Writing (a paper)

I failed use of English at school (passed on second attempt), yet I now edit a journal and write extensively. Writing is a skill that needs learning, and it is not (for most people) a naturally present ability. Like everything in rehabilitation (and in life), with effort and practice you may improve. But, like car drivers who all assume they have above-average driving abilities, many people assume they can write well. My experience as an editor (and as a reader of many work-related documents) is that most people write badly.

This section of the website is not an academic treatise on writing. Instead it highlights some of the major weakness in writing that strike me when reading. I have the advantage of being taught well when about 21 years old, learning from being given excellent (but quite strong) feedback, with advice. My first article, for a newspaper had every word, sentence and paragraph changed by my teacher! I will feedback what I find to be the common problems in papers submitted to Clinical Rehabilitation, and in other documents I read.

The most important single piece of advice is to think of your reader. At all times consider the person who will be reading what you produce. This includes, obviously, the actual content but, when submitting a paper, it also includes other matters such as layout, font size, line spacing, clarity of figures and tables, removing a tracked changes and comments, etc. Questions to ask yourself are:

  • who will be reading this? Ans. Usually a wide variety of people.
  • what will they be looking for? Ans. Often quite different things.
  • will they find what they want easily? Ans. Structure everything logically so they can.
  • does my paper have a clear, unifying main message? Ans. Keep to the point; your article is not a nineteenth century Russian novel.

There are several ways to emulate the reader:

  • ask a friend or colleague unfamiliar with the research or the content of the article to read it and give feedback. They will represent the reader.
  • read the paper out aloud to yourself. You will soon pick up mistakes, and poor writing. (I picked this up from Twitter.)
  • leave the paper completely untouched for one week before submission. Then read it anew.

Four other important general messages are given below, followed by advice on learning to write and improving your presentation of papers.

Your message; stay focused

Summary:

  • have a main message for the document, something you can encapsulate in no more than 50 words
  • ensure that everything you write relates to that key, thematic message.

At every point, you must consider your message. What is this sentence, paragraph, section or page, and whole document saying? Is what it is saying relevant to the larger message? A document is like a story, a sequence of ideas communicated by you to the reader. Does this sentence carry within it the idea I wish to transfer?

One advantage of writing on a computer screen is that you can only see a limited part of the document. When you come back to read it and edit it, ask yourself if you know what the sentence or paragraph is saying without going back to discover.

The most important message, when writing any single document, is to consider the message that the whole document is giving. This forms your theme, and everything within the document must relate to the overall message. If it does not, remove it. Otherwise it will confuse the reader.

Taking a standard Introduction, Methods, Results, Discussion format for a scientific paper, the message for each part is given for you. Stick to it. The introduction is not the place to discuss or give anything to do with your method, or results. At most, as in many stories, you may hint at something to be expanded on later, but it is only a tantalising hint to maintain the reader’s interest.

To help yourself, imagine that your paper has hit the headlines (none of mine ever have!), and you are on national television. You have probably 60 seconds. The interviewer asks, “What is your paper on XXX about?“. In two sentences, you need to say whatever you think is the most important message the paper has. No more. The audience switch off after two sentences.


Structure, structure, …; build in a map

Summary:

  • The reader needs to know where she is, where she has been, and where she is going, at all times.
  • Structure gives the reader a mental map, so they feel confident and can find something they need quickly.

Writing has structure. Letters are formed into words, carrying meaning. Words are formed into sentences, structured (sometimes!) by the rules of grammar, sentences are grouped into paragraphs, and so on. Each level of the structure carries a ‘meta-message’: this word means …. ; this sentence means ….; and so on.

The greatest weakness of most authors is an inability to use paragraphs to provide a structural framework, coupled with an inability to structure a a group of paragraphs. For example a single paragraph in the methods section of a paper might contain, in this order, sentences about: random allocation of patients; recruitment of patients; collecting baseline data; the treatments given; blinding (masking) of the people collecting data; ending with a sentence about trial registration. (this example is real)

This weakness is exacerbated by a tendency to use subheadings, in attempt to give structure. Often the subheading contain material unrelated to the heading. Sometimes the heading is followed by one very long paragraph. The subheadings are rarely in a logical order. They force people to put items in an illogical place. Subheadings should be like chapters in a book, indicating a fresh start on something different.

Any section covering more than one topic must have a logical framework, both to assist the author, and to help the reader. It ensures that the author covers all necessary topics, assuming the framework is complete; it ensures the reader can quickly find what she wants.

In the introduction section the structure usually covers: the problem being addressed; summary of what is known; identification of a gap; how this study will fill that gap. In the method section of most clinical papers, the most obvious framework follows a patient over time: how will or did a patient enter, flow through, and leave the project. In the results section a different logical structure is needed. In most clinical papers it will be: patient flow in numbers, baseline data, important outcome data, secondary data, other data or analyses. The discussion section is fluid, and requires the author to take an overview and consider their message. One general structure is: overview of results; placing results in a wider context; considering limitations and cautions; what are the implications.

No abbreviations or jargon; write clearly

Summary:

  • all abbreviations and all jargon reduces readability and risks serious misunderstanding
  • articles are judged on standard of writing, and clarity, not on word count

One day, at a hospital executive board meeting, the conversation about a paper had been progressing for about five minutes when I asked what an abbreviation (acronym), which was reasonably central to the paper, stood for. No-one knew! But no-one else had been prepared to ask. And the authors of the document must have presumed that everyone would know, as there was no explanation.

Abbreviations hinder understanding and readability. See here, here, and here. Do not use them. The only exceptions I allow in clinical research papers are for common statistical measures and processes. The excuses given by authors include:

  • abbreviations save space (probably untrue, and anyway clear writing will save more space)
  • everyone knows what it means (rarely true)
  • it makes reading quicker (certainly untrue)
  • other journals use them (when was following the crowd ever proof of being correct?)
  • a paper you published in 2018 had them (probably true; some authors just do not read my requests and I give up!).

Jargon is more insidious. Jargon is a form of exclusive, in-house language that serves as much to exclude others as it does to improve communication. Who ever talks about their ‘upper limb’ except when acting as a professional? Or who says, “my lower limb hurts”? In rehabilitation, articles will be read by many different professions and, sometimes, by people outside healthcare, so it is particularly important to use plain words, and to explain any unusual words.

Instead, write clear prose. Avoid over-complicated sentences. Keep it short, and never use three words when one will suffice. If you are uncertain whether something is necessary, remove it. Remember, “If anything at all, perfection is finally attained not when there is no longer anything to add, but when there is no longer anything to take away”. Antoine de Saint-Exupery. (Thank you, Dr James Cauraugh.)

Have respect; take care

Summary:

  • present your paper carefully, to avoid a reputation for a slapdash approach
  • read journal guidance and read journal articles to learn how papers are expected to look in the chosen journal.

When submitting a scientific article for publication, you should show respect for the editor and reviewers. Start by addressing any letter to the editor of the journal you are submitting to (many authors write to another journal). Continue by ensuring that your submitted article is well written, well presented, follows journal guidance on layout etc, and is free of obvious errors.

Photo by Ben Mack on Pexels.com

Some journals employ (I assume) someone to check all this before the editor sees an article. Most do not. It shows a lack of respect to present an article which does not adhere to the journal’s guidance and, as an editor, I am very wary of authors who submit papers full of obvious errors. If the author cannot be bothered to check the quality and accuracy of the submitted article, why should I trust the validity of their reported methods and results? At the end of the submission process there is always a chance to review and check the whole paper. Use it.

Even more importantly, the review process does not and cannot check for errors, mistakes (or fraud) and the authors, all the authors, have complete responsibility for everything written and presented. It behoves anyone who is named as an authors to satisfy him- or herself that the paper is of high quality and accurate. Clinical Rehabilitation enables editors to attach flags and accompanying notes to any submitting author. Beware.

Learn to write:
Practice, practice, practice
And read, read, read

Writing well is important. The pen, or now the word-processor, is indeed mightier than the sword. People will die willingly to defend or promulgate an idea, and ideas ultimately, comes from someone’s writing. Moreover, whoever writes the history of events determines future perception of what happened, and future decisions and actions. ‘Fake News’ is more convincing if accompanied by an image of a printed newspaper or document.

More prosaically, whoever writes the minutes of a meeting often determines what people believe was said and decided. I discovered this as a junior psychiatrist, where junior doctors were responsible for giving electroconvulsive therapy (ECT). As chair of the junior committee, I wrote a meeting minute that we required a policy to ensure patient safety. In reality we had only discussed the matter vaguely, but I wrote something rather more definitive. It became policy, because “it had been agreed at a committee meeting”!

It distresses me that most people seem unable to write. Learning to write well does not appear to be part of learning about research. Yet, researchers depend upon writing applications to obtain grants. A researcher’s status and progression both, ultimately, depend upon publications, and these have to be written. Only a small proportion of grant applications succeed, and only a small proportion of papers submitted to higher impact journals are accepted. Writing well will greatly improve the chances of success in both spheres. As a reviewer, I judge that someone who can write clearly can also think clearly, and that poor writing may indicate poor research skills.

Learning requires hard work. As in every other matter, practice improves ability. Practice is much more effective when the person receives feedback on performance. Failure to gain a grant or have a paper accepted is not effective feedback: there is a long delay, and the connection between quality of writing and feedback is weak because there are many other reasons for failure. Poor writing will rarely be given as a reason, even though it may be the primary reason. Effective feedback needs to be timely, to point out where improvements are needed, and why, and then to suggest ways to improve, with explanations.

There are other ways to learn, some quite enjoyable. When reading a book, article, or other document, consider how easy it is to read and understand, and how much it attracts and maintains your attention. Then analyse what it is that helps. There are also websites. For example, the Equator Network (a good general resource) has a specific section on writing for publication. Another site is Good Reports.

Further advice can be seen in this graphic, and is given this document I have written based on 20 years of editing and reading very bad submissions (here). Another article is also available here.

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