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. Dont invite any co-authors. You will need co-authors eventually, but after 1-2 people are
involved, there just isnt 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 thats OK; youll 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.
 6. Think hard about the discussion section, not the case details. What is your hook besides its a
cool case? If you dont have a theme about reasoning, the practice of medicine, or a general
lesson, the commentary section is likely to fall flat. Teaching points about rare diseases are of
limited interest to most readers.

7. Look at the target journal author instructions carefully (authorship guidelines, permissions, word
limit).

8. Some journals (e.g., BMJ) require patient consent to publish their story. Consider if you should
ask the patient for permission at this time. You must ask patients for permission anytime you
are photographing them.

9. Send a concise pre-submission inquiry to the series editor that includes a brief summary of the
case, how the diagnosis was made, and the teaching points. The editor can encourage
submission or advise that the case is not suitable (e.g., insufficient dilemma or another similar
case already in progress).

Constructing the case discussion

10. The first author should summarize the entire case in 6-8 sections (aliquots). Each 1-2 paragraph
aliquot should provide the discussant with enough information to modify their differential
diagnosis from the section before. (For example, start with chief complaint and HPI, then exam,
then labs and imaging, then clinical course, then more clinical course, then final clinical event,
then gold standard result.)

a. You will need to review and edit this case protocol with a co-author for clarity and
accuracy.
b. The medical details have to be correct, as the case will be part of the scientific record.
c. Select the images you will be showing the discussant along with the case protocol.
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.

11. Locate a clinical discussant.

a. This person must not know the case in advance. Such knowledge makes the case
discussion less authentic and also violates the spirit of the exercise (extemporaneous
thinking).
b. Select a clinician who can discuss a broad range of medical topics, not the final
diagnosis. It is the journey to the final diagnosis, not the final diagnosis, that makes a
great discussion.
c. Invite someone you expect will respond to each aliquot in a timely fashion.

12. At this time, your authorship team is forming, so take stock of who will be an author and in what
sequence. (Example: first author, discussant, coordinating/advising author)

13. Send each aliquot to the discussant sequentially.

 a. Send aliquot 1 to the discussant.
b. Do not provide hints, 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?).
c. After you receive the discussant response (usually 2-4 paragraphs) to aliquot 1, paste
aliquot 2 (only) into the same document and send this new document to the discussant.
d. Repeat this process for all subsequent aliquots.

14. 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. The discussants response to the final aliquot is optional.

Clinical Problem Solving exercise: going from the case to a full manuscript

16. Edit the case protocol and discussants responses keep the main ideas, but cut out extraneous
material. You may decide to merge 2 aliquots and their respective discussant responses.

a. JGIM also requires a clinical reasoning analysis section following most of the discussant
responses; this needs to be drafted and integrated at this time; another author who has
expertise in clinical reasoning is often required for this step (this person will usually be a
middle author).

17. Draft the commentary section: brief summary of case, review of diseases and dilemmas, more
general themes/take-away teaching points.

18. Invite the expertise of a specialist this person can review the clinical discussion, help craft/edit
the commentary, and will be invaluable when specialty-level inquiries come from the journal

a. Re-address authorship at this stage; this person will usually be a middle author (e.g.,
first author, discussant, [CR expert], specialist, coordinating/advising author)

19. Images: add arrows if necessary; draft legends.

20. Draft teaching points section (JHM, JGIM).

21. Add references check the reference formatting requirements of the journal.

22. Determine a manuscript title. The best titles make a clever but obtuse reference to the teaching
points, the manner in which the case unfolds, or the final diagnosis without giving away any
hints to the reader.

23. Engage authorship group in multiple rounds of editing the complete manuscript (remaining
mindful of word count).
 24. Final formatting for submission check the author instructions very carefully. Poor formatting is
a very common reason for immediate manuscript rejection.

Guide to authorship:

The maximum number of authors on a CPS manuscript is 5. There are few exceptions.

While there is no standardized approach, this is a principled one:

First Author = person who initiated the project and remains active/leader throughout; coordinates
among the co-authors; does the submission process and all the interfacing with the journal.

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, sometimes more, than author #1; not based on seniority. 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.

Authorship is reserved for people who contribute substantially to the manuscript.

See: http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-
authors-and-contributors.html

The author thanks Brian Harte, MD, Jeffrey Kohlwes, MD, MPH, Sanjay Saint, MD, MPH, and Caren
Solomon, MD, MPH for their thoughtful review and input to this guide.