Practical

Publishingfor Residents

Rey Vivo, MDAssistant Professor of Medicine

Texas Tech University Health Sciences Center

Objectives

• Benefits and Barriers• Overview of Publication Types

– Emphasis on Case Reports

• Practical Guide– Selecting a Case– Choosing among Medical Journals– Preparing the Manuscript– Submission and Review processes– Other Tips for Success

Why bother to publish?

• Academic triad: (1) clinical service/patient care, (2) medical education, (3) research

• Scholarship– “prior to the completion of training, each resident must

demonstrate acceptable scholarly activity…original research, case reports, or review of clinical and research topics.” – ACGME

– Promotes lifelong learning– Reinforces future academic career

• Literature search and critical appraisal• Advances science; expands body of medical evidence• Bolsters curriculum vitae and career

Potti, et al. Am J Med. 2003;115:510-4.Levine, et al. J Gen Intern Med. 2005;20:155-9.

Challenges to students/residents

• Lack of time• Lack of interest• Lack of money• Lack of teaching program or materials• Lack of faculty time/interest/role models/mentors• Lack of a research director/consultants• Lack of computers or software

Potti, et al. Am J Med. 2003;115:510-4.

What successful residents say…

• Start early• Set aside adequate time and adhere to a timeline• Work with a strong mentor• Choose a research topic that genuinely interests you• Keep the project simple yet innovative

• Provide adequate protected time and encouragement• Improve the technical resources available• Enhance or establish a research curriculum• Match trainees with appropriate mentors• Make funding available

Rivera, et al. J Gen Intern Med. 2005;20:366-9.

It’s all worth it!

Types of publications

• Case Reports• Case Series• Review• Hypothesis-driven Research

– Retrospective vs. prospective– Basic science, clinical outcomes, quality improvement

• Essays

Always note and record the unusual…publish it…place it on permanent record as a short, concise note…such communications are always of value.— Sir William Osler

Case Reports• “...a striking anecdote was the case of

Phineas Gage, the man who had a 4-ft iron bar blown through his frontal lobes and whose immortal remains are now in the Harvard Museum…had it been realized that one could interfere with…the cerebral hemispheres without killing the patient and…cause no obvious intellectual defect, neurosurgery might have been conceived 40 years earlier.”

• A case in American Journal of Dermatopathology was one of the first published reports on what later became known as AIDS.

Nathan. Lancet. 1967;2:607. McCarthy and Reilly. Fam Med. 2000;32:190-5.

The Perfect Fit

• High volume of patients encountered, some of whom may have reportable findings.

• Easy to do and less less time-consuming than other forms of scholarly work.

Case Reports and Residents

Nahata. Ann Pharmacother. 2008;42:273-7.

Step-by-step Guide

1. Look for a good case.

2. Read, read and read some more.

3. Obtain informed consent (required by some journals). -- Make your intentions to publish known.

4. Complete the appropriate work-up to confirm the diagnosis. -- An autopsy may be necessary sometimes.

5. Involve consultants early.

6. Identify potential journals (note word count!).

7. Begin writing!

Wright and Kouroukis. CMAJ. 2000;163:429-31.

Candidate Cases

1. The unique case that appears to represent a newly described syndrome or disease.

2. The case with an unexpected association of 2 diseases that may represent a causal relation.

3. The “outlier” case representing a variation from the expected pattern.

4. The case with a surprising evolution that suggests a therapeutic or adverse drug effect.

A common case with an uncommon presentation or an uncommon case with a common presentation.

Wright and Kouroukis. CMAJ. 2000;163:429-31.

What do journals look for?

• Clinical significance of key point/s• Originality/uniqueness of case• Quality, clarity, and conciseness of writing

• Ask yourself: – “What would this article add to existing knowledge?”– “How significant are the take-home messages?”– “How would this information change patient care?”

Nahata. Ann Pharmacother. 2008;42:273-7.

Leading Medical Journals

1. New England Journal of Medicine

2. Lancet

3. JAMA

4. Annals of Internal Medicine

8. Archives of Internal Medicine

9. American Journal of Medicine

14. Mayo Clinic Proceedings

15. Journal of General Internal Medicine

25. American Journal of the Medical Sciences

32. Southern Medical Journal

www.journal-ranking.com

Case ReportsImages in Clinical Medicine

Case Report

Diagnostic Dilemma, Images in Dermatology, ECG Image of the Month, Images in Radiology

Case Report

Case Report

Case Report

Case Report

Other primary care journals

• Consultant• Hospital Physician• Resident and Staff

Physician• ACP Hospitalist• Hospitalist

• Academic Emergency Medicine

• American Family Physician

• Archives of Family Medicine

• Journal of Family Practice• Journal of the American

Board of Family Practice

Developing the Manuscript

1. Prepare an outline.

2. Draft the case description.

3. Search pertinent literature.

4. Draft the discussion and conclusion.

5. Write the introduction.

6. Write the abstract.

7. List references.

8. Review, edit, revise.

9. Repeat #7 as many times as needed.

10.Prepare title page and cover letter.

Nahata. Ann Pharmacother. 2008;42:273-7.

Outline

• Abstract• Introduction• Case Description• Discussion

– Literature review

• Conclusion– Summary/Recommendations

Case Description

• Demographics (age, sex, height, weight, race, occupation)– Avoid patient identifiers (date of birth, initials)

• Chief complaint and present illness• Complete history (medical, family, social, occupational, medications)• Pertinent findings on physical examination• Pertinent laboratory, imaging, other diagnostic data.

– Provide the reference range for laboratory values– Paraphrase the salient results of the diagnostic procedures– Provide photographs of images, histopathology, etc.

• Narrate events in chronological order– Detail differentials, challenges to diagnosis/treatment

Cohen. Am J Health-Syst Pharm. 2006; 63:1888-92

Discussion

• Summarize the salient features of the case report

• Compare and contrast the nuances of the case report with the existing literature

• Justify the uniqueness of the case

• List the limitations of the case report and describe their relevance

• Confirm the accuracy of the descriptive patient case report

• Draw recommendations and conclusions

Cohen. Am J Health-Syst Pharm. 2006; 63:1888-92

Conclusion

• Provide a justified conclusion– Avoid over-reaching statements

• Provide evidence-based recommendations

• Describe how the information learned applies to one’s own practice

• List opportunities for research

• Ensure that this section is brief and does not exceed one paragraph

Introduction

• Describe the subject matter

• State the purpose of the case report

• Provide background information and pertinent definitions

• Describe the strategy of the literature review and search terms

• Introduce the patient case to the reader

• Make the introduction brief and less than three paragraphs

Cohen. Am J Health-Syst Pharm. 2006; 63:1888-92

Abstract

• Introduction and objective/s

• Case report

• Discussion

• Conclusion

Cohen. Am J Health-Syst Pharm. 2006; 63:1888-92

References

• National Library of Medicine Style Guide for Authors– http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=citmed.TOC&depth=2

• Be aware of limitations

Manuscript checklist

Sorinola, et al. BMC Medical Education. 2004;4:4.

Authorship

• First listed: usually the primary author (the one who contributed the most)

• Last listed: typically the senior author who supervised the work; often also the corresponding author

• Middle authors: may be listed according to amount/weight of contribution

• Critical to decide order before initiating the work• Note whether journal has restrictions on # of authors

(particularly case reports)

Submission process

• Review the journal’s “Author’s Information”• Familiarize yourself with the online submission process• Prepare all documents

– Cover letter– Title page– Manuscript– Figures/Tables/Charts

• Timeline

After submission…

Understanding the Review Process

• ACCEPTED– Address comments– Revisions– Proofread galley

proofs

• Rejected– Review comments– Reflect– Seek advice– Revise– Re-submit

Sample ProofG

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A word on Essays

Essays

• JAMA– A Piece of My Mind

• Annals – On Being a Doctor

• NEJM– Perspective

• JGIM– Reflections

• Academic Medicine – Teaching and Learning Moments

Bonus Tips

• Aim for high-impact journals.

• Check out journals who publish electronically ahead of print.

• Be OC when reviewing your manuscript.

• Solicit feedback thoughtfully and aggressively.

• Be flexible.

Persistence. Persistence. Persistence.

Summary

1. Always keep your eyes (and ears) open for an interesting case.

2. Verify, by literature search, the novelty of your case.

3. Write, write, write!

4. Seek advice from others who have published.

5. Submit and revise as needed.

6. If at first you don’t succeed, try again! There are MANY journals.

7. Do NOT limit yourself to patient care alone…strive to contribute to medicine in meaningful ways!!!

Thank you