1. How to Write A Clinical Review Article: A Medical Writing Seminar Kenneth Lin, MD Assistant Editor, American Family Physician STFM NorthEast Region Meeting October 27, 2006

2. Learning Objectives Define the clinical review article Contrast the objectives of clinical reviews with systematic literature reviews Distinguish between appropriate and inappropriate topics for a clinical review Identify and discuss structural elements of a clinical review Describe the submission and publication process

3. Some Caveats This seminar will NOT –Discuss original research writing –Teach basic composition skills –Provide a list of the “best” clinical review topics to write about –Tell you which journal to submit already- written manuscripts

4. Outline for the Hour What is a clinical review – 15 min Topic selection – 5 min Writing the review – 20 min Submission process – 5 min Questions and answers – 15 min Abstract writing – homework

5. Who Am I? A family physician A published author 2004-05 graduate of the Georgetown/AFP John C. Rose Medical Editing Fellowship Currently edit or co-edit AFP’s Letters to the Editor, Photo Quiz, Curbside Consultation, and clinical review articles. Also write “Tips From Other Journals.”

6. Why Are You Here? You would like to write You are already writing, but you want to be published You have already published, but you want to be published in better journals You want to be read by a large primary care audience

7. What Is A Clinical Review Article? A broad, summary discussion of a clinical topic based on a selective literature review In contrast, systematic reviews synthesize evidence on a narrow aspect of a topic from a structured, comprehensive literature search These distinctions have become blurry in recent years

8. Why Write A Clinical Review? Communicate clinical expertise Reinforce and expand own understanding of a topic Faculty development project Mentor junior faculty and/or residents Peer-reviewed publication is necessary for academic promotion

9. Examples of Clinical Review Topics Asymptomatic bacteriuria in adults Pertussis Leukotriene inhibitors in allergy and asthma Grapefruit-drug interactions Newborn hearing screening Home monitoring of glucose and blood pressure Evaluation of the first seizure

10. American Family Physician: Best Read Journal in Primary Care Peer-reviewed journal published twice monthly by American Academy of Family Physicians Circulation of ~185,000 Publishes clinical review articles rather than original research Emphasizes practical, patient care-oriented applications of medical evidence Topics updated every 4-6 years

11. Topic Selection “Can you please give me a list of topics to write on …”

12. A Checklist for Topic Ideas Is the symptom or condition commonly seen? Are family physicians typically involved in the care of patients with the condition? Can you explain the focus/coverage of the idea in 1-2 sentences? Can this clinical aspect be covered in 1,500 to 1,800 words?

13. Topic Pitfalls to Avoid Too broad (e.g. “Diabetes”) Too narrow (e.g. “Pheochromocytoma”) Too rare (e.g. “Invasive Fusariosis with Osteomyelitis in Uncontrolled Diabetes”) Too speculative (e.g. “Virtual Colonoscopy”) Subspecialty-oriented (e.g. “Adjuvant Chemotherapy for Breast Cancer”) Research (e.g. “Effect of Hurricane Katrina on Psychiatric Care in New Orleans”)

14. Tips on Choosing a Topic Write on what you are familiar with rather than invent interest/expertise from scratch Decide what journal you are writing for before you start writing Read several issues of the target journal to gain familiarity with its content and style Before writing, contact the journal to find out if the topic is available / desired Read and follow the journal’s Author Instructions to the letter

15. Writing the Clinical Review Diagnosis Treatment Prevention

16. Literature Searching Goal to find quality POEM rather than DOE First, consult evidence-based practice guidelines and systematic reviews –e.g. AHRQ, Cochrane Library, Clinical Evidence, InfoPOEMs, National Guideline Clearinghouse Second, consult original research articles –Search with PubMed Clinical Queries Last (only if all else fails!), consult expert consensus, other clinical reviews, texts

17. Weighing the Evidence: Issues to Consider Controversies Unresolved questions Recent developments Alternative viewpoints Conflicts of interest Sources of bias

18. Strength of Recommendation Taxonomy (SORT) A – consistent and good quality patient- oriented evidence B – inconsistent or limited quality patient-oriented evidence C – consensus, usual practice, opinion, disease-oriented evidence, or case series http://www.aafp.org/online/en/home/pu blications/journals/afp/afpsort.htmlhttp://www.aafp.org/online/en/home/pu blications/journals/afp/afpsort.html

19. Structural Elements Abstract Introduction Etiology / Pathophysiology Presentation Diagnosis Treatment Prognosis / Clinical Course Prevention and Screening

20. The Abstract Should Summarize Your Article Think of an abstract as the “executive summary” WRONG: “This paper will discuss how to diagnose type 2 diabetes…” RIGHT: “Diabetes is diagnosed with two separate fasting BGs >=126 or a single nonfasting BG > 200 with symptoms.”

21. Introduction: Reasons to Read On Convey the idea that the rest of the article has useful information Definition of the condition to be discussed Significance of symptom / condition –How common is it? In FP settings? –How lethal is it? Untreated and treated? –Short and long-term consequences? Epidemiology –Geography, demographics, who is at risk

22. Etiology / Pathophysiology What causes the symptom or condition? If multiple causes, what’s more common? Don’t dwell on pathophysiology Give just enough info to allow the reader to understand diagnostic or management issues –e.g. type 2 diabetes is hyperglycemia caused by peripheral insulin resistance. Provides rationale for drugs’ mechanisms of action

23. Presentation: How To Know It When You See It Typical clinical signs and symptoms Atypical clinical signs and symptoms Age- or gender-specific differences If condition is often asymptomatic, discuss typical laboratory findings

24. Diagnosis: If It Looks Like a Duck, and It Quacks … Differential diagnosis: what might the condition be easily confused with? Clinical and laboratory diagnostic criteria Indicated testing (“the workup”) –Initial tests vs. gold standard –Sensitivity and specificity, PPV, NPV –Validated algorithm, if available

25. Treatment: “… While Nature Cures the Disease” Does a treatment exist? Is the treatment effective in all patients with the condition? If not, which patients are eligible for and will benefit from treatment? Patient education / behavior modification –What can be done to reduce co-morbidities? –For ID, strategies to reduce transmission of condition

26. Prognosis / Clinical Course Prognosis if untreated versus modified course if condition is managed appropriately Follow-up intervals after successful treatment Long-term disability from condition Periodic monitoring for recurrence, if applicable

27. Prevention and Screening Types of prevention –Primary –Secondary –Tertiary Don’t forget counseling, chemo- prophylaxis Does early detection via screening reduce morbidity or mortality?

28. The Submission Process “What’s the status of my article? When can I expect to hear something?”

29. What Happens After Submission Processing by editorial office Peer review Decision Revision Re-submission Medical and professional editing Publication Fame and fortune (or at least, something to show your mother / kids / significant other)

30. The Decision: 4 Possible Outcomes ACCEPT “as is” –Congratulations! (This almost never happens!) ACCEPT with revision –Congratulations! RECONSIDER with major revision –After re-write, treated as new manuscript with possible re-review. Still reasonable chance for acceptance. REJECT –If inappropriate topic, may try another journal.

31. A Few Words Regarding Revisions “Great papers are not written – they are re-written.” Do not be discouraged or intimidated by length or number of requested revisions!

32. Questions and Answers

33. Abstract Writing Exercise (optional) Please take a handout Remember that an abstract is the “executive summary” of the article Write a concise (150-250 words), searchable, informative abstract for this article and e-mail it to me for feedback at KWL4@georgetown.eduKWL4@georgetown.edu

34. Standing On the Shoulders of (Editorial) Giants Many thanks to –Mark Ebell –Clarissa Kripke –Sumi Sexton –Allen Shaughnessy –Jay Siwek –Anne Walling –Caroline Wellbery And finally …

35. Thank You And GOOD LUCK!

36. References and Resources Ebell MH et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. Ebell MH. Templates for articles on diagnosis and treatment for American Family Physician, 2006. Lin KW. Renovation 101: constructing clinical review articles for American Family Physician. Fellowship symposium presentation, Georgetown University, 2005. Shaughnessy AF, Slawson DC. Getting the most from clinical review articles: a guide for readers and writers. Am Fam Physician 1997;55:2155-60. Siwek J et al. How to write an evidence-based clinical review article. Am Fam Physician 2002;65:251-8. Siwek J. How to write a good clinical review article. Handout at AAFP Scientific Assembly workshop for new authors, 2006.