Getting Getting Published Published in High‐Prof

Prof

Journals

Edward H. Livingston Livingston, MD, FACS, AGAF

Deputy Editor, JAMA

P f ro essor of Surgery and Biomedi l ca E i ng neerin

University of Texas Southwestern School of Medi

10/17/2012 SURGERY@utsouthwestern.edu 
Where Do You Want to Publ

Publ

• NEJM• JAMA• Lancet
Issues

• Very few surgeons surgeons routinely routinely publish publish in t

very high impact literature

• Why?

– Types of research done by surgeons– Surgeons are not well funded– Surgeons have little presence at the major

journals

– Credibility– Quality of Science
What Do the Big Journals Journals Wa

• RCTs• Meta‐analyses (rigorous)• Practice Changing Fi di n ngs

• Important Discoveries

• Citations/Impact Factor
Types of research done by surge

• Observational• Case Series• Q li ua ty/Outcomes
RCTs

• Routinely done in Medical Subspecialties (Card

Oncology, GI)

• Need more in Surgery

• More difficult difficult to design than drug trials but no

impossible

• JAMA Evidence: Users Guide to the Medical Lit

Guyatt et al.

• Ludwig DS, Ebbeling Ebbeling CB, Livingston Livingston EH. Surgica

Surgica

lifestyle treatment for type 2 diabetes. JAMA. 212;308(10):981‐2.
Meta analyses

• Must use rigorous rigorous methods methods

• Follow Guidelines (PISMA, MOOSE etc)
What Does Not Work

• Logistic Logistic Regression Regression of Administrative Administrative Da• Volume Outcome• Si l ng e Center S di tu es

• Case Series

• Retrospective Analyses

• Obvious COI



Business Business is About Relationsh

Relationsh

• So is Publishing• Get to know editors• Review papers (in depth)• Write editorials, reviews

• The big journals are always looking for

reviewers and authors

• We tend to publish who we know
Stability

• Editors Editors and staff‐15 years with JAMA• Purposeful‐prospective authors should 

who their contacts contacts are

• Work with societies to publish presente

papers

• It may not seem like it‐but we are in the

business of publishing your papers!
How Do Papers Move Through Through JA

• 6,000 MS’s received received each year• Approximately 4 major papers/week• Assi d gne to a speci l a ty contrib i ut ng edi

• Editor decides to reject/send for peer re

• 2 Content/1 Statistical Reviewer
Editorial Process

• Discuss Discuss reviewed reviewed papers at bi‐weekly e

e

meeting

• ERBR (editorial (editorial review before

revision)/Reject/Refer

• ERBR‐Repeat re‐present at editors mee

• Accept‐Contributing editor edits paper 

publication along with copy editors
e t a d C ea

Paper Structure

• Brevity and Clear Writ g in• Abstract‐

– Context: What is the clinical question?– Conclusion: Ensure it follows the data

• Introduction

– 3 Paragraphs

• Introduction to topic‐avoid a summary of what eve

already knows

• What specific aspect of the clinical problem you w

• Explicit statement of a study hypothesis
c ude co de ce te a s o o data e e 

–

Paper Structure

• Methods

– Sufficient detail so others can duplicate study

• Results

– Include confidence intervals or IQ s R for data‐never o 

n

point estimates

• Discussion

– Focused Focused

– How your findings change clinical thought

• Figure/Tables

– Visually Visually appealing appealing and simple

• References

– Complete‐make sure you find all pertinent papers‐the 

miss is always written written by (a now pissed off) reviewer reviewer
–

Common Pitfalls

• Trial registration

– Intervention trials must be registered BEFO

patients are enrolled

• Study Power

– Reference Reference prior studies studies providing providing assumpt

assumpt

about expected mean, SD etc.

Rationale Rationale for expected expected differences differences betwee

betwee

groups (MCID)
Common Pitfalls

• Study Design

– Equivalence– Superiority– Noninferior

Trial Design

• Superiority

– Minimal Detectable Difference– Minimal Minimal Clinically Clinically Important Important Difference Difference

• Equivalence/Noninferiority

– Equivalence Margin

Common Pitfalls

• Clear definition definition of Primary Primary Outcome Outcome Va

Va

• Secondary Outcomes

– Rarely adequately powered– Best if secondary analysis is included in stu

protocol protocol as an a priori analysis analysis
Study Protocol

• We will ask for original original study protocol protocol a

documents

• These must be consistent consistent with the pape

news if it is not‐and that has happened

“ethical problems”)
Statistics

• Differences Differences between between groups should be

clinically significant and important.

• Pharma studies: studies: we will ask for indepen

indepen

statistical review with publication of the

independent independent and not industry industry statistica

statistica

analysis.
Presentation

• Follow author instructions instructions‐we will rejec

that basis alone.

• If sent elsewhere elsewhere first:

– Not as much of a problem as many author– Ensure that you address pri i or reviewers cr

We may ask for the prior reviews
Statistical Matters

• Missing Data

– Missing at Random?– Dropping Dropping observations observations is suboptimal suboptimal– Random Effects Regression– M lti u ple Imputation

– Last Observation Carried Forward (LCOF)

• Can bias towards more favorable results if pat

out

– First Observation Observation Carried Carried Forward Forward (FOCF)
• Propensity

Matching
Propensity Match
Common Pitfalls

• Multiple comparisons

– Alpha penalties

• Regression Regression‐Elimination Elimination Procedures Procedures

– Order and strategy of variable entry/elimin

Common Pitfalls

terim

nalysis‐

topping

ules

Multiplelooks andtype I error

• In

A

S

R

–
Frequent JAMA Authors

• 10:1 Reject:Accept Ratio• Keep Trying

– B t u : T ka e the editors ad i v ce when rej td ec e– i.e. don’t keep resubmitting the same type 

paper that was rejected rejected previously previously

– “I need a JAMA publication to get promote
Write and Submit

• Write well‐it takes practice practice• 2nd draft = 1st draft – 10%

• Wri it ng sh ld ou be interesting to read

• Get others to review MS‐especially thos

intimately familiar with the topic‐take t

advice

• Resubmission –Address EVERY point rai

the editors and reviewers
Write and Submit

• Do not argue with peer reviewers reviewers• You can disagree‐explain why• REALLY BAD idea to argue wi ht the edit

• Don’t be afraid to contact editors direct
VA HSRD

• Thanks for having me!• Edward H. Livingston, MD, FACS, AGAF

• Deputy Editor for Clinical Content

• Journal of the American Medical Associati• 515 N. St t a e Street• Chicago, Illinois, 60654• Tel: 312‐464‐2459• Fax: 312‐464‐5824• edward.livingston@jamanetwork livingston@jamanetwork.org