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How to Read, Write, and Review the Imaging Literature
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How to Read, Write, and Review the Imaging Literature Arielle Sasson MD , Oseogie Okojie MD , Ryan Verano BA , Mariam Moshiri MD , Michael N. Patlas MD , Jason C. Hoffmann MD , John J. Hines MD , Douglas S. Katz MD, FACR PII: DOI: Reference:
S0363-0188(20)30007-4 https://doi.org/10.1067/j.cpradiol.2020.01.002 YMDR 778
To appear in:
Current Problems in Diagnostic Radiology
Please cite this article as: Arielle Sasson MD , Oseogie Okojie MD , Ryan Verano BA , Mariam Moshiri MD , Michael N. Patlas MD , Jason C. Hoffmann MD , John J. Hines MD , Douglas S. Katz MD, FACR , How to Read, Write, and Review the Imaging Literature, Current Problems in Diagnostic Radiology (2020), doi: https://doi.org/10.1067/j.cpradiol.2020.01.002
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
How to Read, Write, and Review the Imaging Literature Arielle Sasson, MD (1)*, Oseogie Okojie, MD (1)*, Ryan Verano, BA (2), Mariam Moshiri, MD (3), Michael N. Patlas, MD (4), Jason C. Hoffmann, MD (1), John J. Hines, MD (5), Douglas S. Katz, MD, FACR (1) From the Departments of Radiology, NYU Winthrop (1), the University of Washington (3), McMaster University (4), and Northwell Health (5), and from the University of Connecticut (2). * = co-first authors Address Correspondence to: Douglas S. Katz, MD, FACR, Department of Radiology, NYU Winthrop Hospital, 259 First Street, Mineola, NY 11501 Phone: 516-663-3800; FAX: 516-663-8172; email: [email protected] Co-author emails: [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected]
Introduction:
There is currently little to no formal training in the requisites of medical journalism at any point, from the medical student to the junior faculty level - yet everyone in training or at some other stage in their academic career is expected to participate in these activities in their 1
specialties, including in reading medical journals, and frequently in reviewing and/or writing for journals and for other types of professional products and forums. This is particularly the case in radiology training, where despite the crucial nature of these inter-related activities, few are taught how to critically evaluate the radiology literature, to formally review manuscripts being considered for publication in an imaging journal, and to combine those two related skill sets and apply them towards writing manuscripts for potential publication in peer-reviewed and other journals, or in other educational products. Although some radiology and other medical residency programs may be more recently teaching the tenets of medical journalism within their core curricula, in our experience radiology residency journal clubs usually do not encourage much discussion related to these general topics. As a result, younger radiologists may not be developing critical reading and writing skills, and are thus unable to extrapolate these skills to evaluate newer imaging techniques or technology, or to maximize their academic potential as reviewers, and as a biomedical writers and researchers. In our experience, the more of all of these activities in which one participates at all levels, the better one becomes at all of them. When it comes to engaging in activities related to reading, reviewing, and writing the imaging literature, junior radiologists may unfortunately have to take a “sink or swim” strategy. They learn how to read, and in particular how to review and/or how to write, mostly by trial and error, with a steep learning curve. Poor or even no real habits are established, and the quality of reviews and/or submitted manuscripts can be suboptimal. No one benefits from such a wellmeaning but poorly delivered approach – other authors of submitted manuscripts, editors, the readership of imaging journals, radiologists in practice – and ultimately our patients. Therefore, 2
the purpose of this review article is to provide our perspective as to how one should be reading, reviewing, and writing the imaging literature, and also providing guidance from other thought leaders in this area, and from the literature itself. We hope to inspire radiology trainees and radiologists at all levels, particularly those in academic careers, to more fully participate in peer review and in radiology publication.
Reading the Imaging Literature: During their residency, radiology trainees must develop strong empirical abilities related to their specialty, including building a wide-ranging and comprehensive clinical imaging knowledge base, and performing a myriad of procedures.1 Yet the field of medicine is constantly evolving, and particularly radiology, given its inherent technological basis and constant innovations, and both trainees and attending radiologists need to have the skill sets to scrutinize the published literature, including very recent publications, to keep up-to-date with these changes, and then to potentially using the information acquired to analyze this wealth of information, to perform and interpret imaging examinations, as well as to potentially make their own contributions to the literature. Evidence-based medicine, and to take this one step further- evidence-based radiology2 - is increasingly important, and has been integrated into daily radiology practice. Thus, having the ability to appraise the imaging and the general medical literature, and to delineate practices with the best research evidence, is now a necessity.1 Reports published by both the Accreditation Counsel for Graduate Medical Education (ACGME) and the American Board of Radiology have also stressed the importance of developing such critical-thinking skills.3
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Given the myriad of educational choices now available on line, including numerous web-based educational sites and databases and teaching files as well as e-books, in addition to more traditional books and journals, certain factors regarding on how radiology trainees and attending should select their educational resources become of outmost importance. Knowing which are the “right” materials to focus on, an overwhelming amount of information, not knowing what is the correct information, and even boredom in the search process, have all been cited as barriers to reading and engaging in the available literature.4 Although the most common approach to literature searching is only using the inclusion criteria of “freely available articles or texts” in one’s native language, this is a haphazard tactic, and is bound to yield texts and sources of all levels of value and usefulness for the reader.5 Out of frustration, and due to their priorities at the time, many radiology residents end up focusing on materials which are only relevant to the boards (which is definitely important, but mostly at the appropriate time of training).2 Thus, the goal of this section is to offer a basic framework of how to select and analyze some of the reading materials available, with a focus on the more traditional types of sources.
What should I be reading? There is much diversity in the content of different medical imaging textbooks on diagnosis and image-guided therapy. Although there is no clear consensus as to what the best sources should be in all situations, above and beyond textbooks, original, peer-reviewed articles (original research articles, as well as review articles, particularly those of which are also peer reviewed, such as in the journal RadioGraphics, or in journals such as this one), are and should remain the 4
top priority.6 Articles presenting primary research are critical in providing information which will progress the field of radiology, and it is essential to remain at the forefront of such advances. Because textbooks cannot be updated every single year - even e-books - reading review articles which fill the gaps between textbook revisions is also of high importance, but less so than reading original research. And although case reports provide salient information about how different disease processes can present, these anecdotal reports are often of uncertain scientific value to budding radiologists, and to the imaging and medical community as a whole. Although it is important to remain well-read in all of these different types of literature, time for reading is increasingly limited, as trainees and attending senior radiologists are increasingly busy clinically, with more extended work hours, and with often greater demands on their time and energy when outside of work. Therefore, we believe it is essential to focus on reading materials which are more specific and which are most appropriate at the particular stage of that person’s training and experience. For first-year radiology residents, we recommend focusing on major textbooks which convey the essential knowledge needed to gain basic competence with imaging interpretation in each of the subspecialty areas. Fundamentals of Diagnostic Radiology is such a book for all radiology residents to obtain a comprehensive overview of vital topics, and many U.S.-based radiology residency programs use this text for monthly formal teaching.7 However, we realize that in this digital age millennials are reading textbooks less and less, and that radiology residents are increasingly reading and studying using on-line materials only. Learning the often high-yield information from current or relatively recent articles discussed during monthly journal club meetings, and which are typically assigned by specific radiology 5
department faculty members in various subspecialty areas, is also useful to begin developing a core knowledge base as a first- or second-year radiology resident. In addition to reading articles presented during journal club, we suggest concentrating on major review articles in RadioGraphics and similar sources for second- and fourth-year radiology residents. It is also important to review “breakthrough”, clinically relevant papers, to stay up-to-date on current changes occurring in the field, and especially if the trainee is considering a fellowship in a particular area. Podcasts, and on-line lectures from various societies, including the RSNA and the ARRS, are increasingly popular, and podcasts can be listened to while commuting. These podcasts, usually hosted by editors of the major imaging journals, highlight select articles from the latest issues of their journals. These can help clarify the main points of important research articles, offer important background material to add context, and help motivate the listener to read the full article. We recommend skimming monthly abstracts presented in Radiology and in the AJR – whether online and/or in the hard copy versions of the journals – to search for these articles. Radiology residents at the second-year level should not be focusing on subspecialty journals, in our opinion. For the third year of radiology residency, U.S.-based trainees realistically have to direct most of their efforts towards the fellowship application process and towards board examination preparation, to pass the core examination. Case-based books (including the on-line versions) are increasingly being used by U.S. radiology residents, especially in the first three years. These include a series of unknown cases with images, followed by the diagnosis and a succinct differential and associated discussion. Such books can be high yield for basic radiology
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education, especially is the spectrum of cases is carefully selected, and if the discussions include pertinent teaching points. With the restructuring of the boards in the U.S. in recent years, fourth-year residents should now have the time to read more general sources, both primary and review, and should also to begin to focus on their chosen area or areas of subspecialty, especially during their elective rotations and mini-fellowships. At the fellowship level, we suggest focusing not only on general review articles, but particularly on publications tailored to one’s subspecialty of training in the major imaging journals, including Radiology, the AJR, and RadioGraphics. Fellows should read subspecialty journals as well, but should be selective as to which ones they choose to concentrate on, and as to what they read within those journals. Preparing for the final portion of the diagnostic radiology boards, the certifying examination, is also of much importance during fellowship training. For attending radiologists in academic practice, we recommend a similar focus as for radiology fellows, but this will vary depending on the scope and nature of the individual’s practice. Reading articles presented in journal club, in addition to those in key clinical and imaging subspecialty journals (such as in the American Journal of Gastroenterology, and in Abdominal Radiology, if one is an abdominal imager, for example), might also be helpful to keep up with current changes in the imaging and clinical communities. If in private practice, reading texts suitable for senior residents, as well as major general and subspecialty review and original articles (depending on one’s focus), is suggested. In summary, peer-reviewed review articles are important for residents, original research as well as review articles are important for fellows and junior attendings, and at the mid to senior 7
attending radiologist level, particularly in academic practice, original research articles become paramount. Review articles are important for private practice radiologists. These are general guidelines, although, as noted, every particular radiologist’s needs to keep up with their area(s) of interest are somewhat different, and reading should be tailored towards those needs. We also have recommendations for what trainees and attendings in radiology should probably NOT be reading. All residents and fellows, unless they already have or are also working towards their PhD degree (in addition to their pre-existent medical or osteopathic degrees), and thus are spending a substantial time engaging in basic or translational research, should in general avoid reading publications which use animal models to investigate the potential clinical application of imaging technologies. It is also critical to make sure that one’s reading materials truly reflect the reality of current clinical practice. Papers which do not provide new knowledge, or which just reinforce knowledge which has already been widely disseminated to the imaging community, unless these articles are discussing a particular technique or procedure whose use is not fully established or which is controversial, may also not be worthwhile. Above all, at all levels, reading materials should pass the cardinal rule of reading and reviewing - Dr. Stanley Siegelman’s (a former editor of the journal Radiology) “who cares?” test. An initial review of the abstract is fundamental to this principle. If this concise summary of the rest of the article is not of interest, or is not clearly presented, do not waste time reading the body of the paper.
How should I be reading?
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With regards to the approach one should take when reading these materials, we suggest perusing key articles in major journals within one to two weeks of that issue’s arrival. Time should be budgeted to read these articles, or else procrastination can lead to a mountain of unread journals… well preserved in their plastic shrink-wrapped covers – if one even receives physical journals anymore! It is even easier to ignore an electronic-only imaging journal which is in your ‘in box’. We recommend using a highlighter (either physically or electronically) to call attention to important points throughout the articles which you are reading. There are several commercial apps available which allow the reader to be notified of newly published manuscripts in the journals one subscribes to/follows. These articles can be quickly added to the readers’ personal collection, and be available to review on one’s handheld device of choice whenever time allows. There are many approaches one can take in beginning to read an article. No matter which approach is used, make sure to evaluate the realistic potential of each article read. Several questions one should routinely ask, when approaching original research publications, and even review articles, include:
What is the question which the authors are attempting to answer?1
Where do the authors’ findings fit into what is – or is not - already established on the subject?
Is the topic pertinent?
We will now focus primarily on original research manuscripts. The abstract of an article should provide a clear synopsis of the entire research study. Most abstracts include sections for the brief background behind the study, the objective or purpose of the entire study, the materials 9
and methods used, the results found, and final conclusions. Some journals are now very recently providing a ‘visual abstract’, the equivalent of a single PowerPoint slide which conveys what was done and what the findings are, which if well done can be highly effective in conveying the main message of the paper. When reading an abstract, identify the article’s key message from the objective/purpose and conclusion, and then skim the rest of the abstract. Grasp whether or not the abstract’s conclusion clearly reveals the main message of the research – positive, or sometimes negative, regarding an imaging technique, a modification of a technique, the findings of a disease process, or the development of new procedures or devices (including, most recently, artificial intelligence), amongst other possibilities. Try to identify the important details of each research project, including the study design, sample size, and what was done prospectively, retrospectively, or both. Anticipate if the paper has potential substantial implications for the practice of radiology, or justifies the current standard of care in the field – or whether it is just an opportunity for the researchers to present their data (and to advance academically, amongst other goals – ‘publish or perish’). Watch out for hidden agendas in each article, and try to critically determine whether or not the study should have been performed in the first place, and then published. The introduction of an original research article is crucial for setting the stage for the entire study. The authors’ hypothesis, goals, and reasoning for undertaking the research should be easy to understand; if not, the readers should question the legitimacy of the study.1 Important details to identify in the introduction include the broad issues that surround the authors’ question, if the article covers a topic of importance, and if the article adds new, critical information to already established medical knowledge. 10
Although some may conjecture that the materials and methods section is the most important section within an article,1 realistically, few people other than the reviewers and the editors thoroughly read this portion of a manuscript. For most papers, we recommend at least skimming through this section to obtain a gestalt of what was done. However, if the implications of a specific research study might alter the way in which one practices radiology and medicine, we suggest reading this section more carefully, to obtain a better idea of how the project was carried out. Since the materials and methods section is virtually a “blueprint” by which a reader should be able to carry out the study,8 the authors should provide adequate information about parameters including how the subjects were recruited, the steps used to test subjects, and how the data collected was analyzed.1 It is critical to discern if the methodology of the project was able to accurately test the authors’ primary question, and also if the study truly attempted to minimize any biases. Additional details to consider in this section include the radiation exposure of any modalities used, and how the images were interpreted. How many radiologists (or other health care practitioners) examined the images, in what manner the images were interpreted and over how many sessions, and what information the radiologists/image interpreters were blinded to. In the results section of any article, the authors should attempt to clearly describe their research findings. We suggest focusing on “the bottom line” of the study here; this might require critically reviewing any charts, tables, and graphs, to find these important take-home messages. Determine if it is clear how the data was obtained, if the results of the study are realistic, and if they can be potentially applicable to actual clinical practice.
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We believe that the discussion section is the second most important portion of any radiology or other scientific paper. An excellent discussion section should clearly reiterate key results of the study, without rehashing the findings in detail, and should declare if the authors’ hypothesis was or was not supported. The current work should also be put in perspective in relation to the literature already published on the topic. Furthermore, the discussion should describe the limitations of the study, and offer a sound reasoning for any discrepancies with the previous literature. No study involving human research is perfect; there are always potential limitations, as well as potential biases, and they should be explicitly declared and briefly explained. Key questions to try to answer here include if the authors’ conclusions are supported and based on the results, and if these conclusions add to the fund of medical knowledge.1 Finally, the authors can suggest future directions of research which might further elucidate or build upon their results. This style of critical reading of published articles translates directly to how one can perform an objective review in a critically constructive manner of a submitted manuscript to a peer-reviewed journal. An excellent review article overviews the current literature on a specific topic, may show some representative images which convey specific teaching points, and explains what recent advances have occurred, and what the practicing radiologist needs to know about a performing and interpreting an imaging procedure, or may cover a topic related to ‘non-interpretive’ skills. The article should be constructed in a logical sequence, explain difficult concepts, and point out any areas of controversy. Potential pitfalls and key points should ideally be covered as well. Although spending so much time and effort on reading might be an arduous task, it is important to remain up-to-date on current advances in radiology and in medicine. What 12
distinguishes to some extent radiologists from other physicians (other than pathologists) is our extremely broad knowledge base and training, even when we focus, and some of us in academics increasingly so, on subspecialty areas. We must be able to use our critical analysis skills to determine which data is valid and clinically applicable, to be then added to what we already know, to be continuously successful in radiology practice.
Reviewing for the Imaging Literature: We would argue that although an integral and in fact critical component of scientific journalism, reviewing is the most unheralded activity in all of academic medicine, and that includes academic radiology. Indeed, reviewing is time-consuming, frustrating, and is relatively unrewarded as an academic pursuit. Few become famous as a peer reviewer. However, it truly can be personally fulfilling, especially when recognizing one’s opportunity to improve the quality of a journal, and ultimately the standard of patient care.9 Being a reviewer comes with great responsibility. One rapidly learns as a reviewer that ‘what comes in, is NOT what comes out.’ Accepted papers can lead to further research, have real implications for clinical practice, and even be used in court, both for the defense and for the plaintiff’s side of radiology-related medical-legal cases, and for a wide variety of other legal actions, some of which go beyond just medical malpractice. Being an excellent reviewer can lead to reviewer awards, and then to being named to an editorial board of the journal, and both of these can be used to support academic promotion, along both traditional as well as more recent clinical educator tracks. There are several ways in which one can become a reviewer. These include contacting a journal’s editorial office and expressing interest at any academic level, invitation by the editor 13
of a journal, and recommendation by a member of a journal’s editorial board.9 In some journals, new reviewers are first entered into a “trial period,” during which their manuscript comments are evaluated by the editor and other reviewers for timeliness and any errors. For most academic journals, the peer review process continues after this trial period to ensure continued improvement.10 Other journals, such as RadioGraphics, now have a mentorship program, where trainees can be mentored by more experienced reviewers in the peer review process. In contrast to other fields within medicine in which the authors choose who reviews their papers, reviewers for radiology journals are usually chosen by the editorial offices of their respective journals. Usually two reviewers are asked to review an original research submission, and sometimes more. Deputy editors or additional reviewers might be added if conflicting or delinquent reviews occur during the process. Two to three weeks are usually allotted to submit the reviews. Reviewers should try their best to abide by this requirement. It is critical for the reviewers and for a journal to “maintain a balance between timeliness and quality, both of which authors value”9. If this balance is maintained, the authors will continue to submit work of the utmost quality to that journal. A reviewer has an ethical responsibility to disclose potential conflicts of interest to a journal’s editorial office, and can exercise the option to recuse oneself from the reviewing process for a particular article. Such conflicts of interest can be professional, personal, or financial. Another common issue is that the reviewer might feel that she or he does not have adequate expertise to review the manuscript. Perhaps, even, the reviewer has already reviewed this manuscript for another imaging journal, and it would not be fair for that reviewer to again review the 14
manuscript if it was recently rejected from another journal, in part because of that reviewer’s comments. Unfortunately, in the experience of the more seasoned authors of this review article, too many reviews submitted to imaging journals are non-substantive, non-constructive, or contain only a few sentences. Authors dedicate much effort to each submitted manuscript, even if it is one which ultimately will not be accepted, and it is critical for reviewers to do the same. A constructive review can be used by the authors to revise their manuscript for potential acceptance to another journal, and we have had such ultimately positive experiences ourselves as clinical researchers, educators, and authors. To start, we recommend that all new reviewers read the journal’s publication information to authors, or “PIA”. Reviewers must ensure that papers submitted to the journal follow the PIA. Blatant disregard for the PIA may indicate “recycling” of a paper that was rejected elsewhere, without any attempt of the authors to revise their manuscript for the journal now being targeted for potential acceptance. A minimum of 1.5-2 hours should be dedicated to a review of an individual manuscript, and each review should be approximately one to three pages long. If not very familiar with the particular topic being discussed, take time as the reviewer to research and read key articles cited in the references of the article under review. Conduct an internet search to pull other relevant articles from the imaging and general medical literature. Participating in the peer review process is an opportunity for reviewers at all levels of experience to further broaden their own knowledge base, and to even gain expertise in a new area of focus.
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The identities of the reviewers at all major imaging journals are currently blinded to the identities of the authors and their institutions and vice versa (‘double-blinded review’), in order for the reviews to remain candid and anonymous, and to potentially reduce bias in the review process. Reviews should be divided into two parts - the first part being confidential comments to the editor of the journal (or to the appropriate section editor). While the specifics may vary from journal to journal, the essential components of a good review are common to all. 9 The comments should first include a short summary of what was accomplished in the research, and what the major results were. Major strengths of the manuscript should then be listed; possible examples include the relevance/importance of the study results, minimization of biases, and appropriate methodology. Manuscript weaknesses should also be written in the comments; these may be an imperfect methodology, lack of clinical importance of the study results and/or lack of new information, and too much speculation as to what the results mean or how the results could be used in practice. Reviewers should additionally comment on any advances in knowledge offered by the study. The reviewer may find relevant articles that were not included in the references; these may help to put the findings in sharper perspective, and can be included in a revision. Lastly, the reviewer should note the most important changes which are needed to improve the manuscript. A specific recommendation should be offered to the editor regarding acceptance or rejection status of the paper as well, but should NOT be included in the comments to the authors. The final portion of a review should consist of non-confidential comments to both the author(s) and the editor. We suggest being constructive, and making very specific recommendations for each part of the manuscript. These suggestions should be numbered and 16
correlated with each section of the paper. It is important to keep the authors’ viewpoint in mind during this entire process; definitely re-read the review before final submission, to ensure that all criticisms are realistic and fair.
Writing for the Imaging Literature: Writing for the imaging literature utilizes many of the same skill sets as when effectively and critically reading and reviewing. We will focus here on writing original research manuscripts, as review articles follow a very different format. When you start writing, it is important to have a basic hypothesis, and data with some interpretation, in which both the often younger primary writer (who will typically be the first author of the manuscript, and of the paper, if published), and the research mentor (who will typically be the last author, and the most senior), agree upon. In addition to this, having a target journal determines a specific format to follow for the writing of the paper. Be realistic when selecting this journal. Although it is good to aim for journals with the highest impact factors, understand that rejection is a substantial part of the process, space in imaging journals is limited (both virtual and even more so physical), and publication in imaging journals has become increasingly competitive. Furthermore, writing is more productive when completed in steps. It is also commonplace, and desirable, to have multiple drafts before a final presentable draft is formed. After settling on a hypothesis, results, and interpretation, start the paper by making an outline. Your outline should follow the format of a template article from your target journal. Try to use one or two articles as your template, and thoroughly read through the articles.11-13 Once you
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have completed these steps, you are ready to move on to develop the other components of the paper.
Abstract When you are ready to start writing, we believe it is important to have a title that does not give away too much information about the results of the study conducted in the paper, i.e., in our opinion a paper should not have a title such as “Glucagon is worthless for CT colonography”, but rather, formulate it as a question, i.e. “Does glucagon improve the quality of CT colonography?”. You want to keep the title brief, and to focus on simply stating what was studied, i.e. the main issue that the study focused on. Then in the abstract, more directly state the results and message of the paper. Usually 300 words or fewer is enough to communicate the information, and most major imaging journals have specific word limits for the abstract, as well as for other portions of the manuscript. Writing the abstract after all the other components of the paper are completed can be beneficial, because the abstract functions as a small blueprint highlighting the most important information about each of the sections of the paper.14 It is important to revisit the abstract once the paper is close to completion, if the abstract was written before the rest of the manuscript. In constructing the abstract, you generally want to have an order as follows:
Purpose/Objective (and sometimes Background, before Purpose)
Materials and Methods
Results
Conclusion 18
Be sure to review the abstract requirements of your target journal. Usually it is also important to include a statement on the statistical tests used, as well as a statement about institutional review board approval/patient informed consent, if this is relevant to the paper.
Introduction With an understanding of the general layout of the abstract, we are ready to delve into writing the introduction. Organize the introduction into several paragraphs, with each paragraph generally focusing on accomplishing one or two tasks.15 As for the introduction, you want to write about 1 to 2 pages, double spaced, which help to “justify” the study, and to place the focus of the study into the context of previous publications. The beginning paragraph or two should state your main conjecture and explain the purpose of your study. Effectively communicating about your hypothesis and the goal(s) of the study increases the chances of publication.16 There are a variety of reasons to write a paper. Most commonly, a paper expands on a previous idea or knowledge, or fills in gaps from a previous study. After explaining the purpose of the paper, expand on the potential importance of the paper to the field of study.
Materials and Methods The next section after the Introduction is the Materials and Methods. For this section, you want to start off by expanding on the study. Clearly explain which patients were included in the study, and how the study was designed. Include patient demographic characteristics, inclusion and exclusion criteria, and details about whether the study was prospective or retrospective – 19
or a combination of both.13 It is surprising how often this seemingly basic information is not clearly explained in manuscripts submitted for peer review at imaging journals. Please list the age range and the age mean for both males and females, as well as the number of males and females. Since the results are obtained primarily from steps taken in the Materials and Methods section, ensure that every result is accounted for in the Methods section. In other words, there should be a one-to-one correspondence of the methods and the results sections – BOTH in the abstract, AND in the main body of the manuscript. Make sure to include the equipment and any pharmaceuticals/contrast media used, and also to mention institutional review board (IRB) approval and informed consent or exemption, in both the abstract and in the body of the manuscript. For the last paragraph of the Materials and Methods section, include information about the classification characteristics and on the methods of statistical analysis.14 This is important because it aides the reproducibility of the study. The number of radiologists involved in the study and/or any other researchers involved, and their number of years of experience, should also be noted. Make sure to clearly state (but in generic terms, in the initial versions of the manuscript, so as to not unblind your identities and your institution(s) during initial peer review – and then to add author initials later on) the contributions made by each of the co-authors, for each portion of the methods section. This basic information is frequently lacking, even amongst manuscripts submitted by experienced researchers. This can also be helpful in navigating co-authorship afterwards, considering that
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the number of listed authors has continued to increase for most biomedical publications over the last 30 years.17
Results As you write think about and write your results, make sure it follows the methods in a logical sequence. This makes it easier for the reader to identify your findings and the procedures you utilized to obtain them. Be sure to include “p” and other statistical values, and to comment on their statistical significance or lack thereof.15 For your first and second paragraphs, list demographic characteristics, including age and sex information – if not already provided in the methods section. Try to include helpful graphs, figures, and diagrams, which are clearly presented, with easy to understand legends and footnotes. The simpler the graphics, the more helpful they are to the reader. Keep the number of tables to a relative minimum, however. If there are a large number of graphs, or if the methods section is very detailed, consider providing additional materials in an appendix, which will usually be published in the online version of the journal. In general, if the manuscript has figures – and most imaging manuscripts do - the figures should be cited in the results section, but occasionally they can be cited in the methods (e.g., if there is a description of a new device or imaging technique, for example). However, the figures, tables, and graphs should generally not be cited in the discussion section. Make sure everything is cited in order – including the references. In the corresponding figure legends, give the patient age, sex, brief clinical presentation, and diagnosis. Also including the imaging modality, plane of section, and main findings.13 Try to demonstrate representative images from your study. 21
Include a few patients, but not only one, and not too many. Often manuscripts are submitted where there are hundreds of patients included in a study, but only one example is shown. Do not show too many outliers, or only the best examples. Give the basic pulse sequence information, if demonstrating MR images, the plane(s) of imaging for all cross-sectional images, and mask industry logos from all submitted images. Please also try to follow the format and style of the journal being targeted – not only for the legends, but for the manuscript in general; this will help to maximize your chance of acceptance. Do the same for the references – PLEASE follow the journal format (a pet peeve of experienced reviewers and of editors), rather than just pulling the references from an internet source or from a reference organizing program, unless the PIA specifically asks the submitting authors to do so.
Discussion The Discussion section of a paper should reflect the main points being made in the manuscript. It should be about 4-5 pages long, and should summarize the most important results and findings. Delve into discussing interpretations of the data, but avoid drawing abstract conclusions.15 For the first few paragraphs of the discussion section, compare the conclusions and findings of your study to the previous literature. Examine how the findings and conclusions are similar and/or different from what is commonly accepted.14 Discuss what your study may potentially contribute, but at the same time be modest, and recognize that your study may only be one piece of the evolving puzzle. Then discuss the potential limitations of your study. It is important to be honest about how the study could have been improved, and what the inherent limitations 22
were.13 It is difficult for an experienced reviewer and editor NOT to find limitations of a research study in radiology, whether related directly to humans or not. Such a section does not hurt the chances of the manuscript for acceptance, and on the contrary a thorough and fair limitations section may actually do the opposite. Possible future studies that could be carried out as a result of your contribution should be discussed in this section. In your introduction and discussion sections, make sure to cite the most recent and relevant references. Recheck the literature as your manuscript is making its way through the peer review process. Pay attention to specific journal guidelines as to the maximum number of references for a specific manuscript type. Lastly, try to anticipate and disclose problems prospectively, and to avoid self-congratulatory statements. Few manuscripts are accepted to major imaging journals without revisions on the first submission. On resubmission, send both annotated and non-annotated revised drafts, and include a detailed cover letter explaining changes.15 All of the changes requested by the reviewers and the editors do not have to be made if you do not agree with them, however the authors must explain why a suggested change was not made, or why the revisions are somewhat different than those specifically requested by the reviewers and/or the editor. Rewriting is important for an ultimately excellent paper, and it is common for a paper to go through multiple revisions prior to publication. To quote another former editor of the journal Radiology, Dr. Anthony V. Proto, “There are no shortcuts.”
Conclusion:
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The process of reading, reviewing, and writing for the imaging literature can be very rewarding. It is important to remember to read selectively and critically, and to approach your writing as a critical reader and reviewer. At all levels of education, continue to read in effort to stay up-to-date, but take into consideration the target audience of different types of literature. Although there is not as much literature about writing an article for the imaging literature, or on reviewing or reading the imaging literature as one might think there is, such writing, once one has a good research project or a good idea for a review article, is relatively formulaic, making the process more manageable, compared with creative writing of a novel, for example. Additionally, the skill sets of critically reading, reviewing, and writing an imaging paper are all inter-related. By following the principles and recommendations laid out in this paper, we hope the reader will feel somewhat more confident and comfortable in doing all of the three. There are also several radiologic journalism fellowships one can participate in, for both trainees and for mid-level career academic radiologists, to continue to develop one’s skill in reading, reviewing and writing, which are sponsored by RSNA, ARRS, and ACR. The editors of the journals published by those societies help to run these fellowships, and also give periodic lectures and workshops at their national meetings and at other venues, on how to be an excellent peer reviewer and scientific writer.
References
1. Budovec JJ, Kahn CE. Evidence-based radiology: a primer in reading scientific articles.
Am J Roentgenol 2010;195:W1-W4. 24
2. Heilbrun ME. Should radiology residents be taught evidence-based radiology? An
experiment with “The EBR journal club.” Acad Radiol 2009;16:1594-1554. 3. Collins J, de Christenson MR, Gray L, et al. General competencies in radiology residency
training: definitions, education and assessment. Acad Radiol 2002;9:721-726. 4. Phillips RS, Glasziou P. What makes evidence-based journal clubs succeed? ACP J Club
2004;140:A11-A12. 5. Blackmore CC, Medina LS. Evidence-based radiology and the ACR Appropriateness
Criteria. J Am Coll Radiol 2006;3:505-509. 6. Skjennald A. What do radiologists read, and what do they want to read? Acta Radiol
2006;47:757-758. 7. Klein J, Pohl J, Vinson EN, Brant WE, Helms CA. Brant and Helms’ Fundamentals of
Diagnostic Radiology. 5th ed. Philadelphia, PA: LWW; 2018.1-1600. 8. Provenzale JM, Stanley RJ. A systematic guide to reviewing a manuscript. Am J
Roentgenol 2005;185:848-854. 9. Proto AV. Reviewing for Radiology. Radiology 2000;215:619-621. 10. Halsted MJ. Radiology peer review as an opportunity to reduce errors and improve
patient care. J Am Coll Radiol 2004;1:984-987. 11. Offiah AC, Chu WCW, Davis R, Dixon AK, Klein JS, Lee EY. How to prepare successful
scientific manuscripts: practical advice from editors of radiology journals. Pediatr Radiol 2014; 44: 1056-1057. 12. Kliewer MA. Writing it up: a step-by-step guide to publication for beginning
investigators. Am J Roentgenol 2005; 185:3. 25
13. Jha KN. How to write articles that get published. J Clin Diagn Res 2014;8(9):XG01-XG03. 14. Provenzale P. Ten principles to improve the likelihood of publication of a scientific
manuscript. Am J Roentgenol 2007; 188(9): 1179-1182. 15. Bannas P, Reeder SB. How to write an original radiological research manuscript. Eur
Radiol 2017;27(11):4455-4460. 16. Kapoor N, Abola MV, Jena AB, Smith SE. Trends in authorship patterns in high-impact
radiology publications, 1980-2013. Acad Radiol 2015;22(12):1587-1591.
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Add: AJR Am J Roentgenol. 2016 Oct;207(4):820-825. doi: 10.2214/AJR.16.16008. Epub 2016 Aug 17.Ethical Issues in Radiology Journalism, Peer Review, and Research. Katz DS1, Gardner JB2, Hoffmann JC1, Patlas MN3, Bhargava P4, Moshiri M4, Remer EM5, Gould ES6, Smith S7. Extra references (not used): Berk RN. Preparation of manuscripts for Radiology Journals: Advice to first-time authors. AJR 1992; 158: 203-208. Siegelman SS. Advice to authors. Radiology 1988; 166: 278-280. Publication information for authors. Radiology, RG, and AJR (every issue & on line). Proto AV. Evaluating and processing your manuscript for publication. Radiology 2007; 244:3-6. Proto AV. Reviewing for radiology. Radiology 2007; 244:7-11. Sheiman RG. The RSNA reviewer mentorship program. Radiology 2007; 244:631-632. Basic Outline Introduction Reading Radiology Literature ● What to read? ● How to read? Reviewing Radiology Literature Writing Radiology Literature ● What do you need to have on hand in order to start writing? ● Specifics of Manuscript Construction ○ Title ○ Abstract ○ Introduction ○ Materials and Methods ○ Results ○ Discussion ○ References
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○ Figures ○ Tables ● Unique specifics for writing literature in 2018 ● What order should the different manuscript sections be written in? ● Finishing touches ● Ethical issues ● Revisions How to improve one’s writing skills ● RSNA “Traveling Editors” Program ● Radiologic Journalism Fellowships Conclusion
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How to Read, Write, and Review the Imaging Literature Arielle Sasson MD , Oseogie Okojie MD , Ryan Verano BA , Mariam Moshiri MD , Michael N. Patlas MD , Jason C. Hoffmann MD , John J. Hines MD , Douglas S. Katz MD, FACR PII: DOI: Reference:
S0363-0188(20)30007-4 https://doi.org/10.1067/j.cpradiol.2020.01.002 YMDR 778
To appear in:
Current Problems in Diagnostic Radiology
Please cite this article as: Arielle Sasson MD , Oseogie Okojie MD , Ryan Verano BA , Mariam Moshiri MD , Michael N. Patlas MD , Jason C. Hoffmann MD , John J. Hines MD , Douglas S. Katz MD, FACR , How to Read, Write, and Review the Imaging Literature, Current Problems in Diagnostic Radiology (2020), doi: https://doi.org/10.1067/j.cpradiol.2020.01.002
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
How to Read, Write, and Review the Imaging Literature Arielle Sasson, MD (1)*, Oseogie Okojie, MD (1)*, Ryan Verano, BA (2), Mariam Moshiri, MD (3), Michael N. Patlas, MD (4), Jason C. Hoffmann, MD (1), John J. Hines, MD (5), Douglas S. Katz, MD, FACR (1) From the Departments of Radiology, NYU Winthrop (1), the University of Washington (3), McMaster University (4), and Northwell Health (5), and from the University of Connecticut (2). * = co-first authors Address Correspondence to: Douglas S. Katz, MD, FACR, Department of Radiology, NYU Winthrop Hospital, 259 First Street, Mineola, NY 11501 Phone: 516-663-3800; FAX: 516-663-8172; email: [email protected] Co-author emails: [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected]
Introduction:
There is currently little to no formal training in the requisites of medical journalism at any point, from the medical student to the junior faculty level - yet everyone in training or at some other stage in their academic career is expected to participate in these activities in their 1
specialties, including in reading medical journals, and frequently in reviewing and/or writing for journals and for other types of professional products and forums. This is particularly the case in radiology training, where despite the crucial nature of these inter-related activities, few are taught how to critically evaluate the radiology literature, to formally review manuscripts being considered for publication in an imaging journal, and to combine those two related skill sets and apply them towards writing manuscripts for potential publication in peer-reviewed and other journals, or in other educational products. Although some radiology and other medical residency programs may be more recently teaching the tenets of medical journalism within their core curricula, in our experience radiology residency journal clubs usually do not encourage much discussion related to these general topics. As a result, younger radiologists may not be developing critical reading and writing skills, and are thus unable to extrapolate these skills to evaluate newer imaging techniques or technology, or to maximize their academic potential as reviewers, and as a biomedical writers and researchers. In our experience, the more of all of these activities in which one participates at all levels, the better one becomes at all of them. When it comes to engaging in activities related to reading, reviewing, and writing the imaging literature, junior radiologists may unfortunately have to take a “sink or swim” strategy. They learn how to read, and in particular how to review and/or how to write, mostly by trial and error, with a steep learning curve. Poor or even no real habits are established, and the quality of reviews and/or submitted manuscripts can be suboptimal. No one benefits from such a wellmeaning but poorly delivered approach – other authors of submitted manuscripts, editors, the readership of imaging journals, radiologists in practice – and ultimately our patients. Therefore, 2
the purpose of this review article is to provide our perspective as to how one should be reading, reviewing, and writing the imaging literature, and also providing guidance from other thought leaders in this area, and from the literature itself. We hope to inspire radiology trainees and radiologists at all levels, particularly those in academic careers, to more fully participate in peer review and in radiology publication.
Reading the Imaging Literature: During their residency, radiology trainees must develop strong empirical abilities related to their specialty, including building a wide-ranging and comprehensive clinical imaging knowledge base, and performing a myriad of procedures.1 Yet the field of medicine is constantly evolving, and particularly radiology, given its inherent technological basis and constant innovations, and both trainees and attending radiologists need to have the skill sets to scrutinize the published literature, including very recent publications, to keep up-to-date with these changes, and then to potentially using the information acquired to analyze this wealth of information, to perform and interpret imaging examinations, as well as to potentially make their own contributions to the literature. Evidence-based medicine, and to take this one step further- evidence-based radiology2 - is increasingly important, and has been integrated into daily radiology practice. Thus, having the ability to appraise the imaging and the general medical literature, and to delineate practices with the best research evidence, is now a necessity.1 Reports published by both the Accreditation Counsel for Graduate Medical Education (ACGME) and the American Board of Radiology have also stressed the importance of developing such critical-thinking skills.3
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Given the myriad of educational choices now available on line, including numerous web-based educational sites and databases and teaching files as well as e-books, in addition to more traditional books and journals, certain factors regarding on how radiology trainees and attending should select their educational resources become of outmost importance. Knowing which are the “right” materials to focus on, an overwhelming amount of information, not knowing what is the correct information, and even boredom in the search process, have all been cited as barriers to reading and engaging in the available literature.4 Although the most common approach to literature searching is only using the inclusion criteria of “freely available articles or texts” in one’s native language, this is a haphazard tactic, and is bound to yield texts and sources of all levels of value and usefulness for the reader.5 Out of frustration, and due to their priorities at the time, many radiology residents end up focusing on materials which are only relevant to the boards (which is definitely important, but mostly at the appropriate time of training).2 Thus, the goal of this section is to offer a basic framework of how to select and analyze some of the reading materials available, with a focus on the more traditional types of sources.
What should I be reading? There is much diversity in the content of different medical imaging textbooks on diagnosis and image-guided therapy. Although there is no clear consensus as to what the best sources should be in all situations, above and beyond textbooks, original, peer-reviewed articles (original research articles, as well as review articles, particularly those of which are also peer reviewed, such as in the journal RadioGraphics, or in journals such as this one), are and should remain the 4
top priority.6 Articles presenting primary research are critical in providing information which will progress the field of radiology, and it is essential to remain at the forefront of such advances. Because textbooks cannot be updated every single year - even e-books - reading review articles which fill the gaps between textbook revisions is also of high importance, but less so than reading original research. And although case reports provide salient information about how different disease processes can present, these anecdotal reports are often of uncertain scientific value to budding radiologists, and to the imaging and medical community as a whole. Although it is important to remain well-read in all of these different types of literature, time for reading is increasingly limited, as trainees and attending senior radiologists are increasingly busy clinically, with more extended work hours, and with often greater demands on their time and energy when outside of work. Therefore, we believe it is essential to focus on reading materials which are more specific and which are most appropriate at the particular stage of that person’s training and experience. For first-year radiology residents, we recommend focusing on major textbooks which convey the essential knowledge needed to gain basic competence with imaging interpretation in each of the subspecialty areas. Fundamentals of Diagnostic Radiology is such a book for all radiology residents to obtain a comprehensive overview of vital topics, and many U.S.-based radiology residency programs use this text for monthly formal teaching.7 However, we realize that in this digital age millennials are reading textbooks less and less, and that radiology residents are increasingly reading and studying using on-line materials only. Learning the often high-yield information from current or relatively recent articles discussed during monthly journal club meetings, and which are typically assigned by specific radiology 5
department faculty members in various subspecialty areas, is also useful to begin developing a core knowledge base as a first- or second-year radiology resident. In addition to reading articles presented during journal club, we suggest concentrating on major review articles in RadioGraphics and similar sources for second- and fourth-year radiology residents. It is also important to review “breakthrough”, clinically relevant papers, to stay up-to-date on current changes occurring in the field, and especially if the trainee is considering a fellowship in a particular area. Podcasts, and on-line lectures from various societies, including the RSNA and the ARRS, are increasingly popular, and podcasts can be listened to while commuting. These podcasts, usually hosted by editors of the major imaging journals, highlight select articles from the latest issues of their journals. These can help clarify the main points of important research articles, offer important background material to add context, and help motivate the listener to read the full article. We recommend skimming monthly abstracts presented in Radiology and in the AJR – whether online and/or in the hard copy versions of the journals – to search for these articles. Radiology residents at the second-year level should not be focusing on subspecialty journals, in our opinion. For the third year of radiology residency, U.S.-based trainees realistically have to direct most of their efforts towards the fellowship application process and towards board examination preparation, to pass the core examination. Case-based books (including the on-line versions) are increasingly being used by U.S. radiology residents, especially in the first three years. These include a series of unknown cases with images, followed by the diagnosis and a succinct differential and associated discussion. Such books can be high yield for basic radiology
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education, especially is the spectrum of cases is carefully selected, and if the discussions include pertinent teaching points. With the restructuring of the boards in the U.S. in recent years, fourth-year residents should now have the time to read more general sources, both primary and review, and should also to begin to focus on their chosen area or areas of subspecialty, especially during their elective rotations and mini-fellowships. At the fellowship level, we suggest focusing not only on general review articles, but particularly on publications tailored to one’s subspecialty of training in the major imaging journals, including Radiology, the AJR, and RadioGraphics. Fellows should read subspecialty journals as well, but should be selective as to which ones they choose to concentrate on, and as to what they read within those journals. Preparing for the final portion of the diagnostic radiology boards, the certifying examination, is also of much importance during fellowship training. For attending radiologists in academic practice, we recommend a similar focus as for radiology fellows, but this will vary depending on the scope and nature of the individual’s practice. Reading articles presented in journal club, in addition to those in key clinical and imaging subspecialty journals (such as in the American Journal of Gastroenterology, and in Abdominal Radiology, if one is an abdominal imager, for example), might also be helpful to keep up with current changes in the imaging and clinical communities. If in private practice, reading texts suitable for senior residents, as well as major general and subspecialty review and original articles (depending on one’s focus), is suggested. In summary, peer-reviewed review articles are important for residents, original research as well as review articles are important for fellows and junior attendings, and at the mid to senior 7
attending radiologist level, particularly in academic practice, original research articles become paramount. Review articles are important for private practice radiologists. These are general guidelines, although, as noted, every particular radiologist’s needs to keep up with their area(s) of interest are somewhat different, and reading should be tailored towards those needs. We also have recommendations for what trainees and attendings in radiology should probably NOT be reading. All residents and fellows, unless they already have or are also working towards their PhD degree (in addition to their pre-existent medical or osteopathic degrees), and thus are spending a substantial time engaging in basic or translational research, should in general avoid reading publications which use animal models to investigate the potential clinical application of imaging technologies. It is also critical to make sure that one’s reading materials truly reflect the reality of current clinical practice. Papers which do not provide new knowledge, or which just reinforce knowledge which has already been widely disseminated to the imaging community, unless these articles are discussing a particular technique or procedure whose use is not fully established or which is controversial, may also not be worthwhile. Above all, at all levels, reading materials should pass the cardinal rule of reading and reviewing - Dr. Stanley Siegelman’s (a former editor of the journal Radiology) “who cares?” test. An initial review of the abstract is fundamental to this principle. If this concise summary of the rest of the article is not of interest, or is not clearly presented, do not waste time reading the body of the paper.
How should I be reading?
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With regards to the approach one should take when reading these materials, we suggest perusing key articles in major journals within one to two weeks of that issue’s arrival. Time should be budgeted to read these articles, or else procrastination can lead to a mountain of unread journals… well preserved in their plastic shrink-wrapped covers – if one even receives physical journals anymore! It is even easier to ignore an electronic-only imaging journal which is in your ‘in box’. We recommend using a highlighter (either physically or electronically) to call attention to important points throughout the articles which you are reading. There are several commercial apps available which allow the reader to be notified of newly published manuscripts in the journals one subscribes to/follows. These articles can be quickly added to the readers’ personal collection, and be available to review on one’s handheld device of choice whenever time allows. There are many approaches one can take in beginning to read an article. No matter which approach is used, make sure to evaluate the realistic potential of each article read. Several questions one should routinely ask, when approaching original research publications, and even review articles, include:
What is the question which the authors are attempting to answer?1
Where do the authors’ findings fit into what is – or is not - already established on the subject?
Is the topic pertinent?
We will now focus primarily on original research manuscripts. The abstract of an article should provide a clear synopsis of the entire research study. Most abstracts include sections for the brief background behind the study, the objective or purpose of the entire study, the materials 9
and methods used, the results found, and final conclusions. Some journals are now very recently providing a ‘visual abstract’, the equivalent of a single PowerPoint slide which conveys what was done and what the findings are, which if well done can be highly effective in conveying the main message of the paper. When reading an abstract, identify the article’s key message from the objective/purpose and conclusion, and then skim the rest of the abstract. Grasp whether or not the abstract’s conclusion clearly reveals the main message of the research – positive, or sometimes negative, regarding an imaging technique, a modification of a technique, the findings of a disease process, or the development of new procedures or devices (including, most recently, artificial intelligence), amongst other possibilities. Try to identify the important details of each research project, including the study design, sample size, and what was done prospectively, retrospectively, or both. Anticipate if the paper has potential substantial implications for the practice of radiology, or justifies the current standard of care in the field – or whether it is just an opportunity for the researchers to present their data (and to advance academically, amongst other goals – ‘publish or perish’). Watch out for hidden agendas in each article, and try to critically determine whether or not the study should have been performed in the first place, and then published. The introduction of an original research article is crucial for setting the stage for the entire study. The authors’ hypothesis, goals, and reasoning for undertaking the research should be easy to understand; if not, the readers should question the legitimacy of the study.1 Important details to identify in the introduction include the broad issues that surround the authors’ question, if the article covers a topic of importance, and if the article adds new, critical information to already established medical knowledge. 10
Although some may conjecture that the materials and methods section is the most important section within an article,1 realistically, few people other than the reviewers and the editors thoroughly read this portion of a manuscript. For most papers, we recommend at least skimming through this section to obtain a gestalt of what was done. However, if the implications of a specific research study might alter the way in which one practices radiology and medicine, we suggest reading this section more carefully, to obtain a better idea of how the project was carried out. Since the materials and methods section is virtually a “blueprint” by which a reader should be able to carry out the study,8 the authors should provide adequate information about parameters including how the subjects were recruited, the steps used to test subjects, and how the data collected was analyzed.1 It is critical to discern if the methodology of the project was able to accurately test the authors’ primary question, and also if the study truly attempted to minimize any biases. Additional details to consider in this section include the radiation exposure of any modalities used, and how the images were interpreted. How many radiologists (or other health care practitioners) examined the images, in what manner the images were interpreted and over how many sessions, and what information the radiologists/image interpreters were blinded to. In the results section of any article, the authors should attempt to clearly describe their research findings. We suggest focusing on “the bottom line” of the study here; this might require critically reviewing any charts, tables, and graphs, to find these important take-home messages. Determine if it is clear how the data was obtained, if the results of the study are realistic, and if they can be potentially applicable to actual clinical practice.
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We believe that the discussion section is the second most important portion of any radiology or other scientific paper. An excellent discussion section should clearly reiterate key results of the study, without rehashing the findings in detail, and should declare if the authors’ hypothesis was or was not supported. The current work should also be put in perspective in relation to the literature already published on the topic. Furthermore, the discussion should describe the limitations of the study, and offer a sound reasoning for any discrepancies with the previous literature. No study involving human research is perfect; there are always potential limitations, as well as potential biases, and they should be explicitly declared and briefly explained. Key questions to try to answer here include if the authors’ conclusions are supported and based on the results, and if these conclusions add to the fund of medical knowledge.1 Finally, the authors can suggest future directions of research which might further elucidate or build upon their results. This style of critical reading of published articles translates directly to how one can perform an objective review in a critically constructive manner of a submitted manuscript to a peer-reviewed journal. An excellent review article overviews the current literature on a specific topic, may show some representative images which convey specific teaching points, and explains what recent advances have occurred, and what the practicing radiologist needs to know about a performing and interpreting an imaging procedure, or may cover a topic related to ‘non-interpretive’ skills. The article should be constructed in a logical sequence, explain difficult concepts, and point out any areas of controversy. Potential pitfalls and key points should ideally be covered as well. Although spending so much time and effort on reading might be an arduous task, it is important to remain up-to-date on current advances in radiology and in medicine. What 12
distinguishes to some extent radiologists from other physicians (other than pathologists) is our extremely broad knowledge base and training, even when we focus, and some of us in academics increasingly so, on subspecialty areas. We must be able to use our critical analysis skills to determine which data is valid and clinically applicable, to be then added to what we already know, to be continuously successful in radiology practice.
Reviewing for the Imaging Literature: We would argue that although an integral and in fact critical component of scientific journalism, reviewing is the most unheralded activity in all of academic medicine, and that includes academic radiology. Indeed, reviewing is time-consuming, frustrating, and is relatively unrewarded as an academic pursuit. Few become famous as a peer reviewer. However, it truly can be personally fulfilling, especially when recognizing one’s opportunity to improve the quality of a journal, and ultimately the standard of patient care.9 Being a reviewer comes with great responsibility. One rapidly learns as a reviewer that ‘what comes in, is NOT what comes out.’ Accepted papers can lead to further research, have real implications for clinical practice, and even be used in court, both for the defense and for the plaintiff’s side of radiology-related medical-legal cases, and for a wide variety of other legal actions, some of which go beyond just medical malpractice. Being an excellent reviewer can lead to reviewer awards, and then to being named to an editorial board of the journal, and both of these can be used to support academic promotion, along both traditional as well as more recent clinical educator tracks. There are several ways in which one can become a reviewer. These include contacting a journal’s editorial office and expressing interest at any academic level, invitation by the editor 13
of a journal, and recommendation by a member of a journal’s editorial board.9 In some journals, new reviewers are first entered into a “trial period,” during which their manuscript comments are evaluated by the editor and other reviewers for timeliness and any errors. For most academic journals, the peer review process continues after this trial period to ensure continued improvement.10 Other journals, such as RadioGraphics, now have a mentorship program, where trainees can be mentored by more experienced reviewers in the peer review process. In contrast to other fields within medicine in which the authors choose who reviews their papers, reviewers for radiology journals are usually chosen by the editorial offices of their respective journals. Usually two reviewers are asked to review an original research submission, and sometimes more. Deputy editors or additional reviewers might be added if conflicting or delinquent reviews occur during the process. Two to three weeks are usually allotted to submit the reviews. Reviewers should try their best to abide by this requirement. It is critical for the reviewers and for a journal to “maintain a balance between timeliness and quality, both of which authors value”9. If this balance is maintained, the authors will continue to submit work of the utmost quality to that journal. A reviewer has an ethical responsibility to disclose potential conflicts of interest to a journal’s editorial office, and can exercise the option to recuse oneself from the reviewing process for a particular article. Such conflicts of interest can be professional, personal, or financial. Another common issue is that the reviewer might feel that she or he does not have adequate expertise to review the manuscript. Perhaps, even, the reviewer has already reviewed this manuscript for another imaging journal, and it would not be fair for that reviewer to again review the 14
manuscript if it was recently rejected from another journal, in part because of that reviewer’s comments. Unfortunately, in the experience of the more seasoned authors of this review article, too many reviews submitted to imaging journals are non-substantive, non-constructive, or contain only a few sentences. Authors dedicate much effort to each submitted manuscript, even if it is one which ultimately will not be accepted, and it is critical for reviewers to do the same. A constructive review can be used by the authors to revise their manuscript for potential acceptance to another journal, and we have had such ultimately positive experiences ourselves as clinical researchers, educators, and authors. To start, we recommend that all new reviewers read the journal’s publication information to authors, or “PIA”. Reviewers must ensure that papers submitted to the journal follow the PIA. Blatant disregard for the PIA may indicate “recycling” of a paper that was rejected elsewhere, without any attempt of the authors to revise their manuscript for the journal now being targeted for potential acceptance. A minimum of 1.5-2 hours should be dedicated to a review of an individual manuscript, and each review should be approximately one to three pages long. If not very familiar with the particular topic being discussed, take time as the reviewer to research and read key articles cited in the references of the article under review. Conduct an internet search to pull other relevant articles from the imaging and general medical literature. Participating in the peer review process is an opportunity for reviewers at all levels of experience to further broaden their own knowledge base, and to even gain expertise in a new area of focus.
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The identities of the reviewers at all major imaging journals are currently blinded to the identities of the authors and their institutions and vice versa (‘double-blinded review’), in order for the reviews to remain candid and anonymous, and to potentially reduce bias in the review process. Reviews should be divided into two parts - the first part being confidential comments to the editor of the journal (or to the appropriate section editor). While the specifics may vary from journal to journal, the essential components of a good review are common to all. 9 The comments should first include a short summary of what was accomplished in the research, and what the major results were. Major strengths of the manuscript should then be listed; possible examples include the relevance/importance of the study results, minimization of biases, and appropriate methodology. Manuscript weaknesses should also be written in the comments; these may be an imperfect methodology, lack of clinical importance of the study results and/or lack of new information, and too much speculation as to what the results mean or how the results could be used in practice. Reviewers should additionally comment on any advances in knowledge offered by the study. The reviewer may find relevant articles that were not included in the references; these may help to put the findings in sharper perspective, and can be included in a revision. Lastly, the reviewer should note the most important changes which are needed to improve the manuscript. A specific recommendation should be offered to the editor regarding acceptance or rejection status of the paper as well, but should NOT be included in the comments to the authors. The final portion of a review should consist of non-confidential comments to both the author(s) and the editor. We suggest being constructive, and making very specific recommendations for each part of the manuscript. These suggestions should be numbered and 16
correlated with each section of the paper. It is important to keep the authors’ viewpoint in mind during this entire process; definitely re-read the review before final submission, to ensure that all criticisms are realistic and fair.
Writing for the Imaging Literature: Writing for the imaging literature utilizes many of the same skill sets as when effectively and critically reading and reviewing. We will focus here on writing original research manuscripts, as review articles follow a very different format. When you start writing, it is important to have a basic hypothesis, and data with some interpretation, in which both the often younger primary writer (who will typically be the first author of the manuscript, and of the paper, if published), and the research mentor (who will typically be the last author, and the most senior), agree upon. In addition to this, having a target journal determines a specific format to follow for the writing of the paper. Be realistic when selecting this journal. Although it is good to aim for journals with the highest impact factors, understand that rejection is a substantial part of the process, space in imaging journals is limited (both virtual and even more so physical), and publication in imaging journals has become increasingly competitive. Furthermore, writing is more productive when completed in steps. It is also commonplace, and desirable, to have multiple drafts before a final presentable draft is formed. After settling on a hypothesis, results, and interpretation, start the paper by making an outline. Your outline should follow the format of a template article from your target journal. Try to use one or two articles as your template, and thoroughly read through the articles.11-13 Once you
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have completed these steps, you are ready to move on to develop the other components of the paper.
Abstract When you are ready to start writing, we believe it is important to have a title that does not give away too much information about the results of the study conducted in the paper, i.e., in our opinion a paper should not have a title such as “Glucagon is worthless for CT colonography”, but rather, formulate it as a question, i.e. “Does glucagon improve the quality of CT colonography?”. You want to keep the title brief, and to focus on simply stating what was studied, i.e. the main issue that the study focused on. Then in the abstract, more directly state the results and message of the paper. Usually 300 words or fewer is enough to communicate the information, and most major imaging journals have specific word limits for the abstract, as well as for other portions of the manuscript. Writing the abstract after all the other components of the paper are completed can be beneficial, because the abstract functions as a small blueprint highlighting the most important information about each of the sections of the paper.14 It is important to revisit the abstract once the paper is close to completion, if the abstract was written before the rest of the manuscript. In constructing the abstract, you generally want to have an order as follows:
Purpose/Objective (and sometimes Background, before Purpose)
Materials and Methods
Results
Conclusion 18
Be sure to review the abstract requirements of your target journal. Usually it is also important to include a statement on the statistical tests used, as well as a statement about institutional review board approval/patient informed consent, if this is relevant to the paper.
Introduction With an understanding of the general layout of the abstract, we are ready to delve into writing the introduction. Organize the introduction into several paragraphs, with each paragraph generally focusing on accomplishing one or two tasks.15 As for the introduction, you want to write about 1 to 2 pages, double spaced, which help to “justify” the study, and to place the focus of the study into the context of previous publications. The beginning paragraph or two should state your main conjecture and explain the purpose of your study. Effectively communicating about your hypothesis and the goal(s) of the study increases the chances of publication.16 There are a variety of reasons to write a paper. Most commonly, a paper expands on a previous idea or knowledge, or fills in gaps from a previous study. After explaining the purpose of the paper, expand on the potential importance of the paper to the field of study.
Materials and Methods The next section after the Introduction is the Materials and Methods. For this section, you want to start off by expanding on the study. Clearly explain which patients were included in the study, and how the study was designed. Include patient demographic characteristics, inclusion and exclusion criteria, and details about whether the study was prospective or retrospective – 19
or a combination of both.13 It is surprising how often this seemingly basic information is not clearly explained in manuscripts submitted for peer review at imaging journals. Please list the age range and the age mean for both males and females, as well as the number of males and females. Since the results are obtained primarily from steps taken in the Materials and Methods section, ensure that every result is accounted for in the Methods section. In other words, there should be a one-to-one correspondence of the methods and the results sections – BOTH in the abstract, AND in the main body of the manuscript. Make sure to include the equipment and any pharmaceuticals/contrast media used, and also to mention institutional review board (IRB) approval and informed consent or exemption, in both the abstract and in the body of the manuscript. For the last paragraph of the Materials and Methods section, include information about the classification characteristics and on the methods of statistical analysis.14 This is important because it aides the reproducibility of the study. The number of radiologists involved in the study and/or any other researchers involved, and their number of years of experience, should also be noted. Make sure to clearly state (but in generic terms, in the initial versions of the manuscript, so as to not unblind your identities and your institution(s) during initial peer review – and then to add author initials later on) the contributions made by each of the co-authors, for each portion of the methods section. This basic information is frequently lacking, even amongst manuscripts submitted by experienced researchers. This can also be helpful in navigating co-authorship afterwards, considering that
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the number of listed authors has continued to increase for most biomedical publications over the last 30 years.17
Results As you write think about and write your results, make sure it follows the methods in a logical sequence. This makes it easier for the reader to identify your findings and the procedures you utilized to obtain them. Be sure to include “p” and other statistical values, and to comment on their statistical significance or lack thereof.15 For your first and second paragraphs, list demographic characteristics, including age and sex information – if not already provided in the methods section. Try to include helpful graphs, figures, and diagrams, which are clearly presented, with easy to understand legends and footnotes. The simpler the graphics, the more helpful they are to the reader. Keep the number of tables to a relative minimum, however. If there are a large number of graphs, or if the methods section is very detailed, consider providing additional materials in an appendix, which will usually be published in the online version of the journal. In general, if the manuscript has figures – and most imaging manuscripts do - the figures should be cited in the results section, but occasionally they can be cited in the methods (e.g., if there is a description of a new device or imaging technique, for example). However, the figures, tables, and graphs should generally not be cited in the discussion section. Make sure everything is cited in order – including the references. In the corresponding figure legends, give the patient age, sex, brief clinical presentation, and diagnosis. Also including the imaging modality, plane of section, and main findings.13 Try to demonstrate representative images from your study. 21
Include a few patients, but not only one, and not too many. Often manuscripts are submitted where there are hundreds of patients included in a study, but only one example is shown. Do not show too many outliers, or only the best examples. Give the basic pulse sequence information, if demonstrating MR images, the plane(s) of imaging for all cross-sectional images, and mask industry logos from all submitted images. Please also try to follow the format and style of the journal being targeted – not only for the legends, but for the manuscript in general; this will help to maximize your chance of acceptance. Do the same for the references – PLEASE follow the journal format (a pet peeve of experienced reviewers and of editors), rather than just pulling the references from an internet source or from a reference organizing program, unless the PIA specifically asks the submitting authors to do so.
Discussion The Discussion section of a paper should reflect the main points being made in the manuscript. It should be about 4-5 pages long, and should summarize the most important results and findings. Delve into discussing interpretations of the data, but avoid drawing abstract conclusions.15 For the first few paragraphs of the discussion section, compare the conclusions and findings of your study to the previous literature. Examine how the findings and conclusions are similar and/or different from what is commonly accepted.14 Discuss what your study may potentially contribute, but at the same time be modest, and recognize that your study may only be one piece of the evolving puzzle. Then discuss the potential limitations of your study. It is important to be honest about how the study could have been improved, and what the inherent limitations 22
were.13 It is difficult for an experienced reviewer and editor NOT to find limitations of a research study in radiology, whether related directly to humans or not. Such a section does not hurt the chances of the manuscript for acceptance, and on the contrary a thorough and fair limitations section may actually do the opposite. Possible future studies that could be carried out as a result of your contribution should be discussed in this section. In your introduction and discussion sections, make sure to cite the most recent and relevant references. Recheck the literature as your manuscript is making its way through the peer review process. Pay attention to specific journal guidelines as to the maximum number of references for a specific manuscript type. Lastly, try to anticipate and disclose problems prospectively, and to avoid self-congratulatory statements. Few manuscripts are accepted to major imaging journals without revisions on the first submission. On resubmission, send both annotated and non-annotated revised drafts, and include a detailed cover letter explaining changes.15 All of the changes requested by the reviewers and the editors do not have to be made if you do not agree with them, however the authors must explain why a suggested change was not made, or why the revisions are somewhat different than those specifically requested by the reviewers and/or the editor. Rewriting is important for an ultimately excellent paper, and it is common for a paper to go through multiple revisions prior to publication. To quote another former editor of the journal Radiology, Dr. Anthony V. Proto, “There are no shortcuts.”
Conclusion:
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The process of reading, reviewing, and writing for the imaging literature can be very rewarding. It is important to remember to read selectively and critically, and to approach your writing as a critical reader and reviewer. At all levels of education, continue to read in effort to stay up-to-date, but take into consideration the target audience of different types of literature. Although there is not as much literature about writing an article for the imaging literature, or on reviewing or reading the imaging literature as one might think there is, such writing, once one has a good research project or a good idea for a review article, is relatively formulaic, making the process more manageable, compared with creative writing of a novel, for example. Additionally, the skill sets of critically reading, reviewing, and writing an imaging paper are all inter-related. By following the principles and recommendations laid out in this paper, we hope the reader will feel somewhat more confident and comfortable in doing all of the three. There are also several radiologic journalism fellowships one can participate in, for both trainees and for mid-level career academic radiologists, to continue to develop one’s skill in reading, reviewing and writing, which are sponsored by RSNA, ARRS, and ACR. The editors of the journals published by those societies help to run these fellowships, and also give periodic lectures and workshops at their national meetings and at other venues, on how to be an excellent peer reviewer and scientific writer.
References
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Diagnostic Radiology. 5th ed. Philadelphia, PA: LWW; 2018.1-1600. 8. Provenzale JM, Stanley RJ. A systematic guide to reviewing a manuscript. Am J
Roentgenol 2005;185:848-854. 9. Proto AV. Reviewing for Radiology. Radiology 2000;215:619-621. 10. Halsted MJ. Radiology peer review as an opportunity to reduce errors and improve
patient care. J Am Coll Radiol 2004;1:984-987. 11. Offiah AC, Chu WCW, Davis R, Dixon AK, Klein JS, Lee EY. How to prepare successful
scientific manuscripts: practical advice from editors of radiology journals. Pediatr Radiol 2014; 44: 1056-1057. 12. Kliewer MA. Writing it up: a step-by-step guide to publication for beginning
investigators. Am J Roentgenol 2005; 185:3. 25
13. Jha KN. How to write articles that get published. J Clin Diagn Res 2014;8(9):XG01-XG03. 14. Provenzale P. Ten principles to improve the likelihood of publication of a scientific
manuscript. Am J Roentgenol 2007; 188(9): 1179-1182. 15. Bannas P, Reeder SB. How to write an original radiological research manuscript. Eur
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Add: AJR Am J Roentgenol. 2016 Oct;207(4):820-825. doi: 10.2214/AJR.16.16008. Epub 2016 Aug 17.Ethical Issues in Radiology Journalism, Peer Review, and Research. Katz DS1, Gardner JB2, Hoffmann JC1, Patlas MN3, Bhargava P4, Moshiri M4, Remer EM5, Gould ES6, Smith S7. Extra references (not used): Berk RN. Preparation of manuscripts for Radiology Journals: Advice to first-time authors. AJR 1992; 158: 203-208. Siegelman SS. Advice to authors. Radiology 1988; 166: 278-280. Publication information for authors. Radiology, RG, and AJR (every issue & on line). Proto AV. Evaluating and processing your manuscript for publication. Radiology 2007; 244:3-6. Proto AV. Reviewing for radiology. Radiology 2007; 244:7-11. Sheiman RG. The RSNA reviewer mentorship program. Radiology 2007; 244:631-632. Basic Outline Introduction Reading Radiology Literature ● What to read? ● How to read? Reviewing Radiology Literature Writing Radiology Literature ● What do you need to have on hand in order to start writing? ● Specifics of Manuscript Construction ○ Title ○ Abstract ○ Introduction ○ Materials and Methods ○ Results ○ Discussion ○ References
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○ Figures ○ Tables ● Unique specifics for writing literature in 2018 ● What order should the different manuscript sections be written in? ● Finishing touches ● Ethical issues ● Revisions How to improve one’s writing skills ● RSNA “Traveling Editors” Program ● Radiologic Journalism Fellowships Conclusion
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