1. How the BMJ triages submitted manuscripts Richard Smith Editor, BMJ www.bmj.com/talks

2. What I want to talk about Why should you triage studies? The aims of BMJ triage of submitted manuscripts The “killer” triage question for you The BMJ’s approach to triage The key questions for triaging papers

3. Why should you triage studies that you might come across You should pay attention to studies that are valid and have a relevant message for your practice--that will make a difference for your patients This is less than 1% of original studies published in medical journals

4. The aims of BMJ triage of submitted manuscripts To identify “good” papers and send them to reviewers as fast as possible To identify papers we don’t want to publish and give succinct but good reasons for not publishing them. To identify awful papers and reject them immediately.

5. The aims of BMJ triage of submitted manuscripts To identify those papers that might or might not be sent for review--and ask others To identify papers where we, the editors, can make a decision and which we might want to publish

6. The first question for you If this study is “true” would it be a POEM (Patient Oriented Evidence that Matters)? If it wouldn’t, move on You will probably be able to discard 70% of studies with this question alone

7. BMJ approach I Read covering letter. Pay small attention. This is a sell.

8. BMJ approach II Look for signs that this is a totally unsuitable paper Written by hand Typed on an ancient typewriter. Full of spelling mistakes. Biblical quotations. A cure for schizophrenia or cancer The answer to SIDS. Incomprehensible first two paragraphs.

9. BMJ approach III Read title page Is this an original study or some other kind of contribution? Are these authors where the study is likely to be sound? Don’t get too carried away by the authors. “Unknown” authors regularly produce great work. “Known” authors sometimes produce dreadful papers.

10. BMJ approach IV Do not read ‘TWIBS’ or ‘What this paper adds’ These are what the authors would like the paper to say rather than what it does say Remember that if we do publish this study we need to sort this out

11. BMJ approach V Read structured abstract Have you got a clear fix on what the paper is about and how it is structured? If you haven’t, it’s looking bad Try to make sense of what the paper is about from the introduction If you can’t, reject it

12. BMJ approach VI Continuing with the structured abstract Have the authors asked a question that we want to know the answer to? We may not for the following reasons: Too specialist. Too inconsequential Too far removed from patient care or public policy Too well known – but remember that lots of things that are well known have no evidence to support them.

13. BMJ approach VII Don’t reject papers that ask an interesting question but get a “negative” answer The question is more important than the result

14. Triage questions: treatment papers Is it a randomised controlled trial or a systematic review (see later)? If it is not an RCT, is it reasonable not to have done one? Look for an answer to the question in the paper. If you can’t find one, reject. If it is an RCT, was it really randomised? If it wasn’t, reject unless you can find a good reason for not randomising

15. Triage questions: diagnosis paper: Is the test compared prospectively and blind with a gold standard? Does the test population include patients with the condition, with related conditions that could be confused with the main condition, and people without the condition? Does the paper include information on sensitivity, specificity, etc? If the answer to any of these questions is no, we probably don’t want it.

16. Triage questions: prognosis studies Is there an cohort of patients followed followed prospectively from when they were first identified with the disease? Are 80% of patients followed up? If the answer to these questions is no, we probably don’t want it.

17. Triage questions: systematic reviews Was a clear question asked? Was a search described? Were quality criteria set? Were studies that didn’t meet them discarded or, if included, done so with a justification or discussion of the effect of doing so? If not to any of these questions, reject.

18. Triage questions: qualitative research Were qualitative methods appropriate for the question? Is it a “why” or “how” study rather than a “does it work” or “how often” study? Is there evidence that the data were analysed by two people independently? If the answer is no to either question, you should probably reject

19. Triage questions: Questionnaire survey We probably don’t want. This is people saying what they do rather than evidence on what they do But is it telling us something important that we probably can’t get information on in any other way? Or might it be a peg for an educational article. If the response rate is below 55% we almost certainly don’t want it.

20. Triage questions: economic evaluation Is the underlying methodology valid? For example, is an evaluation of treatment based on a randomised trial or a systematic review? If the answer is no, reject

21. Triage questions: case study Might it make a “lesson of the week” or a “drug point”? If no, reject Lessons of the week must be: –not so common that everybody should know it –nor so rare that it wouldn’t matter if you didn’t –a good read

22. Triage questions: drug point Does the report simply say that a drug was given and something happened to the patient without any “extra evidence” that there was a causative link? If yes, reject Extra evidence includes –rechallenge –More than one case –Physiological or pharmacological explanation –Seen with other similar drugs

23. Triage questions: Quality improvement report Does the attempt at improvement describe an initial assessment of the problem, the introduction of a change, and a further assessment? If the answer is no to any of these, reject It doesn’t matter whether the change led to improvement Remember we want to know the broad context

24. Triage questions: two sorts of studies we don’t want Prevalence study Boring Usually not possible to generalise beyond the particular population Cost of illness study Boring Value is in the exactness, which is usually of interest to only a few Again hard to generalise

25. Conclusion If your study would survive this triage or if you are uncertain we will be pleased to receive it Send it too if you are uncertain Don’t despair if your study wouldn’t seem to survive--there are many other journals Don’t be upset if you submit your article and it is rejected. The process is inevitably somewhat arbitrary. We often see papers we have rejected in the Lancet (and, I’m sure, vice versa