WritingforImpact:HowtoPrepareaJournalArticle

AndrewM.Ibrahim,M.D.,M.Sc.RobertWoodJohnsonClinicalScholar

InstituteforHealthcarePolicyandInnovationUniversityofMichiganAnnArbor,MI48109

JustinB.Dimick,M.D.,M.P.H.

GeorgeD.ZuidemaProfessorofSurgeryDirector,CenterforHealthcareOutcomesandPolicy

UniversityofMichiganAnnArbor,MI48109

Abstract:Whyarewesoseriousaboutwriting?Becausewebelievewritingisasimportantasthescienceshowcasedinaresearchpaper.Youcouldhaveagreatidea,executethestudydesignperfectlyanddiscoverfindingsthatwouldtransformhowyourprofessionispracticedaroundtheworld.Butifyoucannotwriteaclearandcompellingnarrative,itisnotgoingtohavegreatimpact.And,scienceisallaboutimpact.Or,asSteveJobssaid,“Toputadentintheuniverse.”Atthecoreofeffectivescientificwritingisadisciplinedapproach,alotofpractice,andacommitmenttoimprovement.Weoutlinehereourapproachtostructurethecontentofamanuscriptaswellaspracticaladvicetoimproveyourwritingprocess.RunningTitle:WritingaJournalArticleKeywords:Manuscripts,Writing,Editing

“Iwouldnotgiveafigforthesimplicitythissideofcomplexity,butIwouldgivemylifeforthesimplicityontheothersideofcomplexity.”-OliverWendellHolmes,Jr.,UnitedStateSupremeCourtJustice,1902-1932WHYYOUSHOULDGETSERIOUSABOUTYOURWRITINGConsiderafewofourhighestimpactscientificjournals,suchasNewEnglandJournalofMedicine(NEJM)andtheJournaloftheAmericanMedicalAssociation(JAMA).Publishinginthesejournals,orotherhighimpactfactorjournals,canleadtosignificantchangesinclinicalpracticeandpolicy.Whatdothesehighimpactpublicationshaveincommon?Besideshavingagreatideaandawell-executedstudy,theyalsohaveaclearandcompellingnarrativethatmakestheresearchaccessibletotheiraudience.Thereareacountlessnumberofimportantscientificdiscoveriesthatneverrealizetheirpotentialimpactbecausetheyareburiedwithinpoorlywrittenmanuscripts.

Theimportanceofwritingaclearandcompellingmanuscriptappliesbeyondthetoptierpublications.Evenifyouareaseasonedwriterandresearcher,mostofyourworkwillnotbeinthesejournals.Butyoushouldstillwritewiththesameclarityandfocusasthiswillincreasetheimpactofyourworknomatterwhereitispublished.Theimpactofyourresearchislimitedbyyourabilitytoeffectivelycommunicatethefindingsandimplicationsofthework.Perhapsthemostvaluablereasontogetseriousaboutwritinggoesbeyondmanuscripts.Becomingamoreeffectivewriterwillteachyouhowtocommunicatecomplexideasintoalogicalandclearnarrative.

Suchaskillisnecessarytootherresponsibilitiesoftenencounterbyacademicresearchers:publicspeaking,grantwriting,orinstitutionalleadershippositions.Wepointoutthetransferablenatureofwritingskillstooverallprofessionaldevelopmenttohelpyoujustifyputtinginthetimenecessarytobecomeaneffectivecommunicator.Theremainderofthischapterisorganizedintotwosections.First,weoutlinehowtostructurethekeycontentthatshouldbeincludedinascientificmanuscript.ItdrawsonseminalworkfromGilWelch–“PreparingManuscriptsforSubmissiontoMedicalJournals:ThePaperTrail”1—thatwehaveadoptedandtailoredonovertime.Second,weoffersomepracticaladviceonhowtoimproveyourwritingprocess.Theselessonscomedirectlyfromourownlearningcurveasauthors,ourobservationsaspeer-reviewers,andexperienceworkingwithmentees.

“Theimpactofyourresearchislimitedbyyour

abilitytoeffectively

communicatethefindingsandimplicationsofthework.”

THECONTENTOFASCIENTIFICMANUSCRIPTScientificmanuscriptssubmittedtoacademicjournalsaregenerallyorganizedinthefollowingorder:

• Abstract• Introduction• Methods• Results• Discussion• TablesandFiguresThereissomevariationfromjournaltojournalonthedetailsthatshouldbeincludedwithineachsection.Onthewebsiteofeachjournalyouwillfind“InstructionsfortheAuthors”thatwilldetailanydeviationfromthisformat.Wediscussbeloweachsectionseparately.AbstractWhatisinanAbstract?Theabstractsectionofamanuscriptisasummary(often300wordsorless)oftheresearcharticle.Ittypicallyfollowsthesameformatasthearticle(i.e.introduction,methods,results,conclusion)butinanabbreviatedform.Althoughyourmainmanuscriptmayincludemultiplefindings,theabstractonlyhasspacetofocusononeortwokeyfindings.Assuch,youshouldspendtimethinkingaboutwhichisthemostimportant.Taketimetoensureyourintroduction,methods,resultsandconclusionareconsistentwithinyourabstract.Forexample,yourpapermayexaminemultipleoutcomes(e.g.complications,mortality,costs)butyouonlyplantofocusonmortalityandcostsintheabstract.Yourintroduction,methods,resultsandconclusionshouldallbetailoredtothosetwooutcomes.Readerswillbeveryconfusedifstateinyourabstractthatstudiedthreeoutcomes,butthenonlyreportontwointheresultsoftheabstract.TheThreeRolesofanAbstractAcrosstheManuscriptTimelineAnabstracttakesonthreedifferentrolesfromthetimeyoustartwriting,onceit’ssubmittedandafteritispublished(Figure1).

1.WhenWriting:ImproveYourResearchQuestion.Werecommendthatyouwritetheabstractfirstbecauseithelpsyourefinethenarrativeoftheproject.Weevenencouragedoingsobeforeyouevenhavedatawithplaceholderresults(e.g.“XX%”,“YY%”)assuminganumberofpossibilities.Thisexercisewillhelpyoufocustheresearchquestion,clarifywhichoutcomesyouwanttoevaluateandassessifyourstudydesignanddataareappropriate.Ifyoucannottroubleshoottheseissuesandwriteacompellingabstractwithplaceholderresults,youshouldstop.Thisisasignyouneedtorefineorchangeyourresearchquestionbeforewastingtimeexecutingtheworkplan.2.OnceSubmitted:ConvinceEditorsIt’sWorthofPeer-Reviewed.Theabstractiswherejournaleditorswilllookfirsttodecideifthemanuscriptshouldbesentoutforpeerreview.Athigh-impactjournals,morethanhalfofthesubmissionswillberejectedbasedprimarilyontheabstract.Acommonmistakehereistooverstatetheimportanceofyourfindingswitha“conclusion”thatisnotsupportedbytheresults.Editorshaveasharpradarforthistypeof“overreach”anditgivesthemaneasyreasontoquicklyrejectyourwork.Remember,thislastsectionoftheabstractislabeled“conclusions”not“editorialoverreaching”.3.AfterPublication:GettingtheRestoftheArticleRead.Theabstractisthefirstsectionthatreadersencountertodecidewhetherornottheywanttoreadtheentirearticle.Manyreadersmayneverreadpasttheabstract,soitisimportanttomakesureyou’vecommunicatedyourkeymessage.Apoorlywrittenabstractwillnotenticereaderstospendtimeonmorepoorlywrittenprose.IntroductionThepurposeoftheintroductionistogivecontexttothequestion,createaknowledgegapandpreviewyourstudyplan.Wefeelthisisdonemoreeffectivelywiththreedistinctparagraphs(Figure2).Paragraph1:GiveContexttotheProblemThefirstparagraphoftheintroductionshouldgetthereadertocareaboutthetopic.Itneedstobringthereaderuptospeedonthewhythetopicisimportant.Forexample,ifyourpaperisevaluatingafederalpaymentpolicy,you’llneedtohelpthereaderquicklyunderstandwhythepolicywascreatedandwhatisimportantaboutitnow.Commonmistakesherearetogivecontextthatistoobroadortoonarrowforyouraudience.Mostpeoplestarttoobroadandtelltheiraudiencethingstheyalreadyknow.Forexample,let’sconsideramanuscriptaboutcolorectalcancer.Startingoffwith,“ColorectalcanceristhebiggestkillerinAmerica”isnotgood.Almostallpapersstartthatway,butyouloseahugeopportunitybecauseyouaretellingpeoplethingstheyalreadyknow.Theonlytimeitisokayto

startamanuscriptwithasentencelike,“EveryyearintheUnitedStatesthereare100,000casesofXXX”iswhenyouarewritingaboutepidemiologyandyouaregoingtosaythatnumberiswrong–itisactually200,000.Youhavetoestablishtherightentrypointforyourtopic.Ifyoustarttoobroadyou(A)puteveryonetosleepand(B)arewilltakeuptoomuchwritingspacegettingpeopleallthewayuptoyourknowledgegaps.Paragraph2:CreateaKnowledgeGapThesecondparagraphneedstogetthereadercuriousbycreatingaknowledgegapbetweenwhatisknownandunknown.Youshouldnotsummarizealltheliteratureonthetopichere,buthighlighttheareasthathavetensionoruncertaintyrelatedtoyourstudyquestion.Theknowledgegapsyouintroduceinthisparagraphshoulddirectlycorrelatewiththeoutcomesthatyourstudywilladdress.

Thisisthehardestparagraphoftheintroductiontowriteforafewreasons.First,youactuallyhavetoknowexactlywhatisknownandunknown.Second,thatknowledgegapneedstobeexactlywhatyourstudyisdesignedtodo.Third,youneedtoputthosebothtogetherinacompellingnarrativethatconvincesthereaderitisanimportantgapintheliteraturethatneedstobeaddressed.Forexample,ifyourpaperisaboutthelong-termoutcomesofcolorectalcancerpatientsaftersurgery,youneedtosetuprelatedknowledgegaps.Didpreviousstudiesnotfollowpatientslongenough?Aremostofthestudiesfocusedonnarrowsubpopulations?Whatevergapsyouchoosetohighlighthereshouldplayrightintothestrengthsofyourstudy(e.g.longerfollow-up,

morerepresentativestudyparticipants,etc).Ideally,bytheendofthisparagraph,thereadershouldbethinking,“Ifonlytherewasastudywithlongerfollowupandamorerepresentativesample,wewouldunderstandthistopicsomuchbetter.”Bingo–thenyoutellthem(Paragraph3)that’sexactlywhatyourstudywilldo!Paragraph3:PreviewYourWorkPlanThethirdparagraphoftheintroductionshouldpreviewyourworkplan,i.e.,brieflyexplainhowyouwillclosetheknowledgegapdiscussedinthepriorparagraph.Savethedetailsforthemethodssection,butsimplystatethedatabaseandtheoutcomesyou’regoingtouse.Again,theoutcomesshoulddirectlylineupwiththeknowledgegapsyoujustcreated.Ifyouwrotethefirsttwoparagraphscorrectly–motivatedwhythetopicisimportant,highlightedareaswherethereareknowledgegaps–thenthisshouldbeaneasyparagraphtowrite.Ifyou’rehavingtroublewithparagraph3,gobackandlookatparagraph2again.Acommonmistakeistohighlighttoomanyknowledgegaps.Yougetthereadercuriousaboutsomany

“Theknowledgegapsyou

introduceinthisparagraph

shoulddirectlycorrelatewiththeoutcomesthatyourstudywilladdress.”

controversialareasinthetopic,thenprovideahugeletdowninparagraph3whentheyrealizeyourstudyisonlygoingtofilloneofthem.MethodsThemethodssectionsshouldexplainhowthestudywasconducted.Therearedifferentconventionsonwhatneedstobereportedherefordifferentstudydesigns(e.g.randomizedcontroltrials,surveydata,qualitativeinterviews,etc).Werecommendlookingatpreviousarticlesfromthejournalyourtargetingand/oryourmentortoseehowthissectionwasorganized.Formanypapers,themethodssectionswillincludethesesub-sections:

• DataSource–whatdatadidyouuse?(e.g.MedicareClaims)• PatientPopulation–whodidyoustudy?(e.g.allpatientsundergoingsurgeryfor

colorectalcancer)• Outcomes–whatdidyoumeasure?(e.g.30-daycomplications,readmissions)• StatisticalAnalysis–Whatmethodsdidyouuse?(e.g.multivariablelogisticregression)

Eachofthoseheadings,onaverage,willbetwoparagraphs.Again,werecommendfollowingprecedentfrompreviouspaperswithsimilarmethodologicalapproachtoguideyouhere.Chancesareyourmentorwouldhaveusedmostofthesesamemethodsbefore.Adetailedreadingofyourmentor’spriorworkwilllikelyyieldmostofthemethodsthatyouwillneed.However,youdonotwanttosimplyplagiarizepriorwork.Rewritetheminyourownvoice,withaneyetowardscreatingaclearlinearnarrative,emphasizingthosemethodsmostrelevanttoyourcurrentstudy.Theremaybeafewareasthatareentirelynew,andthosearetheonesyoushouldspendthemosttimecraftingwithyourmentor.

ResultsTheresultssectiondetailsthefindingsfromtheanalysis.Thisshouldbereportedinmultipleparagraphsstartingwithonethatdescribesthepatientcharacteristics.Ifapplicable,thenextparagraphshoulddescribethehospitalcharacteristicsofthegroupsbeingcompared.Thenext2-3paragraphsshoulddescribetheoutcomesofthestudy.Theseshouldbestatedobjectively.Avoidphraseslike,“Surprisingly,wefound…”or“Contrarytowhatweexpected…”Thissectionshouldsimplypresenttheinformationwithoutanyeditorializingorinterpretation.

“Adetailedreadingofyourmentor’spriorworkwill

likelyyieldmostofthemethodsthat

youwillneed…Rewrite

theminyourownvoice,withaneyetowardscreatinga

clearlinearnarrative.”

Youshouldpresenttheoutcomesinthesameorderthatyouintroducedtheminthemethods.Startwithyourprimaryoutcome,thenyoursecondaryoutcomesasappropriate.Eachofthetablesandreferencesinthearticleshouldbereferencesintheresultssection.Infact,thisisagoodstrategytoavoidrepeatinglinesandlinesofresultsthatarealreadyclearlypresentedinthetablesandfigures.DiscussionThediscussionsectionisyouropportunitytoconnectthepreviousthreesections—introductions,methods,results—togetherandputthemintothebroadercontextofthetopic.Wetypicallyusea5paragraphapproachforthissectionthatincludesfourcomponents(Figure3).Paragraph1:SummarizetheFindingsThefirstparagraphofthediscussionshouldbeusedtosummarizethe1or2keyfindingsfromthestudy.You’vetakenthereaderonalongjourneysofar,sothisisagoodtimeto“refresh”inplainlanguagewhatthisstudywasaboutandwhatthekeyfindingswere.Paragraphs2-3:PutYourFindingsIntoContextThenexttwoparagraphsareusedtoplaceyourmainfindingsintocontext.Youmayhavereferencedsomeofthisinformationintheintroduction,butthisisyourchancetotakeadeeperdive.Inadditiontosummarizingprevioussimilarstudies,endeachparagraphwithanadditionalsentenceabouthowyourresearchbuildsoraddstothispriorwork.Itmaychallengepreviousfindings,orextendedadeeperunderstandingofthem.Ifyoucan'twritethatsentencebecauseyourresearchdemonstratestheexactsamefindingsaseightpriorstudiesonthistopic,don'twritethepaper.Animportantstylepointhere:authorswhohavewrittenonthesametopicwilllikelybeareviewerofyourpaper.Somakesureyoureferencethemappropriatelyanddescribetheirstudyaccurately.Paragraph4:RecognizeLimitationsNostudyisperfect,includingyours.Theeasiestwaytoannoyaneditororarevieweristoignorethelimitationsofyourstudy.Limitationsaredesignfeaturesofyourstudythatthreatenthevalidityofthefindings.Youwanttodiscussthreetofivemainlimitations,whichfallintothethreemaincategoriesofthreatstovalidity:Chance,bias,andconfounding.

• Chanceisrandomerror.Addressingrandomerrormeansmakingsurethestatistical

comparisonsareadequatelypoweredandanalyzedwithappropriatetests.• Biasissystematicerror.Addressingsystematicerrormeansdiscussingwhichstrategies

youusedtoensurethatthesebiasesdidnotmakeyourstudyresultsinvalid,e.g.,makingsureyouhaveastrategyforaddressingselectionbias.

• Confoundingiswhentherearevariablesthatareassociatedwiththeexposureandoutcomethatareactuallydrivingyourresults,ratherthanatruerelationshipbetweenexposureandoutcome.Addressingconfoundingincludesathoroughdiscussionofhowyouwereabletoaddressconfoundingwithstudydesignand/ormethodologically.

Toreallytakeadvantageofthissection,youwillwanttoprovideacounterpointabouthowyoutriedtomitigatethatlimitationorwhyitmaynotthreatenyourentirestudy.Youcanthinkofitasprophylacticallyaddressingconcernsyouthinkwillcomeupfromreviewers.Itwilldemonstrateyouwerethoughtfulaboutthestudydesign,andarenotoverreachingyourconclusion.Paragraphs5:ImplicationsMovingForwardThelastparagraphofthemanuscriptshoulddiscusstheimplicationsofyourfindings.Anextremelycommonmistakehereistosimplyconclude“moreresearchisneeded.”Donotdothat.Itmakeseveryonemadandcheapensyourvalueasanauthor.Takeamoresophisticated

anddetailedperspectivewithyourrecommendations.Demonstrateyouhavereallythoughtaboutthesubjectmatterandgenuinelywanttoseeyourfieldadvancebasedonthefindings.Tohelpbrainstormtheimplicationsofyourstudy,weoftenthinkabout“the4P’s”:patients,providers,payers,policymakers.Howwillyourstudyaffecteachofthem?Doesthischangehowpatientschoosetreatments?Howproviderspractice?Howpayersshouldreimburse?Howpolicymakersregulate?Thisisyourchance(withinreason)tomakeacallforactionbasedonyourwork.Havingaco-authorwith

deepexperienceinthetopicareacanbeparticularlyvaluableforhelpinwritingthissection.TablesandFiguresAlthoughtablesandfiguresinfinalprintareincludedwithinthemanuscript,duringsubmissiontheyshouldallbeplacedattheendafterthereferences.Alldataandfiguresshouldbereferencedwithintheresultssectionofthemanuscript.Acleartableorfiguretakesalongtimetocreate.Itisworthlookingatothermanuscriptswhohavedonethiseffectivelyandlearnwhatmadethemusefultothereader.Themosteffectivetableshave:clearheadings,identicalspacingandlogicalorganizationofinformation.

The4P’softheDiscussion:

HowWillthisStudyImpact-Patients?Providers?Payers?

PolicyMakers?

IMPROVINGYOURWRITINGPROCESSThisnextsectionofferssomepracticaltipsandadvicewehaveacquiredovertimetoimproveyourwritingprocess.LearnWhatIsTriedandTrue“Youareunlikelytodiscoversomethingnewwithoutalotofpracticeonoldstuff.”-RichardFeynmanPh.D.,WinneroftheNobelPrizeinPhysicsin1965Ifyouarenewtowritingscientificmanuscripts,youwillwanttostartwithalotofreading.Askyourmentorforahandfulofimportantarticlesinyourfieldandreadthemclosely,sentenceforsentence.Learnthestyle,toneandconventionsthatareusedwithinyourfield.Afterafewarticles,thenre-readthearticlesalongsidetheguideaboveandidentifykeyparagraphswithineachsection.Soonthetemplateabovewillbecomesecondnature,andyou’llquicklyhoneinexactlywhateachparagraphofamanuscriptisdesignedtoachieve.Writein20MinuteBursts&2HourBlocksFormanypeople,sittinginfrontofablankpagecanbeintimidating.Itstillisforus.Thatiswhyatemplateliketheonewe’vegivenyouaboveishelpful.Whenyouhavewriter'sblock,whatcanyoudo?Youcanwriteoneparagraph.Chipawayattheparagraphswhereyouknowwhatthecontentissupposedtobelikethemethodsparagraphaboutthedatasource.Ifyousitdownandwriteaparagrapheverymorningfortwentyminutesfortwoweeks,guesswhatyouhave?Youhaveanentirepaperthattookyoutwentyminutesadaytowrite.Itisnotverygoodbecauseyouhavenoteditedit,butyoudohaveapaper.The20minuteburstscanbeeffectiveforsomewriting,butnotsufficient.Wealsorecommendsettingasidesignificantblocksoftimeinyourschedule(e.g.2hours)forwriting.Thisshouldbeuninterruptedtimetodeeplyfocusonasinglepaper.Theabstract,introductionanddiscussionsectionsparticularlybenefitfromtheselongerwritingperiods.SticktoaParallelWritingStructureAsyoureadmoreandmorescientificarticles,youwillobservethattheyfollowaveryclearstyleandpattern.Youwillwanttodevelopthatsamehabitinyourownwriting.Theeasiestplacetostarthereismakingsurethatyouintroducecontentwithineachsectionofyourmanuscriptinthesameorder.Forexample,ifthetitleofyourpaperisthe“ComplicationsandCostsofRuralSurgery”thenyourintroductionshouldfirstintroducecomplications,thencosts.Similarly,yourmethodsshouldfirstdefinecomplicationsthencosts.Theresultsshouldthenbereportedinthatordertoo,complicationsthencosts.Andfinally,thediscussionshouldfirstdiscussthefindingsaboutcomplications,thenaboutcosts.Beingdiligentaboutkeepthesameorderthroughouteversectionwillmakeyourmanuscripteasiertoreadandfollow.

BeConsistentwithTerminologyUsethesameterminologythroughoutthemanuscript.Scientificmanuscriptsaredifferentthanotherformsofwritingwhereyouwanttousevarietytokeepitinteresting.Thisistheopposite.Ifyou'recallingsomething,forexample,“DeclineinApplicants”,don'tcallit“DiminutioninMedStudentsInterestedinApplyingtoUrology”lateron.Callitthesamethingeverywhere.Itistoohardtoreadapaperwhenyouareinconsistent.Switchingtheterminologyortopicaroundissomethingthateditorsdislikebecauseitmakesthepaperseemunfocusedorconfusing.Thegoalhereisforthereadertounderstandthecontentofyourresearch—notdazzletheeditorswithrhetoricalflourishes.GettingtheMostFromFeedbackAgoodmentorwantstoseeyourwritingearly-onandhelpyouiterate.Itisyourmentor’sjobtohelpimprovethewayyouthink,andtodothat,theyneedtoseewhatyouaredoing.Frequentshortmeetingsarebest.And,recordeverything!Ifyousitdownwithyourmentorfortwentyminutestolookoveryourpaper,bringyouraudiorecorder(oryoursmartphone)becausetheywillsaytwentythingsinthatmeetingandyouwillwalkoutrememberingonlytwo.Ifyoutryandwriteitdown,youmaywalkoutwithfiveofthetwenty.Ifyourecordtheconversation(withtheirpermission,ofcourse),youwalkoutwithalltwenty.Yourmentormightevensaythingslike,“Whydon'tyoutrysomethinglikethis?”anditwillbetheperfectsentencethatpullsitalltogether.Putitintoyourownwordsifyoulike,butthatisthebestuseofyourtimewithyourmentor.Wecanrecallcountlesstimeswe’vegonebacktoaudioandrediscoveredoptimalphrasingorideastoputintoarevision.Wealsocanrecallaskingmenteeswhodidn’trecordtheconversation,“Didn’twetalkaboutchangingthiswhenwemetlasttime?Whyisitstillthesame?”WriteAsYouGoWhencanyoustartwritingthesevarioussections?Youcanwriteanabstractwithoutdata.Youcanwriteanintroductionanytime,becauseithelpsyouunderstandifyourresearchquestionisgood.Particularly,thesecondparagraphoftheintroductionwhereyouidentifyknowledgegaps.Ifyouarethinkingaboutaresearchquestion,trytowriteyourintroduction.Ifitisnotcompelling,thenyoumaywanttoshiftyourresearchquestion.Writethemethodsasyou'redoingtheprojectsoyoudonotforgetdetails,especiallyifyoudoalotofcomplicatedanalysisormakealotofassumptions.Youhavetowaitforyourresultstofinishyourtablesandfigures,butyoucanmockuptablesandfigures.Inthiswayyoucanthinkaboutthetable,freeofanydata.Youcandevelopagoodstructureforpresentingyourdata.

DiversityYourWritingPortfolioAsyouwriteamanuscript,youmayfinditnotgoingasplanned.Thedatayouhadwasmorelimitedthanyouinitiallythoughttomakeacompellingargument.Or,afterthinkingthroughyourknowledgegaps,yourealizedyourresearchquestionismoreappropriateforaspecialtyaudience.Ratherthanhittheseroadblocksandscrapthemanuscript,wesuggestusingthatasanopportunitytorefocusthemanuscripttoadifferentsubmissiontarget.Weusethequalityofthedata(compellingversuslimited)andscopeofthenarrative(broadversusspecialty)tohelpdeterminewherethemanuscriptshouldbesubmitted(Figure4.)Whenthereiscompellingdataandanarrativewithbroadappeal(e.g.Medicareclaimsevaluatinganationalpaymentpolicy),werecommendtargetingageneralmedicinejournalasanoriginalcontribution.Similarqualitydata,butwithamorefocusedtopic(e.g.evaluatingreadmissionsinoncologicsurgery)shouldbesubmittedtoaspecialtyjournal.Whenthereisnotgreatdatatoevaluatethequestion—perhapsitnotavailableyetbecausethepolicyornewprocedurewasjustannounced—westillencouragedevelopingtheideaintoathoughtpiece.Buildinganarrativeintheformofaviewpoint,commentaryoropinion-editorialcanhelpyouthinkthroughknowledgegapsinthatareaandestablishyournameinthatspace.Severaljournals,newspapersandonlineforumssupportthistypeofpublication.Everyauthorseriousaboutimprovingtheirwritingshouldintentionallytargettohitallfourquadrantsofarticlesregularly.Writingfordifferenceaudienceswillsharpenyourabilitytocommunicatecomplexideasinaclearnarrative.Moreover,ittakesadvantageofeffortspentonearlydraftsthatdonotallendupwhereinitiallyplanned.EatSomeHumblePieWhatmostdetermineswhetherornotyouwillbeagoodwriter?Ithastodowithhowoftenyouseekfeedbackandhowyourespondtothatfeedback.Thepeoplewhoarethebestwritersandwhoproducethebestmanuscriptsarethosewhoarethemostopentofeedback.Ifyouthinkyourwritingisgreatandthatyourmentor'scriticismsofitareunfounded,thenyouwillprobablynotbecomeagreatwriter.Putyourbestfootforwardinlisteningtowhattheysay.Wetrytowriteiteratively,andletapaperunfoldoveralongtimehorizon.Ifyouwriteoveralongperiodoftime,youcanseeyourflawsmoreclearlybecauseyoucansetthemasideandcomebacktothem.Wealsotrytobringinsomeonewhohasadifferentperspectivethanus,justtogettheirfeedback.Often,thebestideasemergefromtheseconversations,insteadofwrittenfeedback.Trynottobedefensive,-justfocusonunderstandingtheproblem.And,youdonotneedtotakeeverysuggestion.Youwanttomakeityourown.So,eliminateyourdefensiveness,heartheproblem,andcomeupwithasolution.Themoreiterationyouinvestinyourpaper,thebetteritwillbe.

References1. WelchHG.Preparingmanuscriptsforsubmissiontomedicaljournals:thepapertrail.Effective

clinicalpractice:ECP.May-Jun1999;2(3):131-137.

FiguresandTables

Figure1.TheThreeRolesofanAbstractAcrosstheManuscriptTimeline

Figure2.TheThreeParagraphsofanEffectiveIntroduction

Figure3.FourComponentsofaCompellingDiscussion

Figure4.WhereShouldYouSubmitYourManuscript?