Wri

tin

g t

o S

urv

ive

Tossed in at the Deep End:Tossed in at the Deep End:Writing to Survive in Writing to Survive in Academic MedicineAcademic Medicine

Yellowlees (Jane) DouglasFaculty, CTSI

Associate Professor, Center for Management Communication

Warrington College of Businessyellowleesdouglas@gmail.com

Wri

tin

g t

o S

urv

ive

Why Writing Is So Important

• Requirement for significant patient-oriented research

• Demand for publications, even as journals decrease acceptance rates (>16%), with increasing submissions from outside US (tripling over 20 years)

• Necessary as a prerequisite for extramural funding

• Extramural funding a must for promotion.

Wri

tin

g t

o S

urv

ive

How are articles published?

• Prepared according to structural requirements of the journal.

• Scanned by a senior editor for appropriateness; around half of articles rejected at this point.

• If appropriate mailed to two “experts” in the field- “peer review”.

• Task: Read the article carefully; should the article be accepted as it is; accepted with revisions; resubmitted after rewriting; or rejected.

• Senior editor reviews article with comments, and presents it to the editorial board.

• Most articles are rejected. NEJM accepts 10-15% of those sent out for review. JAMA and BMJ around the same. Regional journals up to 50%.

Wri

tin

g t

o S

urv

ive

Tackling an Article

• Consider: – What is novel or useful about your

findings?• Case reports and reviews educate

clinicians by providing novel presentations or summaries.

– What is unknown or poorly understood?• What data already exists?• What data can you collect inexpensively,

without extra- or intramural funding?

Wri

tin

g t

o S

urv

ive

Consider Collaboration

• Approach your mentor or faculty in other disciplines to collaborate on studies that involve GI/hepatology patients.

• For example,– ESLD has broad impacts outside

hepatology, particularly on QoL– Gastroparesis may be co-morbid

with endocrine, ob-gyn or rheumatology disorders.

Wri

tin

g t

o S

urv

ive

Identifying journals….

• Where are other articles addressing your topic published?

• Who is your audience? • Is it research? If so, are you sure you

recognize limitations that could change where it is submitted?

• If your assignment is primarily clinical and you lack funding, consider retrospective data analysis, reviews, and case reports.

Wri

tin

g t

o S

urv

ive

Online Journals: Case Reports

• Grand Rounds• Journal of Medical Case

Reports• Case Reports in Medicine• Cases Journal• BMJ Case Reports• Radiology Case Reports• Journal of Surgical Case

Reports

Wri

tin

g t

o S

urv

ive

Consider Impact Factors• Submit to the journal with the highest impact

factor first.• Impact factor = # of times articles were cited in

indexed journals during a year/# of articles published in a journal.

• Impact factors: • NEJM – 53.4• Nature - 36• Lancet – 33.6• Cell – 32• Science - 31• JAMA – 30• BMJ – 13• Am J Med - 5

Wri

tin

g t

o S

urv

ive

Classic organizational structure

*FIRST: Read the Instructions for Authors very carefully*

• Abstract: structured vs. non-structured

• IMRAD

– Introduction- why did I do it? Why was it needed? Brief

synopsis of what’s gone before—and how your study

redresses existing oversights or omissions. Shows the

importance of the study…but keep it under 4

paragraphs.

– Methods-what did I do? Most important! Describe

subjects, selection and exclusions, statistical methods,

ethical issues.

Wri

tin

g t

o S

urv

ive

Structure

– Results- what did I find?• Basic descriptive data• Emphasis on relevance• Text=story, tables=evidence, figures=highlights• Use CI’s, not just p values• Clinical significance: NNT, absolute and relative risk

reduction

– Discussion- What does it mean? Or “So what?”• Principal findings• Strengths and weaknesses in comparison to other

studies (especially limitations);• Results in context of policy or change in practice;• What’s next?

Wri

tin

g t

o S

urv

ive

Important details

• Title (include design if possible)

• Abstract

• Minimize references; essential only

• Cover letter…short and to the point

• Authorship- consider carefully, read

guidelines

• Acknowledgments, competing interests

Wri

tin

g t

o S

urv

ive

Common errors in journal submission

• Wrong format or length (READ THE INSTRUCTIONS)

• Excessively long introduction• Inadequate methods section• Clear identification of primary outcome measure• Tables and figures that are confusing and do

not stand alone• Irrelevant material in the results that should be

irrelevant in the discussion• Making conclusions that are not borne out by

the data in the abstract or discussion• Limitations• Case series

Wri

tin

g t

o S

urv

ive

Potential reviewer objections

• Almost all articles require revision “We are sorry….”

• Read the letter very carefully for suggestions by the editor; they are more important than what the reviewers said

• If rejected, most journals allow an appeal, but justification is needed along with revision

• If you disagree with a reviewer’s comments regarding content, style or structure, say so gently

Wri

tin

g t

o S

urv

ive

Nuts and Bolts: Writing Well

• Writing well increases the odds of your getting published.

• Once you tackle the challenges of experimental design, data analysis, and anticipating your reviewers’ objections, proceed with writing carefully.

• Note the caveats and principles that follow as you write.

Wri

tin

g t

o S

urv

ive

General Challenges to Readers

• LexicalLexical– Unfamiliar words or words with multiple

meanings slow processing and inhibit accurate recall (Zwann, 1996; Just et. al., 2004)

– Familiarity or constraint = readers proceed directly to identifying and fixing word meaning

– Meaning and syntax may be interdependent

• The rebel [noun] rebels [verb] by giving a rebel [adjective] yell.

Wri

tin

g t

o S

urv

ive

General Challenges to Readers

SyntacticSyntactic– Anticipate how sentence will play out– Readers rely on deeply embedded syntactic

preferences (Ferreira and Clifton, 1986; Britt, Perfetti, Garrod and Rayner, 1992; McWhorter, 2001).

– Atypical syntax slows down reading, with increases in cortical activity until readers identify syntactic pattern (Hagoort, Brown & Groothusen, 1993). • Conventional syntax is better: S-V-O• Left-branching/heavy NP are worst (Parker &

Riley, 2005)• Whether suppressed mRNA translation due to hypoxia is

exaggerated in hypoxic aged muscle is currently unknown.

Wri

tin

g t

o S

urv

ive

General Challenges to Readers

• SyntacticSyntactic– But…– Even with conventional S-V-O,

length and complexity slow down reading and increase cortical activity (Just, Carpenter, Keller, Eddy, and Thulborn, 1996).

Wri

tin

g t

o S

urv

ive

General Challenges to Readers

• SyntacticSyntactic– Active construction is easier than

passive– Passive construction obscures agency– Passives require semantic roles

assigned in atypical order: object of action before subject

– Subjects recalled implausible passive sentences as plausible 25% of the time, relying on semantic/schematic heuristic, not syntactic algorithms (Ferrerira & Stacey, 2000)

Wri

tin

g t

o S

urv

ive

General Challenges to Readers

• SyntacticSyntactic– Comprehension is based on prediction.

– Significant slowing of reading speed and degradation of recall when grammatical subjects > 7 words after beginning of sentence (Keller, Carpenter, Just, 2001).

– Readers handle complexity better after achieving predication (Ferstl, d’Arcais, 1999).

– Readers have poorest recall of material in the middles of sentences (McWhorter, 2001).

»Absent primacy/recency effects.

Wri

tin

g t

o S

urv

ive

For Example…

• Outflow obstruction from neurogenic sphincter disturbance, chronic bladder infection, direct mechanical trauma from an indwelling catheter, and potentiation of infection by corticotrophin may all play a part.

• –Cases Journal, 2008

Wri

tin

g t

o S

urv

ive

For Example…

• Outflow obstruction from neurogenic sphincter disturbance, chronic bladder infection, direct mechanical trauma from an indwelling catheter, and potentiation of infection by corticotrophin may all play a part.

• –Cases Journal, 2008

• Too much complexity in the grammatical subject can inhibit identification of verb.

Wri

tin

g t

o S

urv

ive

For Example…

• The variations in the microscopic sizes, numbers and states of polarization of neurons, the distances and velocities of communication, and the strengths of mutual excitation and mutual inhibition relative to negative feedback strength all contribute to the breadth of distributions and variations in the center frequencies of the mesoscopic oscillations. At rest the cortical dynamics tends to symmetry, in which the three types of feedback (negative, mutual excitation, mutual inhibition) are balanced, giving the power-law PSD observed in resting ECoG that contains power at all frequencies in a spectral continuum (Freeman 1975).

• –Cognitive Neurodynamics, 2009

Wri

tin

g t

o S

urv

ive

For Example…

• The variations in the microscopic sizes, numbers and states of polarization of neurons, the distances and velocities of communication, and the strengths of mutual excitation and mutual inhibition relative to negative feedback strength all contribute to the breadth of distributions and variations in the center frequencies of the mesoscopic oscillations. At rest the cortical dynamics tends to symmetry, in which the three types of feedback (negative, mutual excitation, mutual inhibition) are balanced, giving the power-law PSD observed in resting ECoG that contains power at all frequencies in a spectral continuum (Freeman 1975).

• –Cognitive Neurodynamics, 2009

Wri

tin

g t

o S

urv

ive

Challenges and Remedies

ChallengeLexical

Syntactic

Inference-building

Remedy

Clarity

Continuity

Coherence

Wri

tin

g t

o S

urv

ive

Guiding the Reader: Clarity

1. Prefer active construction to passive.

2. Place grammatical subjects as close to beginnings of sentences as possible.

3. Place verbs close to subjects. Introduce syntactic complexity after the verb.

Wri

tin

g t

o S

urv

ive

Guiding the Reader: Clarity

4. Prefer S-V-O order. 5. Avoid there is/there are and

other expletive constructions that invert S-V-O order.

6. Pronouns may require readers to verify antecedents, slowing down reading: avoid using them as subjects.

Wri

tin

g t

o S

urv

ive

General Challenges to Readers

• Inference-building within sentences– Schemas resolve syntactic and lexical

ambiguity• Information wants to be free

– Confirm initial identifications of words and meanings against LT memory

– Rely on 5 categories to turn sentences into scenarios: time, space, actor, cause, and intention (Zwaan et al., 1995)

Wri

tin

g t

o S

urv

ive

General Challenges to Readers

• Inference-building between sentences– Schemas may extend across sentences– More easily activated if sentences

conform to iconicity assumption (Zwann et al., 1995)

– Implicit or explicit causation speeds reading times (Brown & Fish, 1983)

– Verbs that concretely attribute causality to an explicit agent speed times further (Green & McKoon, 1995)

Wri

tin

g t

o S

urv

ive

General Challenges to Readers

• Inference-building across sentences:– Best if close fit between syntactic representation and

chronological order of events– Explicit connections between elements in time, space,

causation, or intention speed reading times (Zwann, 1996)

– Referential continuity trims reading times (Garnham, Oakhill, and Johnson-Laird, 1982)

– Priming effects: repetition of key words in paragraph makes schemas easily accessible (Kintsch, 1992; Perfetti, 1999)

– Primacy and recency effects may help link together content across sentences (Huang, 1986)

Wri

tin

g t

o S

urv

ive

Guiding the Reader: Continuity

1. Link content from the end of a sentence to the content at the beginning of the next sentence to form a tight sequence.

2. Use transitions, particularly indicating relationships in time/space/causation/intention.

3. Use common grammatical subjects throughout paragraphs to trigger schemas.

Wri

tin

g t

o S

urv

ive

Challenges to Readers

• Thiazides achieve their diuretic action via inhibition of the Na+Cl- cotransporter (NCC) in the rental distal convoluted tubule. The NCC facilitates absorption of sodium from the distal tubules back to the interstitium and accounts for about 7% of total sodium reabsorption. By decreasing sodium reabsorption, thiazides cause an increase in fluid loss to urine, which leads to decreased extracellular fluid (ECF) and plasma volume. This volume results in diminished venous return, increases in renin release, reduced cardiac output, and decreased blood pressure. Acutely, the decrease in cardiac output increases total peripheral resistance (TPR), which stems mostly from activation of the sympathetic nervous system (SNS) and renin-angiotensin aldosterone system (RAAS).

Wri

tin

g t

o S

urv

ive

Challenges to Readers

• Thiazides achieve their diuretic action via inhibition of the Na+Cl- cotransporter (NCC) in the rental distal convoluted tubule. The NCC facilitates absorption of sodium from the distal tubules back to the interstitium and accounts for about 7% of total sodium reabsorption. By decreasing sodium reabsorption, thiazides cause an increase in fluid loss to urine, which leads to decreased extracellular fluid (ECF) and plasma volume. This volume results in diminished venous return, increases in renin release, reduced cardiac output, and decreased blood pressure. Acutely, the decrease in cardiac output increases total peripheral resistance (TPR), which stems mostly from activation of the sympathetic nervous system (SNS) and renin-angiotensin aldosterone system (RAAS).

Wri

tin

g t

o S

urv

ive

General Challenges to Readers

• Inference-building across sentences:– Schemas easier to access if

information is front-loaded– Priming: key themes/content at

outset of paragraph speeds processing and improves recall (Wagner, Stebbins, Masciari, Flesichman & Gabrieli, 1998; Vernon & Usher, 2003)

Wri

tin

g t

o S

urv

ive

Challenges to Readers• Upper extremity motor dysfunction after stroke

leads to enormous functional disability, which affects quality of life and normal daily living activities like feeding, dressing, and holding delicate objects. To accomplish these upper extremity functions, skill hand movements are required. Loss of hand function accounts for about 90% loss of upper extremity function. Hand recovery after stroke often plateaus in about one year and usually upper arm functions are better than hand function after stroke. Moreover, the hand performs many functions essential to daily activities, including touching, writing, and grasping and manipulating objects.

Wri

tin

g t

o S

urv

ive

Challenges to Readers• Upper extremity motor dysfunction after

stroke leads to enormous functional disability, which affects quality of life and normal daily living activities like feeding, dressing, and holding delicate objects. To accomplish these upper extremity functions, skill hand movements are required. Loss of hand function accounts for about 90% loss of upper extremity function. Hand recovery after stroke often plateaus in about one year and usually upper arm functions are better than hand function after stroke. Moreover, the hand performs many functions essential to daily activities, including touching, writing, and grasping and manipulating objects.

Wri

tin

g t

o S

urv

ive

Guiding the Reader: Coherence

• Documents read most clearly when they contain:– A thesis/hypothesis sentence

that contains the document’s main idea in a telegraphic form.

– Paragraphs organized into issue/discussion/resolution format.

Wri

tin

g t

o S

urv

ive

Guiding the Reader: Coherence

• You should always know when to break your paragraphs because:– A well-written paragraph always contains several

head sentences that introduce the paragraphs primary focus and main points. Head sentences may run from 1-6 sentences, but should occupy no more than 1/3 of the paragraph’s length.

– Your body delivers on the promises sketched out in the issue, developing the main points with description, analysis, examples, or evidence.

– Your resolution or foot sums up the primary conclusions of the paragraph and anticipates the content of the next paragraph’s issue.

Wri

tin

g t

o S

urv

ive

Accumulating evidence indicates that insulin resistance is associated with enhancement of vasomotor and cardiac sympathetic drive and increases in pro-inflammatory status 8. This evidence has led to the proposal that hypothalamic inflammation could be responsible for increased sympathetic drive and associated insulin resistance 9,10. In this model, sympathetic tone, autonomic activity, satiety, and metabolic and fluid homeostasis are all regulated by various hypothalamic nuclei 11. Moreover, animal experiments have demonstrated that hypothalamic inflammation plays an important role in insulin resistance12. …. 14. Furthermore, administration of pro-inflammatory cytokines, such as IL-4, exacerbates weight gain 15. Studies have suggested that peripheral inflammatory responses initiate a cascade of events that lead to increases in activated microglial cells in the metabolic-relevant brain centers, including the hypothalamus 16. Collectively, these observations indicate that an antiflammatory therapeutic strategy targeting central inflammation may be effective. We decided to test this concept with the use of minocycline, a well-tolerated anti-inflammatory agent, in nine patients with obesity, insulin resistance, and Type 2 diabetes. As an anti-inflammatory agent, minocycline freely crosses the blood-brain barrier, is neuro-protective and inhibits microglial activation in the brain. Minocycline also produces beneficial effects in acute and chronic brain disorders, including stroke, traumatic brain injury, and neurodegenerative diseases 17-20.

Wri

tin

g t

o S

urv

ive

Your Best Bet: Use Gambits

• Gambits are opening moves that yield specific results

• Writing gambits = paradoxical statements that excite attention

• Attention heightens both focus and memorability

• Increase the odds of funding or publication• Frontload these paradoxes to create a writing

gambit• Gambits also provide clear focus for organizing

your research• If at a loss to start, try to see if any conventional

gambits resonate with your research.

Wri

tin

g t

o S

urv

ive

Your Best Bet: Use Gambits

Conventional gambits:– New developments in detection, diagnosis, treatment of a condition– Mapping causal relationships between two states previously

considered unrelated– Discoveries that redress shortcomings of established methodology

previously thought as immutable– Inverse relationship between magnitude of a problem and paucity of

research or insight into it– Substantial costs attached to a problem versus dearth of methods to

redress it– Relationship between increase in focus/studies/interventions in a

problem and increased problems associated with it– Contrast between apparent simplicity of a problem and its complex

structure– Highlighting disparity between initial understanding of an issue and

the light shed by subsequent research or your study– Acknowledged importance of a problem and dearth of available

methods or strategies to redress it– Implications of an approach and results that differed significantly from

anticipated outcomes.

Wri

tin

g t

o S

urv

ive

Submitting Manuscripts

• Compose your cover letter carefully, targeting the article’s contents to the journal’s audience, aims and scope.• Also mention your qualifications and your

collaborators’ for writing this study.

• Identify potential reviewers carefully.• Enlist mentors, ask your mentors for

suggestions, or direct the ms to scholars whose work(s) you’ve cited.

Wri

tin

g t

o S

urv

ive

Questions?

• Or objections?• Or a bloody good argument?