- Email: [email protected]
Writing for publication
Writing for publication M. Evans Consultant Technical Editor, Scar-borough Hospital, Scarborough, UK
Nobody goes into a kitchen to cook a meal without knowing something about the ingredients and the recipes that they are going to cook. Indeed, most people take lessons first. Why, then, do people think that they can just sit down and write a perfect paper? Good scientific writing is just as hard as the research that it is trying to describe. It needs revising again and again; it needs criticism by someone unfamiliar with the subject; but above all it needs clarity and directness from you the author. Not only must the paper be understandable. It must be impossible to misunderstand it. One thought should dominate: I have done this work; it was expensive, difftcult, and time-consuming; but if I fail to communicate it to my peers it is worthless. Lock’ put it this way:
Many papers suffer from having strings of authors, and they all want their say. A committee cannot write a paper, however, and it is better to have one person who is in charge of the writing. Writing a paper is a humbling experience, particularly for those of us who think that they are quite good at it. It is not a comfortable feeling to have a manuscript that you thought was ready for submission returned to you by a colleague, covered in red pen, arrows, omission marks, and queries. But you must swallow your pride, and remember that those colleagues (and editors) are on your side. They recognize that you have something to say that is worth saying or they would not have given up their time to help you. They want you to get your message across in the clearest possible way. They want you to avoid jargon and ‘galumphing prose . . . interminable sentences utterly unredeemed by wit, irony or polish’.7 Prose that is ‘thuddingly prosaic” is not easy to read, and common sense tells you that what is not easy to read will probably not be read. We must never forget that language is ‘. . a precision tool, conforming to simple rules and conveying meaning logically’* and surgeons should use it as they would any other tool, be it scalpel, diathermy, or suture. There is a distinction between a technical vocabulary (and of course such a vocabulary is essential) and jargon. Jargon is useful shorthand that we use in speech every day. To try and avoid it when you are writing a paper is difficult and painful but, if you are to achieve clarity and readability. you must.” The problem is not new, and not restricted to medical writing. Orwell”’ wrote that ‘It is easier ~ even quicker, once you have the habit - to say: “In mu’ opinion it is u not unjustifiable assumption that” than to say “I think”.’ Some other examples of tortured English are given in Table 1. Another problem is the disease that you can easily catch by reading a newspaper: every noun is qualified by an adjective and every verb by an adverb. Table 2 shows some instances; in each case the word in bold type is superfluous. There is a quick and easy way to get a rough idea how readable your prose is, and that is by applying the ‘Gunning fox index’.” The formula is: 0.4 x (mean sentence length + percentage of words of more than two syllables). The score ranges from 5 (very easy), 6 (easy), 7 (fairly easy), 9 (standard English), 12 (fairly difficult), 14-16 (difficult) to 16+ (very difficult). If we aim for overall scores of 7-9, we should be writing fairly readable English. The fog index of this paragraph is 7.
The 4000 or so articles the BMJ sees every year are most dreadfully written, with numerous faults in English and overall construction. Many of these articles, of course, are published somewhere largely in their original form, because if the matter in them fulfils the other criteria the editor has not the time to translate them into decent prose, and it is the author who signs them. Unfortunately these articles are not fulfilling their purpose: they are largely being left unread because of their turgidity.
STYLE There are two main problems, neither of which is insoluble. Firstly, about 20 years ago it became fashionable in schools for teachers to concentrate on the joys of free expression instead of teaching the rules of grammar and language. There are, however, many good, useful, and cheap books that will help you.’ 6 The second problem is that many surgeons are obliged to read the sort of scientific papers that Lock referred to, together with a daily newspaper, perhaps, and some ‘airline fodder’ when on holiday. I have no doubt that to write well you must read well, and I have no hesitation in recommending the fiction of Graham Greene and the travel books of Bill Bryson, to name but two. Don’t spurn ‘light’ reading. Raymond Chandler and Dick Francis can teach scientists an awful lot about writing good English. 161
162
British
Journal
of Oral and Maxiliofacial
Surgery
Table 1 - Examples of tortured English (all of which have been taken from original manuscripts submitted for publication to various journals)
Excessive interposed adipose tissue Mobility of the leg was present In the author’s opinion On account of the fact that One out of every two Surgical procedure Exogenous nutrient elements
Fat The leg moved I think Because Half Operation Food
Table
2 - Superfluous words
action Distinct possibility Active consideration Absolute end
In actual fact Personal opinion Real danger Agonising reappraisal
Positive
Diametrically
opposed
STRUCTURE
to Authors of the journal to which you are going to submit your paper to find out what the editor wants.r4 Editors (and referees) are likely to be pleasantly disposed towards those who have obviously taken the trouble to do things their way.
Medical writers are lucky in that they have a readymade structure on which to hang their prose:
Introduction (Why did you start?)
Introduction, Material (or Patients) and Methods, Results, and Discussion, usually abbreviated as
IMRAD. Hill’* defined these as the answers to the following questions: Why did you start? What did you do? What answer did you get? and What does it mean anyway? After you have written those you must choose a title and write an abstract (or summary). I will.start with these accessories. Title A good title is essential, so that MEDLINE skimmers will be able to tell at a glance what your paper is about. Only if you are writing a review paper should the title be anything but simple and descriptive, and even then wit and double entendre should be used with care to avoid offending the sensibilities of colleagues. Abstract People do not usually read papers from beginning to end. If they are interested in a title they will skim the abstract; if this does not retain their interest, their attention will wane and they will turn the page and browse elsewhere.i3 The abstract should comprise about six short sentences: one that describes the introduction, perhaps two about the material and methods, two about the results, and one that summarizes the conclusion. It requires rigorous discipline to limit yourself in this way, but it is worth remembering that MEDLINE limits the abstracts that it prints to 250 words, so stick to the rule. There are a couple of other points to remember about the abstract. Firstly, it is likely to be the only part of the paper that many people will read (apart from the title), and, secondly, in some parts of the world doctors can afford only abstracting journals and it may be that patients are being treated on the basis of abstracts. The abstract must therefore contain facts, and those facts must be accurate. More and more journals are now specifying structured abstracts, which require additional discipline. Journals vary slightly in the headings that they like to see in a structured abstract, so do read the Instructions
The introduction to a research paper should answer the first of Hill’s four questions. State your hypothesis with, if necessary, some brief background. Do not review all the published papers on the subject. It is a common misconception that authors of research papers are required to ‘review the literature’; editors may regard this as uncritical verbosity. A carefully chosen selection of apposite references is more impressive, and its place is in the discussion, not the introduction.
Material (or Patients) and Methods (What did you do?) State what you did in the order in which you did it. Be honest about mistakes and omissions.15 Before you started your project, you will have written a protocol that describes what was to be done and by whom. That protocol should, with minor alterations, form the basis of your introduction and material and methods sections. If you used a well-known experimental method, it is enough to give a reference to a detailed description, but be sure to mention any modifications that you made, however small. Give generic as well as trade names for drugs and sutures (as formulations and even names may differ from country to country), and give the name and address of the manufacturer of any equipment that you used. Specify your statistical methods and the software package that you used to apply them. Define your terms, and avoid abbreviations. If something is so cumbersome that you have to abbreviate (for example, enzyme-linked immunosorbent assay - ELISA) always use a standard abbreviation, and always spell it out first.i6 No research involving patients should be done without the patients’ informed consent, and all research requires the approval of the ethics committee. Both should be mentioned. Results (What answer did you get?) Tabulate your results if you can. Readers have the right to see as many raw data as possible within the confines of editorial space, and columns of figures take up less space than explanatory text. There is also
Writing for publication
the possibility that a reader may draw a conclusion from your figures that is different from yours, and this will provoke controversy. Editors like controversy. Always give whole numbers in preference to percentages, and never use percentages when you are dealing with fewer than 20 observationsI Use decimal points sparingly and only for large numbers (more than 100) and P values. Beware spurious precision; biological data are seldom precise. Use statistical tests intelligently. Just because your computer can do a test does not mean that it is the correct test to do - or even that a test of significance is appropriate.17 If a result doesn’t make sense, it is probably not true, whatever the P value. It is easy to forget that ‘P = 0.05’ means that the event is likely to happen by chance once in 20 times. Be critical of analyses of small samples and consider the Type II error if appropriate. Do not use the f sign,‘* and never say that something is ‘NS’, meaning not significant. As Murray19 wrote: If one obtains a ‘non-significant’ result then one has failed to demonstrate a difference, which does not mean that one has established equivalence. A non-significant finding rather is analogous to the Scottish legal verdict of ‘not proven’, which is generally if mischievously regarded as meaning ‘not guilty, but don’t do it again.’ In other words, a non-significant finding often simply reflects a lack of evidence, rather than a lack of difference. Report normally distributed data as mean (SD), and skewed data as median (range) or (interquartile). A good rough guide as to whether data are normally distributed or not is to see whether the SD is more than half the mean. If it is, then the data are probably skewed.‘” Avoid using the SEM: give the 95% confidence interval (CI) of the mean instead.” If you are testing significance, use a parametric test for normally distributed data and a non-parametric test for skewed data. Always give units of measurement and, unless you are aiming for the North American market, always use SI (Systeme International) units (except for blood pressure which is always given as mmHg and ventilator pressures which are always given as cm HzO). Above all, make no deductions: stick to facts.
163
the Type III error (‘no data were presented to support the conclusions expressed’).2” Mention how your work might influence clinical practice and future research. Modest conclusions are always the most telling. For example, Fleming2’ concluded the description of his discovery with the words ‘Penicillin, in regard to infections with sensitive microbes, appears to have some advantages over the well-known chemical antiseptics’ and Watson and Crick2’ concluded their letter to Nature with ‘It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material’. References A new disease has developed in recent years. It is called the ‘MEDLINE syndrome’. Those affected regurgitate vast, unselected lists of references, which proves nothing except that they have have access to computer databases. This breaks one of the fundamental laws of referencing (which I suspect is more honoured in the breach than the observance) that you should never quote a paper unless you have read the original or a photocopy of it. A reasonable number of references for a letter is up to three, for a case report or surgical technique up to 10, and for an original paper up to 25. They should be typed in double line spacing, in the style specified by the journal, and with a consistent layout. Give your typist an up-to-date copy of the journal and invite her to follow style slavishly. Tables Tables must not repeat results described in the text. Each one must be accompanied by a caption that stands on its own. It should not be necessary to refer to the text to understand the table, so abbreviations should be avoided or explained. The table must disclose whole numbers (with or without percentages) and, like everything else in the paper, must be typed in double line spacing, even if this means that a table takes up more than one sheet of typewritten manuscript. It is best not to rule any lines at all, and tabulated data should never be presented in boxes. Diagrams
Discussion (What does it mean anyway?) A young registrar once told me that the best piece of advice his chief had given him before an operation was ‘Think of the worst thing you can do, and avoid it’. The worst thing a writer can do is draw unwarranted conclusions from limited data and write a biased discussion. So, discuss only what you found. Put your work in context, and remember to mention the views of those who disagree as well as those who agree with you. If possible, suggest why their conclusions differ. Avoid
Diagrams should be used only if it is not possible to show the data in any other way. Captions to artwork should be typed on a separate sheet of paper. Make sure that relevant numbers are clearly shown. Minimize what TufteZ3 called the ‘non-data ink’ (lines or shading that do not actually express data, such as background hatching). Use histograms sparingly, as it is often difficult to calculate the precise numbers studied, and never, under any circumstances, use three-dimensional histograms (though these may make perfectly good slides).24
164 British
Journal
of Oral and Maxillofacial
Surgery
Line drawings and photographs These must be professionally prepared. Points of interest should be clearly marked with contrasting arrows, and extraneous detail removed. Photomicrographs should contain an internal scale or the original magnification given in the caption; the stain must be mentioned. Photographs of specimens should include a centimetre rule. Those of patients should be accompanied by their signed consent to publication. If you use artwork that has been published elsewhere, it is essential that you obtain permission from the copyright holder (usually the publisher).
CONCLUSION There are people who are naturally good at writing and those who are not. But comfort yourself with the thought that even the best writers find it hard work, and revise their papers time and time again. The frisson that you get when you open a letter of acceptance, and the sense of achievement when you see your paper in print, make it all worthwhile. Acknowledgement I thank Alan Pollock, who smoothed out my infelicities and made me tight for every word. References 1. Lock SP. How editors survive. BMJ 1976; iii: 1118-l 119. 2. Day RA. How to write and publish a scientific paper, 3rd edn. Cambridge: Cambridge University Press, 1991. 3. Hall GM, ed. How to write a paper. London: BMJ 1994. 4. Strunk W Jr, White EB. The elements of style, 3rd edn. New York: Macmillan, 1979. 5. Huth EJ. How to write and publish papers in the medical sciences,2nd edn. Baltimore: Williams & Wilkins, 1990. 6. Bryson B. Penguin dictionary of troublesome words, 2nd edn. London: Penguin, 1987. 7. Parris M. I couldn’t possibly comment . Sketches and follies from the Commons again. London: Robson Books, 1997: 61.
APPENDIX:
8. Layton PR. Grammar from a one-sided view. The Times 1989; June 26: 10, co1 3. 9. Evans M. Style and substance: maintaining a balance. Eur J Surg 1992; 158: 336. 10. Orwell G. Inside the whale and other essays.London: Penguin, 1957: 143-158. 11. Roberts JC, Fletcher RH, Fletcher SW. Effect of peer review and editing on the readability of articles published in Annals of Internal Medicine. JAM A 1994; 272: 1199121. 12. Hill AB. The reasons for writing. BMJ 1965; ii: 87%871. 13. Burrough-Boenisch J. Survey of EASE conference delegates sheds light on IMRAD reading strategies. European Science Editing 1998; 24: 3-5. 14. Evans M. (Editorial) Structured abstracts: rationale and construction. Eur J Surg 1993; 159: 131-132. 15. Pollock AV, Evans M. Writing a scientific paper. In: Troidl H, McKneally MF, Mulder DS,Wechsler AS; I&Peek B, Spitzer WO, eds. Surgical research. Basic principles and clinical practice, 3rd edn. New York: Springer, 1998: 111-117. 16. Evans M. Presentation of manuscripts for publication in The British Journal of Surgery. Br J Surg 1989; 76: 1311-1315. 17. Lang TA, Secic M. How to report statistics in medicine. Philadelphia, PA: American College of Physicians, 1997. 18. Altman DG, Gore SM, Gardner MJ, Pocock SJ. Statistical guidelines for contributors to medical journals. BMJ 1983; 286: 1489-1493. 19. Murray GD. Statistical aspects of research methodology. Br J Surg 1991; 78: 777-781. 20. Condon RE. Type III error. Arch Surg 1986; 121: 8777878. 21. Fleming A. On the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of B. influenzae. Br J Exper Path01 1929; 10: 226236. 22. Watson JD, Crick FHC. Molecular structure of nucleic acids. A structure for deoxyribose nucleic acid. Nature 1953; 4356: 737-738. 23. Tufte ER. The visual display of quantitative information, Cheshire, CT: Graphic Press, 1983. 24. Jolley D. The glitter of the t table. Lancet 1993; 342: 27729
The Author Mary Evans BA Consultant Technical Editor Scarborough Hospital North Yorkshire Y012 6QL, UK Tel: + 44 (0)1723-368 111, ext. 2299 Fax: + 44 (0)1723-501692 E-mail: [email protected]
ADVICE TO AUTHORS TYPE EVERYTHING IN DOUBLE LINE SPACING
Writing a letter Word count: up to 500 words References: up to 3 Form: usually a comment on an article in the
journal, but may be an account of an incident or an item of news. Writing a technical note or case report Word count: up to 1000 words References: up to 10 Form: usually accompanied by a photograph.
If this includes a face, get written permission from the patient.
Writing an original paper Word count: up to 3000 words References: up to 25 Form: Title, Summary, Introduction,
Methods, Results, Discussion. Segregate each section. Tables: must have a fully explanatory caption. Draw no lines. Charts: preferably only for life tables and scattergrams. Histograms may occasionally be used, but not three-dimensional ones. Diagrams and pho tographs: type captions on a separate sheet of paper. Get written permission from patients if they can be identified. Style: prefer active to passive voice; prefer English words to Latin; make sure that you cannot be misunderstood.
Nobody goes into a kitchen to cook a meal without knowing something about the ingredients and the recipes that they are going to cook. Indeed, most people take lessons first. Why, then, do people think that they can just sit down and write a perfect paper? Good scientific writing is just as hard as the research that it is trying to describe. It needs revising again and again; it needs criticism by someone unfamiliar with the subject; but above all it needs clarity and directness from you the author. Not only must the paper be understandable. It must be impossible to misunderstand it. One thought should dominate: I have done this work; it was expensive, difftcult, and time-consuming; but if I fail to communicate it to my peers it is worthless. Lock’ put it this way:
Many papers suffer from having strings of authors, and they all want their say. A committee cannot write a paper, however, and it is better to have one person who is in charge of the writing. Writing a paper is a humbling experience, particularly for those of us who think that they are quite good at it. It is not a comfortable feeling to have a manuscript that you thought was ready for submission returned to you by a colleague, covered in red pen, arrows, omission marks, and queries. But you must swallow your pride, and remember that those colleagues (and editors) are on your side. They recognize that you have something to say that is worth saying or they would not have given up their time to help you. They want you to get your message across in the clearest possible way. They want you to avoid jargon and ‘galumphing prose . . . interminable sentences utterly unredeemed by wit, irony or polish’.7 Prose that is ‘thuddingly prosaic” is not easy to read, and common sense tells you that what is not easy to read will probably not be read. We must never forget that language is ‘. . a precision tool, conforming to simple rules and conveying meaning logically’* and surgeons should use it as they would any other tool, be it scalpel, diathermy, or suture. There is a distinction between a technical vocabulary (and of course such a vocabulary is essential) and jargon. Jargon is useful shorthand that we use in speech every day. To try and avoid it when you are writing a paper is difficult and painful but, if you are to achieve clarity and readability. you must.” The problem is not new, and not restricted to medical writing. Orwell”’ wrote that ‘It is easier ~ even quicker, once you have the habit - to say: “In mu’ opinion it is u not unjustifiable assumption that” than to say “I think”.’ Some other examples of tortured English are given in Table 1. Another problem is the disease that you can easily catch by reading a newspaper: every noun is qualified by an adjective and every verb by an adverb. Table 2 shows some instances; in each case the word in bold type is superfluous. There is a quick and easy way to get a rough idea how readable your prose is, and that is by applying the ‘Gunning fox index’.” The formula is: 0.4 x (mean sentence length + percentage of words of more than two syllables). The score ranges from 5 (very easy), 6 (easy), 7 (fairly easy), 9 (standard English), 12 (fairly difficult), 14-16 (difficult) to 16+ (very difficult). If we aim for overall scores of 7-9, we should be writing fairly readable English. The fog index of this paragraph is 7.
The 4000 or so articles the BMJ sees every year are most dreadfully written, with numerous faults in English and overall construction. Many of these articles, of course, are published somewhere largely in their original form, because if the matter in them fulfils the other criteria the editor has not the time to translate them into decent prose, and it is the author who signs them. Unfortunately these articles are not fulfilling their purpose: they are largely being left unread because of their turgidity.
STYLE There are two main problems, neither of which is insoluble. Firstly, about 20 years ago it became fashionable in schools for teachers to concentrate on the joys of free expression instead of teaching the rules of grammar and language. There are, however, many good, useful, and cheap books that will help you.’ 6 The second problem is that many surgeons are obliged to read the sort of scientific papers that Lock referred to, together with a daily newspaper, perhaps, and some ‘airline fodder’ when on holiday. I have no doubt that to write well you must read well, and I have no hesitation in recommending the fiction of Graham Greene and the travel books of Bill Bryson, to name but two. Don’t spurn ‘light’ reading. Raymond Chandler and Dick Francis can teach scientists an awful lot about writing good English. 161
162
British
Journal
of Oral and Maxiliofacial
Surgery
Table 1 - Examples of tortured English (all of which have been taken from original manuscripts submitted for publication to various journals)
Excessive interposed adipose tissue Mobility of the leg was present In the author’s opinion On account of the fact that One out of every two Surgical procedure Exogenous nutrient elements
Fat The leg moved I think Because Half Operation Food
Table
2 - Superfluous words
action Distinct possibility Active consideration Absolute end
In actual fact Personal opinion Real danger Agonising reappraisal
Positive
Diametrically
opposed
STRUCTURE
to Authors of the journal to which you are going to submit your paper to find out what the editor wants.r4 Editors (and referees) are likely to be pleasantly disposed towards those who have obviously taken the trouble to do things their way.
Medical writers are lucky in that they have a readymade structure on which to hang their prose:
Introduction (Why did you start?)
Introduction, Material (or Patients) and Methods, Results, and Discussion, usually abbreviated as
IMRAD. Hill’* defined these as the answers to the following questions: Why did you start? What did you do? What answer did you get? and What does it mean anyway? After you have written those you must choose a title and write an abstract (or summary). I will.start with these accessories. Title A good title is essential, so that MEDLINE skimmers will be able to tell at a glance what your paper is about. Only if you are writing a review paper should the title be anything but simple and descriptive, and even then wit and double entendre should be used with care to avoid offending the sensibilities of colleagues. Abstract People do not usually read papers from beginning to end. If they are interested in a title they will skim the abstract; if this does not retain their interest, their attention will wane and they will turn the page and browse elsewhere.i3 The abstract should comprise about six short sentences: one that describes the introduction, perhaps two about the material and methods, two about the results, and one that summarizes the conclusion. It requires rigorous discipline to limit yourself in this way, but it is worth remembering that MEDLINE limits the abstracts that it prints to 250 words, so stick to the rule. There are a couple of other points to remember about the abstract. Firstly, it is likely to be the only part of the paper that many people will read (apart from the title), and, secondly, in some parts of the world doctors can afford only abstracting journals and it may be that patients are being treated on the basis of abstracts. The abstract must therefore contain facts, and those facts must be accurate. More and more journals are now specifying structured abstracts, which require additional discipline. Journals vary slightly in the headings that they like to see in a structured abstract, so do read the Instructions
The introduction to a research paper should answer the first of Hill’s four questions. State your hypothesis with, if necessary, some brief background. Do not review all the published papers on the subject. It is a common misconception that authors of research papers are required to ‘review the literature’; editors may regard this as uncritical verbosity. A carefully chosen selection of apposite references is more impressive, and its place is in the discussion, not the introduction.
Material (or Patients) and Methods (What did you do?) State what you did in the order in which you did it. Be honest about mistakes and omissions.15 Before you started your project, you will have written a protocol that describes what was to be done and by whom. That protocol should, with minor alterations, form the basis of your introduction and material and methods sections. If you used a well-known experimental method, it is enough to give a reference to a detailed description, but be sure to mention any modifications that you made, however small. Give generic as well as trade names for drugs and sutures (as formulations and even names may differ from country to country), and give the name and address of the manufacturer of any equipment that you used. Specify your statistical methods and the software package that you used to apply them. Define your terms, and avoid abbreviations. If something is so cumbersome that you have to abbreviate (for example, enzyme-linked immunosorbent assay - ELISA) always use a standard abbreviation, and always spell it out first.i6 No research involving patients should be done without the patients’ informed consent, and all research requires the approval of the ethics committee. Both should be mentioned. Results (What answer did you get?) Tabulate your results if you can. Readers have the right to see as many raw data as possible within the confines of editorial space, and columns of figures take up less space than explanatory text. There is also
Writing for publication
the possibility that a reader may draw a conclusion from your figures that is different from yours, and this will provoke controversy. Editors like controversy. Always give whole numbers in preference to percentages, and never use percentages when you are dealing with fewer than 20 observationsI Use decimal points sparingly and only for large numbers (more than 100) and P values. Beware spurious precision; biological data are seldom precise. Use statistical tests intelligently. Just because your computer can do a test does not mean that it is the correct test to do - or even that a test of significance is appropriate.17 If a result doesn’t make sense, it is probably not true, whatever the P value. It is easy to forget that ‘P = 0.05’ means that the event is likely to happen by chance once in 20 times. Be critical of analyses of small samples and consider the Type II error if appropriate. Do not use the f sign,‘* and never say that something is ‘NS’, meaning not significant. As Murray19 wrote: If one obtains a ‘non-significant’ result then one has failed to demonstrate a difference, which does not mean that one has established equivalence. A non-significant finding rather is analogous to the Scottish legal verdict of ‘not proven’, which is generally if mischievously regarded as meaning ‘not guilty, but don’t do it again.’ In other words, a non-significant finding often simply reflects a lack of evidence, rather than a lack of difference. Report normally distributed data as mean (SD), and skewed data as median (range) or (interquartile). A good rough guide as to whether data are normally distributed or not is to see whether the SD is more than half the mean. If it is, then the data are probably skewed.‘” Avoid using the SEM: give the 95% confidence interval (CI) of the mean instead.” If you are testing significance, use a parametric test for normally distributed data and a non-parametric test for skewed data. Always give units of measurement and, unless you are aiming for the North American market, always use SI (Systeme International) units (except for blood pressure which is always given as mmHg and ventilator pressures which are always given as cm HzO). Above all, make no deductions: stick to facts.
163
the Type III error (‘no data were presented to support the conclusions expressed’).2” Mention how your work might influence clinical practice and future research. Modest conclusions are always the most telling. For example, Fleming2’ concluded the description of his discovery with the words ‘Penicillin, in regard to infections with sensitive microbes, appears to have some advantages over the well-known chemical antiseptics’ and Watson and Crick2’ concluded their letter to Nature with ‘It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material’. References A new disease has developed in recent years. It is called the ‘MEDLINE syndrome’. Those affected regurgitate vast, unselected lists of references, which proves nothing except that they have have access to computer databases. This breaks one of the fundamental laws of referencing (which I suspect is more honoured in the breach than the observance) that you should never quote a paper unless you have read the original or a photocopy of it. A reasonable number of references for a letter is up to three, for a case report or surgical technique up to 10, and for an original paper up to 25. They should be typed in double line spacing, in the style specified by the journal, and with a consistent layout. Give your typist an up-to-date copy of the journal and invite her to follow style slavishly. Tables Tables must not repeat results described in the text. Each one must be accompanied by a caption that stands on its own. It should not be necessary to refer to the text to understand the table, so abbreviations should be avoided or explained. The table must disclose whole numbers (with or without percentages) and, like everything else in the paper, must be typed in double line spacing, even if this means that a table takes up more than one sheet of typewritten manuscript. It is best not to rule any lines at all, and tabulated data should never be presented in boxes. Diagrams
Discussion (What does it mean anyway?) A young registrar once told me that the best piece of advice his chief had given him before an operation was ‘Think of the worst thing you can do, and avoid it’. The worst thing a writer can do is draw unwarranted conclusions from limited data and write a biased discussion. So, discuss only what you found. Put your work in context, and remember to mention the views of those who disagree as well as those who agree with you. If possible, suggest why their conclusions differ. Avoid
Diagrams should be used only if it is not possible to show the data in any other way. Captions to artwork should be typed on a separate sheet of paper. Make sure that relevant numbers are clearly shown. Minimize what TufteZ3 called the ‘non-data ink’ (lines or shading that do not actually express data, such as background hatching). Use histograms sparingly, as it is often difficult to calculate the precise numbers studied, and never, under any circumstances, use three-dimensional histograms (though these may make perfectly good slides).24
164 British
Journal
of Oral and Maxillofacial
Surgery
Line drawings and photographs These must be professionally prepared. Points of interest should be clearly marked with contrasting arrows, and extraneous detail removed. Photomicrographs should contain an internal scale or the original magnification given in the caption; the stain must be mentioned. Photographs of specimens should include a centimetre rule. Those of patients should be accompanied by their signed consent to publication. If you use artwork that has been published elsewhere, it is essential that you obtain permission from the copyright holder (usually the publisher).
CONCLUSION There are people who are naturally good at writing and those who are not. But comfort yourself with the thought that even the best writers find it hard work, and revise their papers time and time again. The frisson that you get when you open a letter of acceptance, and the sense of achievement when you see your paper in print, make it all worthwhile. Acknowledgement I thank Alan Pollock, who smoothed out my infelicities and made me tight for every word. References 1. Lock SP. How editors survive. BMJ 1976; iii: 1118-l 119. 2. Day RA. How to write and publish a scientific paper, 3rd edn. Cambridge: Cambridge University Press, 1991. 3. Hall GM, ed. How to write a paper. London: BMJ 1994. 4. Strunk W Jr, White EB. The elements of style, 3rd edn. New York: Macmillan, 1979. 5. Huth EJ. How to write and publish papers in the medical sciences,2nd edn. Baltimore: Williams & Wilkins, 1990. 6. Bryson B. Penguin dictionary of troublesome words, 2nd edn. London: Penguin, 1987. 7. Parris M. I couldn’t possibly comment . Sketches and follies from the Commons again. London: Robson Books, 1997: 61.
APPENDIX:
8. Layton PR. Grammar from a one-sided view. The Times 1989; June 26: 10, co1 3. 9. Evans M. Style and substance: maintaining a balance. Eur J Surg 1992; 158: 336. 10. Orwell G. Inside the whale and other essays.London: Penguin, 1957: 143-158. 11. Roberts JC, Fletcher RH, Fletcher SW. Effect of peer review and editing on the readability of articles published in Annals of Internal Medicine. JAM A 1994; 272: 1199121. 12. Hill AB. The reasons for writing. BMJ 1965; ii: 87%871. 13. Burrough-Boenisch J. Survey of EASE conference delegates sheds light on IMRAD reading strategies. European Science Editing 1998; 24: 3-5. 14. Evans M. (Editorial) Structured abstracts: rationale and construction. Eur J Surg 1993; 159: 131-132. 15. Pollock AV, Evans M. Writing a scientific paper. In: Troidl H, McKneally MF, Mulder DS,Wechsler AS; I&Peek B, Spitzer WO, eds. Surgical research. Basic principles and clinical practice, 3rd edn. New York: Springer, 1998: 111-117. 16. Evans M. Presentation of manuscripts for publication in The British Journal of Surgery. Br J Surg 1989; 76: 1311-1315. 17. Lang TA, Secic M. How to report statistics in medicine. Philadelphia, PA: American College of Physicians, 1997. 18. Altman DG, Gore SM, Gardner MJ, Pocock SJ. Statistical guidelines for contributors to medical journals. BMJ 1983; 286: 1489-1493. 19. Murray GD. Statistical aspects of research methodology. Br J Surg 1991; 78: 777-781. 20. Condon RE. Type III error. Arch Surg 1986; 121: 8777878. 21. Fleming A. On the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of B. influenzae. Br J Exper Path01 1929; 10: 226236. 22. Watson JD, Crick FHC. Molecular structure of nucleic acids. A structure for deoxyribose nucleic acid. Nature 1953; 4356: 737-738. 23. Tufte ER. The visual display of quantitative information, Cheshire, CT: Graphic Press, 1983. 24. Jolley D. The glitter of the t table. Lancet 1993; 342: 27729
The Author Mary Evans BA Consultant Technical Editor Scarborough Hospital North Yorkshire Y012 6QL, UK Tel: + 44 (0)1723-368 111, ext. 2299 Fax: + 44 (0)1723-501692 E-mail: [email protected]
ADVICE TO AUTHORS TYPE EVERYTHING IN DOUBLE LINE SPACING
Writing a letter Word count: up to 500 words References: up to 3 Form: usually a comment on an article in the
journal, but may be an account of an incident or an item of news. Writing a technical note or case report Word count: up to 1000 words References: up to 10 Form: usually accompanied by a photograph.
If this includes a face, get written permission from the patient.
Writing an original paper Word count: up to 3000 words References: up to 25 Form: Title, Summary, Introduction,
Methods, Results, Discussion. Segregate each section. Tables: must have a fully explanatory caption. Draw no lines. Charts: preferably only for life tables and scattergrams. Histograms may occasionally be used, but not three-dimensional ones. Diagrams and pho tographs: type captions on a separate sheet of paper. Get written permission from patients if they can be identified. Style: prefer active to passive voice; prefer English words to Latin; make sure that you cannot be misunderstood.