BMJ. 2007 Aug 18;335(7615):333-5
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Write about what
you believe in
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Ability to convince others
Get it done
Withstand the
• slings and arrows of publishing and
• its highly variable, unpredictable
and intermittent reinforcement
How are papers organized?

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Logical structure with a basic formula
Five sections
• Abstract: summary
• Introduction: set the stage, why
important, state hypothesis
• Methods: what you did, IRB
• Results: data only
• Discussion: what you found, what it
means, what’s next, what you found
Introduction
Start building the case why the
reader should be interested in your
study

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Describe the area being studied
Review the pertinent literature in that
area that leads ups to your study
Conclude with a description of how your
study is the logical next step, fills a gap,
or in other ways adds to the existing
literature
Write hypothesis
Methods

Describe what you did, so the reader
can understand and someone else
potentially could repeat your study
• Setting
• Sample
• Timeframe
• Outcomes
• Measures
• Data analysis plan
Results

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Describe what you found (not what
you believe it means)
Present the positive and negative
data of your findings in
• Text – little space, most important
findings
• Tables and figures – present more of the
data
Discussion
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Summarize what you found
Describe what you believe the findings
displayed in your Results section mean in
the context of other research
Describe the strengths and limitations of
your study and findings, without overgeneralizing
To conclude, describe where your findings
lead and possible logical next steps
Aim High

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Who is your
audience? What do
they ready?
Review what the
Journal is currently
publishing
Consult with
colleagues
• Time to first decision
• Review process
• Duration

Look at Journal’s
impact factors
PRIMARY MED ED JOURNALS
Education Papers
don’t only get
published in
education journals
Med Educ
2.7
Acad Med
2.3
Adv Health Sci Educ Theory Pract
1.4
Med Teach
1.3
J Contin Educ Health Prof
1.0
Teach Learn Med
0.7
Acad Psychiatry
BMC Med Educ
1.2
J Surg Educ
Clin Teach
Write About
Education and the
Other Things You
Do/Study
PRIMARY MEDICAL JOURNALS
N Engl J Med
47.0
JAMA
28.9
Lancet
30.8
Ann Intern Med
16.2
BMJ (
13.7
CMAJ
7.2
J Gen Intern Med
2.6
Am J Surg
2.3
J Fam Pract
1.4
Fam Med
1.3
Mission of a Journal
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Find the best work
Report it
dispassionately
How does the process work?
Manuscripts Received
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Types of Research 2012
Case Reports
Other
Genetics
Biology
Epidemiology
Small
Interventions
Large
Interventions
Origin of Research
100.0%
90.0%
80.0%
70.0%
60.0%
US
50.0%
US(%)
40.0%
30.0%
20.0%
10.0%
0.0%
International
NonUS(%)
Initial Submission
Editor-in-chief
Associate/
Deputy
Editor
Peer Review
Editorial
Meeting
Statistical
Review
Initial Decision
Initial Submission
Editor-in-chief
Associate/
Deputy
Editor
Peer Review
Editorial
Meeting
Statistical
Review
Initial Decision
Initial Submission
Editor-in-chief
Associate/
Deputy
Editor
Peer Review
Editorial
Meeting
Statistical
Review
Initial Decision
Peer Review

Peer review is a mechanism by which the
research community asserts quality control.

It has become an essential feature of the
decision-making processes used by most
funding agencies and all major medical journals.

A feature common to all peer reviews is that they
are performed by one or more individuals active
in a field of study that is central to the item being
reviewed.
Types of Peer Review

Double blind
• Article is de-identified, and identity of reviewer
remains confidential.

Single blind
• Reviewer knows identity of authors. Authors
don’t find out identity of reviewers.

Open
• Identity of authors, reviewers known to all
• Often reviews are published with the article.
Editors use the Reviews
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Once reviews are in the editor reads
the paper and the reviews
The editor, not the reviewer, makes
the decision about the paper
Reviewers’ comments are valuable,
but reviewers are only consultants to
the thinking process
Reviewers’ Grades of Papers
Rejected
Accepted
Editors are looking for work
that is….
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Important
Informative
Novel
Ethical
Important
informative
novel
ethical
What is Important?

Research results that will
• change or affect practice,
• teach us about biology, or
• serve as a launching platform to
define new directions in medicine
Important
informative
novel
ethical
What is Informative?
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Study adds appreciably to available
data
Conclusions provide clear direction
Conclusions follow from the data
• Free from commercial or intellectual
bias
Important
informative
novel
ethical
What is Novel ?
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A study that
• breaks new ground,
• defines new treatments or
• resolves major controversies
Important
informative
novel
ethical
What is Ethical?
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Adequate informed consent
obtained
Minimum number of subjects put
at risk to gain needed
information
Honest reporting
Important
informative
novel
ethical
Associate Editor
makes a decision

Full consideration?
• Manuscript is presented to all the
editors

Minimal consideration?
• Manuscript is on the agenda but
discussion is minimal
Initial Submission
Editor-in-chief
Associate/
Deputy
Editor
Peer Review
Editorial
Meeting
Statistical
Review
Initial Decision
The Editors Meet
Initial Submission
Editor-in-chief
Associate/
Deputy
Editor
Peer Review
Editorial
Meeting
Statistical
Review
Initial Decision
About 20% of
papers fail at
this step
Possible Decisions
Initial Reject
60.5%
Reject After
Peer Review
33.8%
Needs additional
Experiments-1%
We’re very interested
0.8%
We’re interested
3.5%
Three Major Reasons for Rejection
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Quality – the science is flawed
Novelty – the science is good, but has
previously been published or does not
advance the field
Specialty – it’s good, but not of general
interest and belongs in a specialty
journal
Reasons for Rejection
Bordages G. Acad. Med. 2001;76:889–896.
Initial Submission
Revision Submitted
Editor-in-chief
Associate/
Deputy
Editor
Peer Review
Editorial
Meeting
Statistical
Review
Initial Decision
Associate
Editor
Peer Review
Editorial
Meeting
Final Decision
Expanded Mission of Medical Journals


Find the best work
 Solicit submissions
 Meet authors needs for
expeditious review
 Best reviewers
 Thoughtful debate
Report it dispassionately
 Careful manuscript
editing
 Content
 Language
 Remove ‘spin’
 Clear graphics
 Supplementary
commentary
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Disseminate the findings
 Attract readers to the
site
 Email and print
 Support teachers
Support the reader
 Easy search and
retrieval
 Portfolio
Provide an educational
program
 Support the scientific
mission
 Meet the needs of
readers
 Enhance the experience
Differing Perspectives
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Authors role
•
•
•
•
•
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Journal’s Role
Do the right study
• evaluate work do determine
if it is important, informative,
Write about it clearly
Report it dispassionately novel and ethical
• ensure the data has been
Submit to the right Journal
analyzed appropriately and
Respond clearly
that conclusions follow from
the data
• relationships that could lead
to perceptions of bias are
disclosed
Submissions in 2012 (n=14,441)
Perspectives
NEJM.org Audience
PCPs = FMs + IMs + GP
46%
Assigning the Manuscripts
About 10% of papers are rejected at this stage
Assigned manuscripts are sent to the Associate Editors
Associate Editors
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Local experts in major areas of medicine
Being local facilitates in-person meetings
10 AEs:
•
•
•
•
•
Cardiology,
Infectious Disease,
Cancer,
Endocrinology,
Gastroenterology,
•Maternal-Fetal
•Neurology
•Office Practice,
•Health Policy &
•Vascular Disease
Honest Reporting

All the data, analyzed as intended
• Vioxx (VICTOR)
• Rosiglitazone (RECORD)

Full disclosure
• Henschke et al
• Others
Articles Published 2011
Original Research n=225
4.9%
Review Articles n=70
25.0%
Letters
n=700
20%
Images n=104
2.2%
Editorials n=99
95%
Perspectives n=216
25%
Other Articles n=91
18%
Research Published in NEJM
NEJM
100%
90%
80%
Percentage
Other
70%
Brief Reports
60%
Biology/Genetics
50%
Epidemiology
40%
Small Interventions
30%
20%
10%
64
62
69
77
84
85
0%
Year
99
92
91
115
88
Large Interventions
Percentage
Percentage of the Top 100
citations/decade in the NEJM
Year