Concise Academic Writing

Mark I. Langdorf, MD, MHPE, FACEP, FAAEM, RDMS Professor and Chair University of California, Irvine Editor, Western Journal of Emergency Medicine

Choosing a target journal

   35 general and subspecialty journals in EM 11 indexed in Medline (National Library of Medicine)   most established and prestigious most discriminating Rough order: most discriminating to least are:  Most: Annals, Academic   Middle tier: Journal of, American Journal of, Canadian Journal of, European Journal of, Journal of Accident and EM, EM Journal (formerly Journal of Accident and EM) Lower tier: Internal and EM (Italy), EM Australasia (formerly EM), Journal of Trauma: Injury, Infection and Critical Care

20 Non-Medline EM Journals

   Author pays for publication: BMC Emergency Medicine ($1860 if accepted) World Journal of Emergency Surgery ($1665) Brand new (2007-08): Western Journal of EM International Journal of EM Electronic only: Internet Journal of EM

Emergency Medicine Conventions

       Emergency physician (EP) Emergency department (ED) Emergency medicine (EM) Not: emergency room physician, emergency room, emergency medicine physician, ER physician, EM physician or even ED physician First time use: spell them out, and then, in parentheses, abbreviate Then use abbreviation throughout paper  Except for tables and figures Abstract stands alone

Rules of the Road

  Be brief!

 Journal editor wants as much content in as few pages as possible Strunk and White, 1918, The Elements of Style: 

“Vigorous writing is concise. A sentence should contain no unnecessary words, a paragraph no unnecessary sentences, for the same reason that a drawing should have no unnecessary lines and a machine no unnecessary parts. This requires not that the writer make all his sentences short, or that he avoid all detail and treat his subjects only in outline, but that every word tell .”

The Structure of DNA Watson and Crick,

Nature

, 1953

How to Get Your Paper Reviewed

      Follow the instructions to authors completely.

Follow the instructions to authors completely.

Follow the instructions to authors completely.

Follow the instructions to authors completely.

Follow the instructions to authors completely.

Get the picture?

Other Tips and Requirements

     Avoid complicated medical terms and jargon  Not, “juxtaposed,” but “adjacent” or even “next to.” Use medical terms only when the appropriate lay term is not precise enough.

Expect active voice almost all the time.

Use the template to include all vital elements Avoid using the same word twice in a sentence

Other Tips and Requirements

  Avoid redundant hyperbole  “extremely arachnophobic,      “close proximity” “summarize briefly” “very deep” “overcrowded” “very precarious”

Vary sentence length

   Avoid run-on sentences Use no more than one parenthetical phrase per sentence Alternate short sentences with long ones.

Rules of the Road

   Paragraphs need to have at least three sentences:  a topic   an explanation some sort of conclusion. If there are only two, incorporate this thought into the paragraph before.

Paragraphs should not generally have more than six sentences.

Rules of the Road

    Someone not in EM, or not even in medicine, should understand the paper. A college graduate should be able to understand much of medical writing If they would be lost, the paper needs more work Goal is to

NOT

write in a language called “medicine,” but rather in English

Rules of the Road

      Avoid politics in the paper Little room for opinion in a scientific paper Facts speak for themselves Discussion section: Allow the author to opine a bit, for maybe 2-3 sentences, if at all Assure such opinions, are clearly marked, such as, “we believe.” If the concept is provocative, it probably doesn’t belong in a research paper.

Reviewing Papers

      Helps gain experience in academic writing Flips your perspective from author to consumer Provides insight into common problems and mistakes Time consuming; good review = two hours Will dramatically improve the quality of the journal Ultimate Medline indexing depends on this

The Title

     Answer the question posed by the paper in the title Type of study belongs in the title: retrospective, randomized controlled trial, cohort study, before and after, case report, case series 120 character limit for

West

JEM Strike balance between brevity and accuracy Spell out all abbreviations.

Structured Abstract

         Introduction: two sentences max Objective: one sentence Methods: 2-3 sentences Results: as many as you have, but major only Conclusion: one sentence Parallel the rest of the paper in content and order Limit for

West

JEM: 300 words Normally, abstract written first, then paper Must assure consistency with body of the paper

Internal Consistency

     Sample size, numbers, results Make sure these are the same in Abstract, Methods and Results Nothing brands a paper as amateurish than inconsistencies Casts doubt in the reviewer’s mind What else is wrong if they can’t even get this right?

Introduction

     Typically four paragraphs Not a literature review Cite references in the introduction that set stage for the problem or hypothesis All other citations belong in the discussion (except methods description from previous work) Last sentence:   We hypothesized….

Our objective was….

 We sought to….

Methods

         Describe setting How inclusive was the sample Specific inclusion/exclusion criteria What was the intervention?

How were subjects identified?

How was data gathered and recorded?

How was it analyzed?

   What tests?

Have statistician or senior mentor write or review What computer program, version, manufacturer, corporate headquarters….

Make and model of all equipment Goal of methods is to enable replication

Methods: Retrospective Chart Review

  Adhere to seven elements of methods described in Gilbert and Lowenstein, 1996, or

Annals Emerg Med

, Worster and Bledsoe, 2005;45:448-451 with 12 criteria for a proper methods section:

Ann Emerg Med

.

Worster and Bledsoe

Results

      Present primary outcome measure first, followed by secondary Graphs easily visible in black and white, with different patterns, not colors For more than 4-5 related results, use table Tables are easier to digest Don’t repeat results from a table in text Instead refer to general synopsis of the tabular results

Results: Statistical and Reporting Conventions

     All results in absolute not relative terms “The

absolute risk reduction

4% to 2% was 2%,” rather than, “The

risk reduction

was 50%.” from a mortality of

relative

Relative changes inflate the magnitude of the effect artificially.

To compare two groups, use p values with 95% confidence intervals AND calculate NNT/NNH from the absolute difference in outcomes Gives information to gauge clinical import

Results: Diagnostic Tests

   Use likelihood ratios in addition to sensitivity, specificity, and positive/negative predictive values Allows reader to change probability of a given condition after the diagnostic test Pre-test probability modified by likelihood ratio = post-test probability by the Fagan nomogram

Pulmonary Embolism and d-Dimer

d-D + d-D - Total PE + 30 3 33 PE - 42 30 72 Sensitivity = 91% Specificity = 42% LR Pos = (30/33) / (42/72) =

1.5

LR Neg = (3/33) / (30/72) =

0.22

Total 72 33 105 Heit JA, et al.

Arch Path Lab Med

. 1999;123:235-240

Plain Language

  A negative d-dimer is 0.22 times as likely to occur in patients

with PE

than in patients

without PE

A negative d-Dimer is 4 ½ times occur in patients

with PE less likely

than in patients

without PE

to

Fagan Nomogram

Figures

   Even if it seems obvious, annotate figures and pictures with arrows (point to the brain hemorrhage or appendicitis) High resolution, at least 300 dpi Low resolution images “pixel out.”

Legends for Tables and Figures

     Tables and Figures with their legends are separate pages, not imbedded in text of paper Must stand alone and be very descriptive Must spell out all abbreviations used each time Must be large and clear (little white space) Make sure they are numbered in proper order

Discussion

      Most important findings first Same order as results section Then secondary outcome measures This is the place for opinion, though quite limited How could or should this change clinical care?

Discussions should be limited to 5-6 items, each with one to two paragraphs

Conclusions

      Don’t allow overstatement Definitive study is almost impossible Insist on words such as, “it appears,” or “from these data.” Always call for further investigation Retrospective studies cannot show causation, only association Make conclusion specific enough to stand alone. Include, “in adults,” or “in emergency department patients with a chief complaint of chest pain.”

Limitations

   Limit to 1-2 paragraphs Should acknowledge:  Small sample size/underpowered study      Incomplete patient enrollment Lost to follow up Retrospective design Lack of blinding Lack of generalizability Author should be honest about shortcomings and biases, or appears naïve

References

     Consistent format, adherent to journal requirements Citations go at end of sentence, unless sentence compound and citation applies only to first part Need to be up to date: look at most recent reference Lit review from two years ago is out of date Suggest new references as your expertise dictates

Questions?