PRACTICAL NON-CLINICAL SKILLS FOR SURGEONS
ANZJSurg.com
How to write a paper: revising your manuscript
Introduction
Melina Kibbe recently published on how to write an academic
paper.1 This paper addresses the challenge of responding to the
reviewer’s comments on your paper. Following months of writing,
data collection and analysis; submission and acceptance of your
carefully and lovingly prepared manuscript into your journal of
choice may be thought of as a forgone conclusion.2 However,
acceptance to your journal of first choice is uncommon. Your
chances of acceptance are further reduced when submitting to jour-
nals with a wide audience and scope, with reported rejection rates
of up to 70%.2–4
Accompanying a journal response are editor and reviewer com-
ments. Editor and reviewer comments are peer review and provide
insight on ways to improve your manuscript.5 It is important to note
that most journal reviewers are not compensated for their time spent
reviewing.
Reviewer comments vary depending on whether your manuscript
has been accepted provisionally or rejected outright following man-
uscript submission. Based on the authors’ editorial, reviewing,
research and publication experience, we outline below how best to
respond to editor and reviewer comments, and discuss ways to pre-
pare your manuscript for re-submission. This article is intended for
young researchers, aspiring academic surgeons and surgical trainees
seeking to publish (and re-submit) their research.
After manuscript submission
Following manuscript submission, you will receive one of four
responses from the journal editor.
Acceptance without any changes
Due to the vigorous and comprehensive peer-review process used
by most journals, acceptance without changes rarely occurs. Manu-
scripts that are accepted without changes often include perspectives
and editorials. Usually no further action is required.
Provisional acceptance
Provisional acceptance, also known as acceptance with minor revi-
sions a most common response should your manuscript be accepted
into a journal. Revised manuscripts are reviewed by the journal edi-
tor and/or reviewers before final acceptance. Although acceptance
is likely, it is not guaranteed. Minor revisions range from altering
the title or adding a sentence, to including a paragraph that further
© 2016 Royal Australasian College of Surgeons
explains a methodology, or identifies additional clinical implica-
tions of your study.
Provisional rejection
These are manuscripts that require significant alteration to the man-
uscript. Major revisions include a requirement to rewrite entire
paragraphs and sections. The submitted manuscript covers an
important scope of the journal; however, the aim/direction of how
the manuscript was written may need to be altered.
Although not usually grounds for rejection, poor grammar and
punctuation are a common requirement for revision. In this
instance, enlisting the help of a native English speaker, an academic
editing service may be helpful.
With any of the above responses (acceptance, provisional accept-
ance and provisional rejection), it is imperative that you respond
and re-submit your manuscript in a timely fashion. Manuscripts re-
submitted many months after provisional acceptance risk rejection.
A guide on how to respond to reviewers’ comments is outlined
below.
How to respond: first steps
When receiving reviewer comments, the first steps are to:
(1) Sit down
(2) Take a deep breath
(3) Carefully read through the comments
(4) Then put aside for 1–2 days
(5) Do not write a response immediately
How to respond: cover letter
Most journals require authors to re-submit their manuscript with a
cover letter attached. A cover letter template that outlines that basic
structure is shown in Figure 1. Throughout the cover letter, it is
important to be polite, thankful and acknowledge the reviewers for
their time and effort. Communicate that you are able to understand
their perspective and comments. In addition to critical comments, it
is important to respond to positive comments as well.
Depending on the journal, you will be required to respond to
each comment in a logical and sequenced manner (i.e. cut and paste
the comments). In each case, clearly highlight revisions made using
page, paragraph and line numbers; and in a different colour or font.
Alternatively, journals may ask for ‘track changes’ in a Word docu-
ment. It is important to try to modify your manuscript as much as is
practical according to the reviewers’ comments.
ANZ J Surg (2016)
2 Practical non-clinical skills for surgeons

[DATE]

TO: [Journal]

Editor-in-Chief

Dear Editor-in-Chief

RE: Manuscript submission to the [Journal]

Title: [Title of your manuscript]

A sentence thanking the journal for considering your manuscript

A sentence thanking the reviewers

List each Reviewer points and criticism, followed by your response. This is the author’s
opportunity to explain to the reviewers why you may disagree with their comments

Reviewer 1:

Criticism A: The study does not comment on….

Response A: We agree that newer studies have shown… thus we have included a paragraph
to explain…

Criticism B: The lack of power calculation…

Response B: Power calculation was not possible due to…

Reviewer 2:

Criticism A:

Response B:

Final sentence thanking the reviewers and editors for their time and for considering your
paper for publication.

Yours sincerely,

[Your name] [Qualifications ]

Fig. 1. Cover letter.

How to respond: disagreeing with a reviewer’s comments
There will be times, however, when you disagree with reviewers’
comments. In such cases, do not openly argue with the reviewer in
your cover letter. Demonstrate that you have thought about the
issue extensively. Communicate clearly that it is a controversial
topic, and respectfully disagree, or perhaps accept that you may
have not communicated clearly enough. Explain by using concrete
data to support your point. Furthermore, consider altering the man-
uscript so your point is better demonstrated in the revised
manuscript.

© 2016 Royal Australasian College of Surgeons

Practical non-clinical skills for surgeons
Rejection
There are many reasons for manuscript rejection. The most com-
mon is where the submitted manuscript does not align with the
journal’s scope.6–8
Although disheartening, manuscript rejection should be viewed
as a valuable learning experience. Reviewers’ critique of your man-
uscript can be used to improve your manuscript for re-submission
to another journal. Depending on comments received with your
rejection letter, there are ways to respond accordingly.
Give up
Restart from scratch. This is indicated if the editor and reviewer cri-
ticisms of your paper are extremely damaging or if the editor or
reviewers identify major methodological deficiencies in your manu-
script. In this situation, it is important to discuss these issues with
your co-investigator(s) and senior author in order to develop a strat-
egy to avoid similar problems in the future.
Re-submit to another journal
Editor and reviewer comments can be helpful in improving your
manuscript for submission to other journals. There may be an
opportunity to improve your data such as adding more patients or
including additional analyses. Reviewers often review for more
than one journal, thus it is important you consider the comments
received, in the event the same reviewer reviews your manuscript
for another journal. Your paper may be better submitted as a letter
to the editor, as at least this can count as a form of publication on
your curriculum vitae.
Re-submit to the same journal
This may appear counter-intuitive. However, this is possible in
instances where the journal has provided detailed reasons and criti-
cisms that can be fully addressed. Of note, disagreeing with the
reviewer is not an option in this instance. In this situation, it can be dif-
ficult for a journal to reject a manuscript a second time as it was
rejected for reasons A, B, C and D and you have now removed these.
Other
The final option is to write an emotional letter to the editor
arguing about the review or the rejection of your manuscript. This
© 2016 Royal Australasian College of Surgeons
3
seldom works and is likely to create further problems for you in
the future.
Conclusion
Manuscript rejection, with reviewer comments, offers great peer
review to allow you to improve your manuscript for future submis-
sion. Although sometimes disheartening, reviewer comments
should be responded to in a respectful and clear manner.
References
1. Kibbe MR. How to write a paper. ANZ J. Surg. 2013; 83: 90–2.
2. Harris JP. How can I reduce the chances of my paper being rejected?
ANZ J. Surg. 2016; 86: 325.
3. Lee KP, Schotland M, Bacchetti P, Bero LA. Association of journal
quality indicators with methodological quality of clinical research articles.
JAMA 2002; 287: 2805–8.
4. Lamb CR, Mai W. Acceptance rate and reasons for rejection of manu-
scripts submitted to Veterinary Radiology & Ultrasound during 2012.
Vet. Radiol. Ultrasound 2015; 56: 103–8.
5. Snell L, Spencer J. Reviewers’ perceptions of the peer review process for
a medical education journal. Med. Educ. 2005; 39: 90–7.
6. Bordage G. Reasons reviewers reject and accept manuscripts: the
strengths and weaknesses in medical education reports. Acad. Med.
2001; 76: 889–96.
7. Okike K et al. Nonscientific factors associated with acceptance for publi-
cation in The Journal of Bone and Joint Surgery (American volume).
J. Bone Joint Surg. Am. 2008; 90: 2432–7.
8. Wyness T, McGhee CNJ, Patel DV. Manuscript rejection in ophthalmol-
ogy and visual science journals: identifying and avoiding the common
pitfalls. Clin. Exp. Ophthalmol. 2009; 37: 864–7.
Bruce Su’a, MBChB†
Wiremu S. MacFater, MBChB
Andrew G. Hill, MD (Thesis), FRACS
Department of Surgery, The University of Auckland, Auckland,
New Zealand
†Bruce Su’a is the current recipient of the inaugural Health
Research Council Pacific Clinical Research Training Fellowship.
doi: 10.1111/ans.13847