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How to write an article
How to Write an Article
A. G. Apley articles are favoured presented.
Before Writing Writing an article is rather like having a baby: the conception is delightful, the gestation period is long and the labour is painful, but in the end you have something to show for it. To convert the notes of your study into an article which editors will want to publish is no easy matter. You need to have something worth saying, as well as the time and energy to say it. What follows is designed to help you achieve publication.
Reading It is essential to scan the literature thoroughly. You will have done a good deal of reading while planning and conducting your research. Now is the time to consolidate and extend that reading. Good sources of reference can be found in Medline, Index Medicus and in review articles or chapters of books on related topics; and a good librarian is worth his/her weight in gold. It is useful to keep a separate card or sheet for each important reference, or to photocopy it. You need to know the exact title, the names of the authors and of the book or journal, the year of publication, and the first and last page numbers. Then add a two or three line summary of the article. All this may seem unnecessarily arduous, but it will save time later. It is possible to store the information on a word processor, but cards have advantages. Discussion with knowledgeable colleagues or with anyone expert in your field is also worthwhile, You need not be afraid that your work will be stolen, though you might want to withhold your most brilliant ideas.
Selecting your target
Try to decide in which journal you want to see your article published. The Journal of Bone and Joint Surgery is the gold standard in orthopaedics, but it has a high rejection rate and even a reasonably good article may not be accepted. Other very good journals include the one you are reading now (Current Orthopaedics), Clinical Orthopaedics and Related Research, Ijury, and Acta Scandinavica; all of these
have peer review, the recognised benchmark of quality. There are also more specialised journals, such as the Journal of Hand Surgery, the Journal of Arthroplasty and many others which, if your article is dealing with highly specialised information, may be more appropriate. The basic sciences have their own journals and for more general information the British Medical Journal and the Lancet are available. The most prestigious general journal of all is Nature, but for that your article needs to be scientifically immaculate and splendidly original. Whichever journal you select it is important to look through three or four recent issues to see what kind of
Deciding the type of article
Before you begin to write you need to decide what kind of article you are aiming at. Is it about basic science, or a case report, a clinical study, a new instrument or procedure, or a review article? Each of these presents special problems, some of which are discussed below.
Alan G. Apley FRCS, Editor Emeritus, Journal of Bone and Joint Surgery, Singleton Lodge, 1 Blackwood Close, West Byfleet,
Basic science studies tend to be full of jargon which, in
Surrey KY14 6PW, UK. Currenr Orlhopaedics (1992) 6, 252-251 Q 1992 Lon.@mn
Group
UK Ltd
and in what style they are
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HOW I WRITE AN ARTICLE
this context, can be defined as the use of technical words when they are not needed. Of course they are sometimes necessary, but it is a mistake to suppose that long words are better than short ones, or cleverer: they are not. If a group of old women have lost most of their teeth, is it really necessary to refer to them as an ‘ageing oligodentulous female cohort’? And are ‘immature males and females’ all that much better than ‘boys and girls’? The difficulty may derive from the fact that you have become so immersed in your subject that its technicalities have assumed the familiarity of ordinary words. Unhappily your readers may be 1eSserudite in your field and you should never lose sight of the fact that unless you are easily understood you will not get your message across -and unless an editor and his reviewers readily comprehend you, publication is unlikely. A good way of getting into the right frame of mind for simple writing is to assume that you have been commissioned by a quality newspaper to write a brief account of your work ; you will not enjoy the publicity, nor will you be paid, unless you use words which the intelligent layman can understand. Single case reports are best written as if you were presenting the case at a conference. Use the active voice, saying what you did and what you found, rather than what was done and what was found. And remember that even case reports should be more than mere curiosities. The phrase ‘this is the first published report’ seems to exert an irresistible fascination, although uniqueness is easy to achieve if you pile on enough qualifications, thus : ‘This is the first published report of an osteoid osteoma in the right navicular bone of a left-handed basket-ball player from Trinidad’. Moreover, even the most esoteric case is liable to attract an angry response from an author who claims priority, though he may not mention that his case was published in a rather obscure Mongolian journal and has never been translated. So be content with ‘I have not been able to find . ,. . . ’ It is always tempting to add a ‘Review of the literature’ which displays your erudition. But if this merely summarises the previous publications on your subject it has little value. Ernest Hemingway said that editors always recognised (and rejected) such material - he called it ‘crap detection’. A review of the literature is valuable only if it contributes to our understanding of the subject. A series qf ?hree or.four cases is often more interesting
and has a better chance of acceptance, providing the similarities between them are not simply that they are of the same sex or have the same political affiliation. Significant shared features may be sufficiently important to constitute a new syndrome which may come to be known by your name, so detailed perusal of the literature is even more essential than usual. I once saw a man who complained of pain in his leg due to melorheostosis: however, he had only one arm, the
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other had been amputated because it had multiple aneurysms. The association of aneurysms with melorheostosis was curious and a search of the literature revealed two other articles with that combination, one in an orthopaedic, the other in a radiological journal. Here seemed to be a new syndrome. Unhappily detailed study of the two previous cases showed that they were both describing the same patient; moreover he was the man who was the starting point of this story. Back to the drawing board ! Large scale clinical studies are of special value, whether
they are describing the natural history of a disorder, or comparing the results of different methods of treatment. Often multiple authors and even multiple centres are involved. If so, the importance of one person co-ordinating the findings and of a detailed proforma cannot be over-emphasised. These articles (and some others) are often described under headings which have the well-known acronym IMRAD. This stands for Introduction, Material and Methods, Results and Discussion. These are considered in detail later, but meanwhile it is useful to think of them in simple terms : Introduction - why did I start? Material and Methods - what did I do (and to whom)? Results-what did I find? and Discussion -what does it matter (or who cares)? A new instrument or procedure usually needs only a
brief description with an illustration. But you should also say how often it has been used and whether there were any difficulties or complications. Review articles correspond to the first or second leader in the Times. They are mainly for the purpose of
sorting out a whole subject or debating a current controversy. They do not necessarily contain original work, but they do need to have a mature, balanced way of looking at their subject. A review article should always be discussed with the editor before being written. Writing the Article Before you put pen to paper (or hand to word processor) you should try to formulate the message you hope to convey, .You can probably sum it up in 50 words or less. Write them down or print them in large letters and display the message where it will confront you whenever you are writing. This will help to prevent you from straying into irrelevancies which waste your time and would distract a reader. Next assemble your material. Collect every scrap of information you have, including your notes, clinical records, X-rays, scans, path. reports, illustrations, graphs, references - everything: leave nothing out. Then sort this material into heaps, each under the appropriate heading and each heap arranged in date order. Headings are vital; they are the signposts which
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254 CURRENT ORTHOPAEDICS-MASTERCLASS tell the reader where he is. So they must be disciplined, including under each one every item which belongs there and, no less important, excluding every item which does not. The actual writing You are now ready to begin writing. That word ‘writing’ is here used to include using a word processor or even dictating. Amending is so easy on a word processor that you may prefer this method of producing your first draft. But speed is not everything and if you think better with a pen in your hand (I certainly do) then that is the method for you. Shakespeare and Bach used quill pens but still produced vast quantities of marvellous material. You may elect to write the article in small carefully constructed sections, or to dash the entire manuscript off in one inspired swoop; that depends on your temperament. In either case remember this is only the first draft. Introduction: This should tell the reader what shortcomings in our present knowledge, or inadequacies in our results, prompted you to study this particular subject. So you will probably need to quote from previous publications; but this does not mean that you should cite every article which is even remotely connected with the subject. Try not to get carried away by the desire to show the depth and breadth of your reading. It is true that you need to convince reviewers and readers that you really have studied the literature, but you should also demonstrate that you are selective; so you should quote only those articles which are strictly relevant, important, and which contain further references if these are needed. A list of 88 previous publications is simply verbal Mogadon; it is so boring that, even if the reader remains awake he will probably turn to the next article. Try to interest the reader from the start. An article on backache might persuade him to continue if it began something like this: ‘Eminent surgeons including Hugh Owen Thomas, Robert Jones and McMurray treated backache with a red hot needle driven unexpectedly into the tender spot. A slight shriek was followed by a wisp of smoke and a whiff of burning flesh. Then, after a dab of iodine and a quick rub of the tender spot the patient was led to the door, told she was cured, and invited to make a further appointment. Apparently they seldom did’. (Wainwright 1991). Or you might like to begin with a bang: ‘The results of treating chronic backache are appalling’. Above all, get to the point early - remember, if you don’t strike oil quickly, stop boring. Material and methods: The object here is to give enough information for other workers to be able to repeat your work if they so wish, and to be able to compare their findings with yours. You must be explicit and you need to specify how many patients or
animals were involved and how all of them fared. If it was patients, how were they selected; do not say they were chosen at random because ‘randomized ’ has a precise statistical meaning and to use the word without specifying the meaning is to invite the suspicion that your choice was biassed. If you are using animals and kill them, it is not necessary to say that you ‘sacrifice’ them, unless you are actually performing a ritual killing to propitiate the gods, which is what the word means. You may need to divide the population studied into groups and subgroups according to age, sex, length of follow-up, or the particular procedure adopted. Make sure that the basis on which the sub-divisions are made is clearly specified; otherwise you leave the reader floundering. Then ask yourself if the number in each is sufficient to justify your conclusions, or indeed any conclusions; do not only ask yourself, also ask a statistician. The time to seek statistical help is before the figures are compiled ; indeed it should really be when the project is planned.. As for controls, their number and method of selection also must be specified ; if you are not using controls you may need to justify their omission. Your methods also must be described explicitly, but if some particular measurement is well known a reference to an earlier account is sufficient. Results: It is essential that you say how you are assessing your results. If you are using words like ‘good’ ‘fair’ ‘satisfactory’ or ‘poor’ you must define them with precision and leave no room for grey areas. If you are using a known scoring system you should specify which one and acknowledge its drawbacks. Any new scoring system will certainly need justification. It is worth reading the comments on scoring systems in the Journal of Bone and Joint Surgeq (1990; 72A: 159-168 and 72B: 9.57-958). Errors of arithmetic in expressing the results are astonishingly common (the staff of one journal estimated their incidence at 70%). They slip in unobtrusively and diminish your credibility. For example, the population of the patients described in the section on ‘Material and Methods’ may consist of 11 men and 17 women, but the results (on another page of the manuscript) may be assessed in terms of 29 patients; presumably one was added as the study proceeded, but the effect is disturbing. Even more disturbing is for the total number to be less than the sum of its constituent parts; the reader is left wondering if the missing ‘patients are dead (or ‘sacrificed ‘), defaulters, or have results opposed to those of your thesis. A common numerical error concerns bilateral procedures. You are perhaps describing the results of 98 knee replacements in 70 patients, and you go on to say that 66 were satisfactory : 66 knees or patients? Clearly all numbers need to be checked carefully and it is wise to ask an independent person (not necessarily medical) to check them.
HOW I WRITE AN ARTICLE
Percentages, means, modes and averages are words which are sometimes used meaninglessly or misleadingly. It is always a mistake to apply percentages to small numbers; to say that 50% of 2 patients survived is absurd. It is a more subtle mistake to convert numbers to percentages, and conclude from them that method A is better than B, if a different result in only one case would have contradicted that view. As for averages, does it really advance the cause of science to say that a man and his dog average three legs apiece? You may feel that you need to consult a statistician but, unless you sought his advice much earlier (as suggested), he may tell you that your methodology is worthless. And never seek advice from two statisticians ; they are no more likely to agree than two economists, and you will be caught in the crossfire. Remember also that consultation must be acknowledged but need not imply co-authorship; an article by a surgeon and a statistician will not necessarily embody the virtues of both. When a famous beauty suggested to Bernard Shaw that, with her looks and his brain they should have a child, he replied ‘suppose it had my looks and your brain ‘. Results should not be expressed in long continuous sentences such as ‘in men over 70 the mean range of movement was 72.5 (range 64.3 to 77, SD+3.5) and the mean fixed flexion was 15.3 (range 5.6 to 22.7, SD + 5.8) ; in men under 70 the mean range of movement was 8 1.9 (range 74.3 to 93.6, SD + 8.2) and the mean fixed flexion was 12.8 (range 10.2 to 15.5, SD +2.8); in women over 70 the mean range . . . . . . ’ This sort of thing is almost unreadable; so are lists of laboratory reports if presented in toto instead of being interpreted. Writers who bespatter the page with lists tend to develop a sameness of voice, like eunuchs. Tables or charts are better and are discussed later. No account of the results of any surgical procedure is complete without discussing the complications. Do not assume that the reader will regard omission as meaning that no complications occurred; he is more likely to think that their existence has been suppressed. Always admit, or even parade your complications ; this will enhance your credibility, especially if you can provide a reasonable explanation for their occurrence. In the discussion you should explain the significance of your work (does it matter?), why your results differ from those of other people (if they do), and what the implications are for future work (what next?). Your writing in this section can be speculative, unlike that in ‘Material and methods ’ or ‘Results ’ where it should be purely factual. But in speculating you should avoid extravagant claims and, in the interests of brevity, you should avoid repeating what you have written in the earlier sections,
Discussion:
Conclusions: This should consist of a very brief statement or series of statements containing what you hope the reader will remember. It may be the only part
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of the paper which he reads (other than the ‘Abstract ‘) so simplicity is the keynote. Above all you should not seize the opportunity to state once again the minutiae of your methodology or your detailed statistics. Illustrations,
graphs, tables and charts
Illustrations are attractive, but in scientific papers they are not simply for decoration, nor is their purpose merely ‘to add verisimilitude to an otherwise bald and unconvincing narrative’ (W. S. Gilbert). So do not send more than you really need, nor a selection from which you expect the editor to choose the best. Quality also is important and no printer can produce a beautiful picture from an underexposed, uncentred, fogged film of a fat man’s spine. Pictures do not gain during the printing process, they may lose a little, so clarity of the original is vital. Send sharp and clearly labelled prints, cropped to leave only the relevant area. Do not mark the prints with arrows or in any other way; if marks are needed put them on attached tracing paper for the printer to incorporate. In all events use a soft crayon not a pen. Colour is more difficult and more expensive, so use it only where it is essential. And remember that though a picture may be worth a thousand words; nobody wants the picture and the thousand words. Operation photographs seldom print well; often it is difficult to see which part of the body is being displayed. Drawings are usually better because unimportant structures can be omitted and vital ones highlighted. In some instances a photograph and a drawing of that photograph make an excellent combination; this applies with particular force to ultrasonograms. A useful way of assessing an illustration is to show it to a colleague without a word of explanation and see if he understands it. Pie charts and bar charts are a vivid way of illustrating results or other numerical information. If you are preparing these manually be careful to ensure that the proportions tally with the figures in your text. It is better to use a word processor with facilities for graphics; supplied with the figures this can construct charts or graphs with complete accuracy. Tables are a useful way of presenting information, but it needs considerable craftsmanship to steer a middle course between over-simplicity and excessive complexity. If, out of 5 patients, 3 did well and 2 badly, this is better expressed as a sentence in the text; it would look pretentious as a table. On the other hand it is daunting to face a table which is the size of a bed sheet and as full of exceptions as a railway timetable. As with illustrations and charts, tables should not simply be a repetition of what is in the text; the written description should be a commentary. highlighting notable features. Language
and style
YOU cannot
overnight,
expect to achieve stylistic excellence but why not read good writing, in your
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ORTHOPAEDICS-MASTERCLASS
spare time: Jane Austen and Bernard Levin for a start - or P. G. Wodehouse, a real wordsmith and its nice to laugh while you learn. Fortunately, you are not aiming to produce a literary masterpiece sparkling with jewelled epigrams, you are only seeking to be understood, clearly and unambiguously - no easy matter. Here are a few useful guidelines: 1. Never use a long word if a short one will do. 2. Never use a long sentence if short ones will do; long sentences with parentheses are hard to control and difficult to take in. 3. Try to ensure that your sentences follow one another logically with a steady progression of ideas, avoiding a staccato succession of topics. 4. Make sure that the subject of each paragraph is self-evident. By following these guidelines you may hope to achieve a smooth read with a low ‘fog index’. At all costs avoid gobbledegook (verbal diarrhoea if you like) which is the curse of much medical literature (or should the word be ‘illiterature’). Here is a nonmedical example ‘The situation at this moment in time and for the foreseeable future is such that every individual male adult shall hereafter be regarded as not differing dimension-wise or indeed in any specific parameter from any other specified or unspecified male adult’. Are you sure you understand that? Happily, when he was writing the constitution of the United States, Thomas Jefferson simply wrote ‘All men are created equal ‘. A dictionary is, of course, an indispensable adjunct to writing; it should be at your elbow and used frequently. Authors who grew up with English as their mother tongue usually disregard this advice; they assume they know the meaning of English words. Nevertheless, mistakes abound; ‘mitigate’ is confused with ‘militate ‘, ‘track’ with ‘tract’ and the word ‘parameter’ is perhaps the most misused word in medical writing. Authors whose mother tongue is not English avoid these mistakes’ because they have to use a dictionary; they write more accurately, if less idiomatically.
Final Stages Assembling, abstract and title Assembling simply means putting together the separate parts you have written, ensuring that the arguments and statements follow one another in a logical sequence and that the total product adds up to a single, comprehensible article. This is also the stage at which to write the abstract (unless you are submitting a case report which may not need one). Go back to the summary of your message, which you wrote earlier; for the abstract it will probably need to be expanded from its 50 words to as many as 150 or even 200 words, but certainly not more. It is best to avoid details and precise statistics; these belong in the body of the article. Too lengthy an abstract may be so
indigestible that the reader never finishes it, and if he does, he may feel that he no longer needs to read the article itself. The title is best left till last. You will probably have thought of half-a-dozen while writing the article and. if you are wise, you will have written them down. NOW is the time to make your final choice. You may prefer a long title such as ‘the effect of combinations of dihydroergotamine and heparin on the incidence of deep vein thrombosis and pulmonary embolism following total hip replacement in normotensive patients aged over 70 years’ or a short one like ‘Drugs for Venous thrombosis’. The first makes an impressively long addition to your CV, but personally I prefer the simplicity of the second, especially as it can always be amplified by a sub-title. If you are lucky enough to think up a striking title, use it: who was able to resist the article which once appeared in the JBJS entitled ‘Man with three legs’? Polishing and pruning Every article needs polishing. When you think you have finished writing, put the article away in a drawer and forget about it. After 2 or 3 weeks take it out and read it straight through. You are sure to find passages’ with which you are dissatisfied - otherwise you are not being sufficiently self-critical; even Beethoven repeatedly revised his early drafts. Try to adopt an attitude of critical hostility to the writing, seeking errors of logic, of clarity and of grammar. Then set about pruning. Aim to make the article shorter and simpler. Shorter, because space in journals is at a premium and because those who read the journal are all busy people - in medical writing brevity is the kiss of life. You may resent the suggestion that an article as important as yours should be shortened: if so, remember that Watson and Crick’s first account of the double helix, which changed the thinking of the scientific world, occupied only one page of Nature. To shorten an article you need to omit irrelevancies and to reduce repetition. Any word, phrase, sentence or paragraph can be considered irrelevant, if its omission does not weaken your message. Excision is always painful but, if in doubt, cut it out. Repetition of certain points is, of course, necessary, but in excess it iscounter-productive; in Hamlet’s words, ‘methinks he doth protest too much’. Simplifying an article helps reviewers to assess your paper, editors to publish it and readers to understand it. And when published it helps those readers to whom English is a foreign language. Obscurities and ambiguities are often revealed if you read the paper aloud, to a small but select audience; they need not be expert in your subject but they should be medically literate and attentive to the flow of words. Reading aloud may reveal the absurdity of phrases which, when you read them to yourself, seemed sensible: ‘under general anaesthesia in the prone position the surgeon makes a vertical incision’ or even ‘if the baby
HOW I WRITE AN ARTICLE
fed on milk fails to thrive, boil it ‘. Reading aloud may also bring to light ambiguities such as ‘scars on the anterior aspect of the shoulder were particularly liable to become keloid in our female patients; they were very ugly ‘.
Checking You have already checked your facts, your arithmetic and your phrases, so you have nearly finished, but not quite. A considerable number of submitted papers include references which contain errors such that the reader would fail to find the listed articles. So every single reference should be checked carefully (hence the cards or photocopies suggested earlier) and they should be presented in the form which your selected
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journal requires. After that you should make sure that any co-authors agree with your amended version. Finally, before posting the article, read once again the page of the journal headed Instructions to Authors and follow those instructions meticulously. Make sure that you are sending the required number of copies (or a floppy disc if acceptable), that your illustrations have been prepared correctly and so on. Acceptance of your paper may not depend on your having fulfilled all the requirements, but a sweet-tempered editor is a splendid ally.
Acknowledgement Some of the material in this article is due to be published by the American Association of Orthopaedic Surgeons in their series of Instrucrional Course Lectures. I am grateful to them for permission to publish this present article.
A. G. Apley articles are favoured presented.
Before Writing Writing an article is rather like having a baby: the conception is delightful, the gestation period is long and the labour is painful, but in the end you have something to show for it. To convert the notes of your study into an article which editors will want to publish is no easy matter. You need to have something worth saying, as well as the time and energy to say it. What follows is designed to help you achieve publication.
Reading It is essential to scan the literature thoroughly. You will have done a good deal of reading while planning and conducting your research. Now is the time to consolidate and extend that reading. Good sources of reference can be found in Medline, Index Medicus and in review articles or chapters of books on related topics; and a good librarian is worth his/her weight in gold. It is useful to keep a separate card or sheet for each important reference, or to photocopy it. You need to know the exact title, the names of the authors and of the book or journal, the year of publication, and the first and last page numbers. Then add a two or three line summary of the article. All this may seem unnecessarily arduous, but it will save time later. It is possible to store the information on a word processor, but cards have advantages. Discussion with knowledgeable colleagues or with anyone expert in your field is also worthwhile, You need not be afraid that your work will be stolen, though you might want to withhold your most brilliant ideas.
Selecting your target
Try to decide in which journal you want to see your article published. The Journal of Bone and Joint Surgery is the gold standard in orthopaedics, but it has a high rejection rate and even a reasonably good article may not be accepted. Other very good journals include the one you are reading now (Current Orthopaedics), Clinical Orthopaedics and Related Research, Ijury, and Acta Scandinavica; all of these
have peer review, the recognised benchmark of quality. There are also more specialised journals, such as the Journal of Hand Surgery, the Journal of Arthroplasty and many others which, if your article is dealing with highly specialised information, may be more appropriate. The basic sciences have their own journals and for more general information the British Medical Journal and the Lancet are available. The most prestigious general journal of all is Nature, but for that your article needs to be scientifically immaculate and splendidly original. Whichever journal you select it is important to look through three or four recent issues to see what kind of
Deciding the type of article
Before you begin to write you need to decide what kind of article you are aiming at. Is it about basic science, or a case report, a clinical study, a new instrument or procedure, or a review article? Each of these presents special problems, some of which are discussed below.
Alan G. Apley FRCS, Editor Emeritus, Journal of Bone and Joint Surgery, Singleton Lodge, 1 Blackwood Close, West Byfleet,
Basic science studies tend to be full of jargon which, in
Surrey KY14 6PW, UK. Currenr Orlhopaedics (1992) 6, 252-251 Q 1992 Lon.@mn
Group
UK Ltd
and in what style they are
252
HOW I WRITE AN ARTICLE
this context, can be defined as the use of technical words when they are not needed. Of course they are sometimes necessary, but it is a mistake to suppose that long words are better than short ones, or cleverer: they are not. If a group of old women have lost most of their teeth, is it really necessary to refer to them as an ‘ageing oligodentulous female cohort’? And are ‘immature males and females’ all that much better than ‘boys and girls’? The difficulty may derive from the fact that you have become so immersed in your subject that its technicalities have assumed the familiarity of ordinary words. Unhappily your readers may be 1eSserudite in your field and you should never lose sight of the fact that unless you are easily understood you will not get your message across -and unless an editor and his reviewers readily comprehend you, publication is unlikely. A good way of getting into the right frame of mind for simple writing is to assume that you have been commissioned by a quality newspaper to write a brief account of your work ; you will not enjoy the publicity, nor will you be paid, unless you use words which the intelligent layman can understand. Single case reports are best written as if you were presenting the case at a conference. Use the active voice, saying what you did and what you found, rather than what was done and what was found. And remember that even case reports should be more than mere curiosities. The phrase ‘this is the first published report’ seems to exert an irresistible fascination, although uniqueness is easy to achieve if you pile on enough qualifications, thus : ‘This is the first published report of an osteoid osteoma in the right navicular bone of a left-handed basket-ball player from Trinidad’. Moreover, even the most esoteric case is liable to attract an angry response from an author who claims priority, though he may not mention that his case was published in a rather obscure Mongolian journal and has never been translated. So be content with ‘I have not been able to find . ,. . . ’ It is always tempting to add a ‘Review of the literature’ which displays your erudition. But if this merely summarises the previous publications on your subject it has little value. Ernest Hemingway said that editors always recognised (and rejected) such material - he called it ‘crap detection’. A review of the literature is valuable only if it contributes to our understanding of the subject. A series qf ?hree or.four cases is often more interesting
and has a better chance of acceptance, providing the similarities between them are not simply that they are of the same sex or have the same political affiliation. Significant shared features may be sufficiently important to constitute a new syndrome which may come to be known by your name, so detailed perusal of the literature is even more essential than usual. I once saw a man who complained of pain in his leg due to melorheostosis: however, he had only one arm, the
253
other had been amputated because it had multiple aneurysms. The association of aneurysms with melorheostosis was curious and a search of the literature revealed two other articles with that combination, one in an orthopaedic, the other in a radiological journal. Here seemed to be a new syndrome. Unhappily detailed study of the two previous cases showed that they were both describing the same patient; moreover he was the man who was the starting point of this story. Back to the drawing board ! Large scale clinical studies are of special value, whether
they are describing the natural history of a disorder, or comparing the results of different methods of treatment. Often multiple authors and even multiple centres are involved. If so, the importance of one person co-ordinating the findings and of a detailed proforma cannot be over-emphasised. These articles (and some others) are often described under headings which have the well-known acronym IMRAD. This stands for Introduction, Material and Methods, Results and Discussion. These are considered in detail later, but meanwhile it is useful to think of them in simple terms : Introduction - why did I start? Material and Methods - what did I do (and to whom)? Results-what did I find? and Discussion -what does it matter (or who cares)? A new instrument or procedure usually needs only a
brief description with an illustration. But you should also say how often it has been used and whether there were any difficulties or complications. Review articles correspond to the first or second leader in the Times. They are mainly for the purpose of
sorting out a whole subject or debating a current controversy. They do not necessarily contain original work, but they do need to have a mature, balanced way of looking at their subject. A review article should always be discussed with the editor before being written. Writing the Article Before you put pen to paper (or hand to word processor) you should try to formulate the message you hope to convey, .You can probably sum it up in 50 words or less. Write them down or print them in large letters and display the message where it will confront you whenever you are writing. This will help to prevent you from straying into irrelevancies which waste your time and would distract a reader. Next assemble your material. Collect every scrap of information you have, including your notes, clinical records, X-rays, scans, path. reports, illustrations, graphs, references - everything: leave nothing out. Then sort this material into heaps, each under the appropriate heading and each heap arranged in date order. Headings are vital; they are the signposts which
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254 CURRENT ORTHOPAEDICS-MASTERCLASS tell the reader where he is. So they must be disciplined, including under each one every item which belongs there and, no less important, excluding every item which does not. The actual writing You are now ready to begin writing. That word ‘writing’ is here used to include using a word processor or even dictating. Amending is so easy on a word processor that you may prefer this method of producing your first draft. But speed is not everything and if you think better with a pen in your hand (I certainly do) then that is the method for you. Shakespeare and Bach used quill pens but still produced vast quantities of marvellous material. You may elect to write the article in small carefully constructed sections, or to dash the entire manuscript off in one inspired swoop; that depends on your temperament. In either case remember this is only the first draft. Introduction: This should tell the reader what shortcomings in our present knowledge, or inadequacies in our results, prompted you to study this particular subject. So you will probably need to quote from previous publications; but this does not mean that you should cite every article which is even remotely connected with the subject. Try not to get carried away by the desire to show the depth and breadth of your reading. It is true that you need to convince reviewers and readers that you really have studied the literature, but you should also demonstrate that you are selective; so you should quote only those articles which are strictly relevant, important, and which contain further references if these are needed. A list of 88 previous publications is simply verbal Mogadon; it is so boring that, even if the reader remains awake he will probably turn to the next article. Try to interest the reader from the start. An article on backache might persuade him to continue if it began something like this: ‘Eminent surgeons including Hugh Owen Thomas, Robert Jones and McMurray treated backache with a red hot needle driven unexpectedly into the tender spot. A slight shriek was followed by a wisp of smoke and a whiff of burning flesh. Then, after a dab of iodine and a quick rub of the tender spot the patient was led to the door, told she was cured, and invited to make a further appointment. Apparently they seldom did’. (Wainwright 1991). Or you might like to begin with a bang: ‘The results of treating chronic backache are appalling’. Above all, get to the point early - remember, if you don’t strike oil quickly, stop boring. Material and methods: The object here is to give enough information for other workers to be able to repeat your work if they so wish, and to be able to compare their findings with yours. You must be explicit and you need to specify how many patients or
animals were involved and how all of them fared. If it was patients, how were they selected; do not say they were chosen at random because ‘randomized ’ has a precise statistical meaning and to use the word without specifying the meaning is to invite the suspicion that your choice was biassed. If you are using animals and kill them, it is not necessary to say that you ‘sacrifice’ them, unless you are actually performing a ritual killing to propitiate the gods, which is what the word means. You may need to divide the population studied into groups and subgroups according to age, sex, length of follow-up, or the particular procedure adopted. Make sure that the basis on which the sub-divisions are made is clearly specified; otherwise you leave the reader floundering. Then ask yourself if the number in each is sufficient to justify your conclusions, or indeed any conclusions; do not only ask yourself, also ask a statistician. The time to seek statistical help is before the figures are compiled ; indeed it should really be when the project is planned.. As for controls, their number and method of selection also must be specified ; if you are not using controls you may need to justify their omission. Your methods also must be described explicitly, but if some particular measurement is well known a reference to an earlier account is sufficient. Results: It is essential that you say how you are assessing your results. If you are using words like ‘good’ ‘fair’ ‘satisfactory’ or ‘poor’ you must define them with precision and leave no room for grey areas. If you are using a known scoring system you should specify which one and acknowledge its drawbacks. Any new scoring system will certainly need justification. It is worth reading the comments on scoring systems in the Journal of Bone and Joint Surgeq (1990; 72A: 159-168 and 72B: 9.57-958). Errors of arithmetic in expressing the results are astonishingly common (the staff of one journal estimated their incidence at 70%). They slip in unobtrusively and diminish your credibility. For example, the population of the patients described in the section on ‘Material and Methods’ may consist of 11 men and 17 women, but the results (on another page of the manuscript) may be assessed in terms of 29 patients; presumably one was added as the study proceeded, but the effect is disturbing. Even more disturbing is for the total number to be less than the sum of its constituent parts; the reader is left wondering if the missing ‘patients are dead (or ‘sacrificed ‘), defaulters, or have results opposed to those of your thesis. A common numerical error concerns bilateral procedures. You are perhaps describing the results of 98 knee replacements in 70 patients, and you go on to say that 66 were satisfactory : 66 knees or patients? Clearly all numbers need to be checked carefully and it is wise to ask an independent person (not necessarily medical) to check them.
HOW I WRITE AN ARTICLE
Percentages, means, modes and averages are words which are sometimes used meaninglessly or misleadingly. It is always a mistake to apply percentages to small numbers; to say that 50% of 2 patients survived is absurd. It is a more subtle mistake to convert numbers to percentages, and conclude from them that method A is better than B, if a different result in only one case would have contradicted that view. As for averages, does it really advance the cause of science to say that a man and his dog average three legs apiece? You may feel that you need to consult a statistician but, unless you sought his advice much earlier (as suggested), he may tell you that your methodology is worthless. And never seek advice from two statisticians ; they are no more likely to agree than two economists, and you will be caught in the crossfire. Remember also that consultation must be acknowledged but need not imply co-authorship; an article by a surgeon and a statistician will not necessarily embody the virtues of both. When a famous beauty suggested to Bernard Shaw that, with her looks and his brain they should have a child, he replied ‘suppose it had my looks and your brain ‘. Results should not be expressed in long continuous sentences such as ‘in men over 70 the mean range of movement was 72.5 (range 64.3 to 77, SD+3.5) and the mean fixed flexion was 15.3 (range 5.6 to 22.7, SD + 5.8) ; in men under 70 the mean range of movement was 8 1.9 (range 74.3 to 93.6, SD + 8.2) and the mean fixed flexion was 12.8 (range 10.2 to 15.5, SD +2.8); in women over 70 the mean range . . . . . . ’ This sort of thing is almost unreadable; so are lists of laboratory reports if presented in toto instead of being interpreted. Writers who bespatter the page with lists tend to develop a sameness of voice, like eunuchs. Tables or charts are better and are discussed later. No account of the results of any surgical procedure is complete without discussing the complications. Do not assume that the reader will regard omission as meaning that no complications occurred; he is more likely to think that their existence has been suppressed. Always admit, or even parade your complications ; this will enhance your credibility, especially if you can provide a reasonable explanation for their occurrence. In the discussion you should explain the significance of your work (does it matter?), why your results differ from those of other people (if they do), and what the implications are for future work (what next?). Your writing in this section can be speculative, unlike that in ‘Material and methods ’ or ‘Results ’ where it should be purely factual. But in speculating you should avoid extravagant claims and, in the interests of brevity, you should avoid repeating what you have written in the earlier sections,
Discussion:
Conclusions: This should consist of a very brief statement or series of statements containing what you hope the reader will remember. It may be the only part
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of the paper which he reads (other than the ‘Abstract ‘) so simplicity is the keynote. Above all you should not seize the opportunity to state once again the minutiae of your methodology or your detailed statistics. Illustrations,
graphs, tables and charts
Illustrations are attractive, but in scientific papers they are not simply for decoration, nor is their purpose merely ‘to add verisimilitude to an otherwise bald and unconvincing narrative’ (W. S. Gilbert). So do not send more than you really need, nor a selection from which you expect the editor to choose the best. Quality also is important and no printer can produce a beautiful picture from an underexposed, uncentred, fogged film of a fat man’s spine. Pictures do not gain during the printing process, they may lose a little, so clarity of the original is vital. Send sharp and clearly labelled prints, cropped to leave only the relevant area. Do not mark the prints with arrows or in any other way; if marks are needed put them on attached tracing paper for the printer to incorporate. In all events use a soft crayon not a pen. Colour is more difficult and more expensive, so use it only where it is essential. And remember that though a picture may be worth a thousand words; nobody wants the picture and the thousand words. Operation photographs seldom print well; often it is difficult to see which part of the body is being displayed. Drawings are usually better because unimportant structures can be omitted and vital ones highlighted. In some instances a photograph and a drawing of that photograph make an excellent combination; this applies with particular force to ultrasonograms. A useful way of assessing an illustration is to show it to a colleague without a word of explanation and see if he understands it. Pie charts and bar charts are a vivid way of illustrating results or other numerical information. If you are preparing these manually be careful to ensure that the proportions tally with the figures in your text. It is better to use a word processor with facilities for graphics; supplied with the figures this can construct charts or graphs with complete accuracy. Tables are a useful way of presenting information, but it needs considerable craftsmanship to steer a middle course between over-simplicity and excessive complexity. If, out of 5 patients, 3 did well and 2 badly, this is better expressed as a sentence in the text; it would look pretentious as a table. On the other hand it is daunting to face a table which is the size of a bed sheet and as full of exceptions as a railway timetable. As with illustrations and charts, tables should not simply be a repetition of what is in the text; the written description should be a commentary. highlighting notable features. Language
and style
YOU cannot
overnight,
expect to achieve stylistic excellence but why not read good writing, in your
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spare time: Jane Austen and Bernard Levin for a start - or P. G. Wodehouse, a real wordsmith and its nice to laugh while you learn. Fortunately, you are not aiming to produce a literary masterpiece sparkling with jewelled epigrams, you are only seeking to be understood, clearly and unambiguously - no easy matter. Here are a few useful guidelines: 1. Never use a long word if a short one will do. 2. Never use a long sentence if short ones will do; long sentences with parentheses are hard to control and difficult to take in. 3. Try to ensure that your sentences follow one another logically with a steady progression of ideas, avoiding a staccato succession of topics. 4. Make sure that the subject of each paragraph is self-evident. By following these guidelines you may hope to achieve a smooth read with a low ‘fog index’. At all costs avoid gobbledegook (verbal diarrhoea if you like) which is the curse of much medical literature (or should the word be ‘illiterature’). Here is a nonmedical example ‘The situation at this moment in time and for the foreseeable future is such that every individual male adult shall hereafter be regarded as not differing dimension-wise or indeed in any specific parameter from any other specified or unspecified male adult’. Are you sure you understand that? Happily, when he was writing the constitution of the United States, Thomas Jefferson simply wrote ‘All men are created equal ‘. A dictionary is, of course, an indispensable adjunct to writing; it should be at your elbow and used frequently. Authors who grew up with English as their mother tongue usually disregard this advice; they assume they know the meaning of English words. Nevertheless, mistakes abound; ‘mitigate’ is confused with ‘militate ‘, ‘track’ with ‘tract’ and the word ‘parameter’ is perhaps the most misused word in medical writing. Authors whose mother tongue is not English avoid these mistakes’ because they have to use a dictionary; they write more accurately, if less idiomatically.
Final Stages Assembling, abstract and title Assembling simply means putting together the separate parts you have written, ensuring that the arguments and statements follow one another in a logical sequence and that the total product adds up to a single, comprehensible article. This is also the stage at which to write the abstract (unless you are submitting a case report which may not need one). Go back to the summary of your message, which you wrote earlier; for the abstract it will probably need to be expanded from its 50 words to as many as 150 or even 200 words, but certainly not more. It is best to avoid details and precise statistics; these belong in the body of the article. Too lengthy an abstract may be so
indigestible that the reader never finishes it, and if he does, he may feel that he no longer needs to read the article itself. The title is best left till last. You will probably have thought of half-a-dozen while writing the article and. if you are wise, you will have written them down. NOW is the time to make your final choice. You may prefer a long title such as ‘the effect of combinations of dihydroergotamine and heparin on the incidence of deep vein thrombosis and pulmonary embolism following total hip replacement in normotensive patients aged over 70 years’ or a short one like ‘Drugs for Venous thrombosis’. The first makes an impressively long addition to your CV, but personally I prefer the simplicity of the second, especially as it can always be amplified by a sub-title. If you are lucky enough to think up a striking title, use it: who was able to resist the article which once appeared in the JBJS entitled ‘Man with three legs’? Polishing and pruning Every article needs polishing. When you think you have finished writing, put the article away in a drawer and forget about it. After 2 or 3 weeks take it out and read it straight through. You are sure to find passages’ with which you are dissatisfied - otherwise you are not being sufficiently self-critical; even Beethoven repeatedly revised his early drafts. Try to adopt an attitude of critical hostility to the writing, seeking errors of logic, of clarity and of grammar. Then set about pruning. Aim to make the article shorter and simpler. Shorter, because space in journals is at a premium and because those who read the journal are all busy people - in medical writing brevity is the kiss of life. You may resent the suggestion that an article as important as yours should be shortened: if so, remember that Watson and Crick’s first account of the double helix, which changed the thinking of the scientific world, occupied only one page of Nature. To shorten an article you need to omit irrelevancies and to reduce repetition. Any word, phrase, sentence or paragraph can be considered irrelevant, if its omission does not weaken your message. Excision is always painful but, if in doubt, cut it out. Repetition of certain points is, of course, necessary, but in excess it iscounter-productive; in Hamlet’s words, ‘methinks he doth protest too much’. Simplifying an article helps reviewers to assess your paper, editors to publish it and readers to understand it. And when published it helps those readers to whom English is a foreign language. Obscurities and ambiguities are often revealed if you read the paper aloud, to a small but select audience; they need not be expert in your subject but they should be medically literate and attentive to the flow of words. Reading aloud may reveal the absurdity of phrases which, when you read them to yourself, seemed sensible: ‘under general anaesthesia in the prone position the surgeon makes a vertical incision’ or even ‘if the baby
HOW I WRITE AN ARTICLE
fed on milk fails to thrive, boil it ‘. Reading aloud may also bring to light ambiguities such as ‘scars on the anterior aspect of the shoulder were particularly liable to become keloid in our female patients; they were very ugly ‘.
Checking You have already checked your facts, your arithmetic and your phrases, so you have nearly finished, but not quite. A considerable number of submitted papers include references which contain errors such that the reader would fail to find the listed articles. So every single reference should be checked carefully (hence the cards or photocopies suggested earlier) and they should be presented in the form which your selected
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journal requires. After that you should make sure that any co-authors agree with your amended version. Finally, before posting the article, read once again the page of the journal headed Instructions to Authors and follow those instructions meticulously. Make sure that you are sending the required number of copies (or a floppy disc if acceptable), that your illustrations have been prepared correctly and so on. Acceptance of your paper may not depend on your having fulfilled all the requirements, but a sweet-tempered editor is a splendid ally.
Acknowledgement Some of the material in this article is due to be published by the American Association of Orthopaedic Surgeons in their series of Instrucrional Course Lectures. I am grateful to them for permission to publish this present article.