You are on page 1of 4

How to Write a Clinical Problem Solving Manuscript: step-by-step guide

Gurpreet Dhaliwal MD
January 1, 2015

Characteristics of a suitable case for publication (TEACH)*

Teaching points can be made
Enigma - the answer cannot be obvious
Answer must be definitely known by a gold standard test
Cool and interesting case - readers should say "wow" at the end
Honest - cannot change facts

*Sanjay Saint, MD, MPH

Planning stage

1. Don’t invite any co-authors. You will need co-authors eventually, but after 1-2 people are
involved, there just isn’t enough work to go around early on. Everyone wants to be a co-author,
but fewer want to (or can) do the work. A useful rule of thumb: the likelihood of completion is
inversely related to the number of early authors. [See authorship guide below.]

2. Find a faculty member who has co-authored a clinical problem solving (CPS) case for guidance.
This person will often become an active collaborator and co-author, but neither is assumed up
front. This person is rarely the faculty member on the primary team or the consulting service,
because who you are in search of is someone who understands the process of writing the case,
not the case itself.

3. Be certain that you want to share your case in the clinical problem solving format (as published
in NEJM, JHM, or JGIM). It usually takes more than a year from start to finish. Case reports and
clinical images manuscripts take less time to write.

4. Has this case been published anywhere?

a. Oral or poster presentation at a medical conference – that’s OK; you’ll note that in the
acknowledgment section.
b. A medical conference proceedings abstract is generally OK.
c. If the case has been disseminated in any other way by you or another clinician (internet,
another language), it is difficult to publish as a CPS manuscript because you risk
duplicate publication.

5. Collect images (e.g., skin, surgery, radiology, pathology, EKG) that you may want to publish or
can anticipate a reviewer or editor asking for later. The manuscript is substantially enhanced by
including 1 or 2 images. Sometimes procuring or interpreting images requires assistance from a
colleague, but beware when this assistance is provided only with the condition of being an
author. Such assistance is grounds for acknowledgement, not authorship.

7. discussant. The editor can encourage submission or advise that the case is not suitable (e. then clinical course. b.g. not the final diagnosis. Invite someone you expect will respond to each aliquot in a timely fashion. Some journals (e. 6. (For example. BMJ) require patient consent to publish their story. Send each aliquot to the discussant sequentially. Look at the target journal author instructions carefully (authorship guidelines. your authorship team is forming. Constructing the case discussion 10. coordinating/advising author) 13. Teaching points about rare diseases are of limited interest to most readers. Consider if you should ask the patient for permission at this time. that makes a great discussion. The medical details have to be correct. insufficient dilemma or another similar case already in progress). permissions. It is the journey to the final diagnosis. and the teaching points. then gold standard result. 11. Select the images you will be showing the discussant along with the case protocol. This person must not know the case in advance. You will need to review and edit this case protocol with a co-author for clarity and accuracy. then more clinical course. word limit). . (Example: first author. The first author should summarize the entire case in 6-8 sections (aliquots). Such knowledge makes the case discussion less authentic and also violates the spirit of the exercise (extemporaneous thinking).) a. Select a clinician who can discuss a broad range of medical topics. Think hard about the discussion section. 9. the commentary section is likely to fall flat. then exam.. how the diagnosis was made. At this time. Send a concise pre-submission inquiry to the series editor that includes a brief summary of the case. so take stock of who will be an author and in what sequence. Locate a clinical discussant. then final clinical event. a. What is your hook besides “it’s a cool case”? If you don’t have a theme about reasoning. Each 1-2 paragraph aliquot should provide the discussant with enough information to modify their differential diagnosis from the section before. the practice of medicine. 8. as the case will be part of the scientific record. or a general lesson. d. The case protocol should be finalized before you show it to a discussant and should not be modified during the back-and-forth exchange with the discussant. then labs and imaging.g. b. not the final diagnosis. 12. c. start with chief complaint and HPI.. You must ask patients for permission anytime you are photographing them. c. not the case details.

another author who has expertise in clinical reasoning is often required for this step (this person will usually be a middle author). 21. JGIM). more general themes/take-away teaching points. 20. c. a. the manner in which the case unfolds. Images: add arrows if necessary. review of diseases and dilemmas. this person will usually be a middle author (e. 14. Re-address authorship at this stage. The discussant’s response to the final aliquot is optional. .. 17. coordinating/advising author) 19. but cut out extraneous material. help craft/edit the commentary. [CR expert]. this needs to be drafted and integrated at this time. Edit the case protocol and discussant’s responses – keep the main ideas. The best titles make a clever but obtuse reference to the teaching points. and will be invaluable when specialty-level inquiries come from the journal a. d. Engage authorship group in multiple rounds of editing the complete manuscript (remaining mindful of word count). You may decide to merge 2 aliquots and their respective discussant responses. Add references – check the reference formatting requirements of the journal. Send aliquot 1 to the discussant. or the final diagnosis – without giving away any hints to the reader. but with each aliquot you may direct the discussant to address specific issues (“please elaborate on the initial differential diagnosis here” or “what conditions are you most concerned about?”). Draft the commentary section: brief summary of case. Repeat this process for all subsequent aliquots. Do not provide hints. paste aliquot 2 (only) into the same document and send this new document to the discussant. Draft teaching points section (JHM. 23. JGIM also requires a clinical reasoning analysis section following most of the discussant responses. specialist. discussant. Determine a manuscript title.g. a. 18. first author. b. Give the discussant a warning that final aliquot is next so they will know to make a final commitment before the diagnosis is revealed. 15. Clinical Problem Solving exercise: going from the case to a full manuscript 16. 22. After you receive the discussant response (usually 2-4 paragraphs) to aliquot 1. Invite the expertise of a specialist – this person can review the clinical discussion. draft legends.

MPH for their thoughtful review and input to this guide. See: http://www. MD. Sanjay Saint.html The author thanks Brian Harte. While there is no standardized approach. and Caren authors-and-contributors. MPH. Authorship is reserved for people who contribute substantially to the manuscript. The discussant oftentimes does enough work to merit this position. Middle authors = in order of descending amount of work and stage of involvement in project What does not make someone a co-author:  “I made the diagnosis”  “I took care of the patient”  “I was on the team”  “I was the consultant”  “I was the attending”  “I am the primary care provider”  “I interpreted the image or pathology” Taking care of the patient does not equal scholarship. There are few exceptions. sometimes more. this is a principled one: First Author = person who initiated the project and remains active/leader throughout. Final formatting for submission – check the author instructions very carefully. 24. MD. than author #1. coordinates among the co-authors. Last Author = person who was involved at early or middle stage (never late) and played an instrumental role and did close to as much work. Poor formatting is a very common reason for immediate manuscript rejection. does the submission process and all the interfacing with the journal. MPH.icmje. not based on seniority. . MD. Guide to authorship: The maximum number of authors on a CPS manuscript is 5. Jeffrey Kohlwes. MD.