HEADMIRROR PODCAST: RESEARCH & PUBLICATIONS, WHY & HOW?

WHY PARTICIPATE IN RESEARCH?
Patient care, education and research comprise the three cornerstones of academic medicine. During the busy years of medical school and residency, the former two often dominate all waking hours leaving little time or energy for the latter. While research is often overlooked, there are many important reasons why residents should consider finding time to complete meaningful research.

The ultimate goal of research is the advancement of medicine and improvement in patient outcomes. However, there are many other immediate benefits that also deserve mention. First, working on a project forces you to study a topic in depth, beyond the superficial facts that are presented in Baileys or Cummings. Thus, participating in clinical research makes you a better clinician. Second, by studying background data, designing a research plan, and drafting a manuscript, you will become more efficient at critically reviewing the literature – a skill that will continue to benefit you throughout your career. Third, by focusing your research on a particular niche, you may quickly become recognized as an authority on that subject. In this way, research is a very important part of early career development. Fourth, publications are one of the tangible measures of academic productivity. A lot of people can start a research project or work in a lab, but finishing with a publication or two demonstrates determination and commitment. If you are able to publish even one paper each year of residency, this will significantly strengthen any fellowship or academic job application. Lastly, scientific publications are indirect advertisements for your department and institution.

HOW TO DECIDE ON A TOPIC?
If you have decided early that you are interested in pursuing a particular subspecialty, then focusing your research in that field is advantageous. This motivation will allow you to present at national meetings and publish within subspecialty journals which will significantly add to your fellowship application. However, even if you are undecided, a track record of consistent research involvement will strengthen your curriculum vitae.

 Your research needs to have a “hook” or a sales pitch - why does your project matter and why should it be published? There are several common features of most successful projects. In general, you need to have a large “N”, a new angle, or a novel idea to get published in a decent journal. When brainstorming ideas, consider the unique strengths of your institution. For example, if you are interested in endoscopic skull base surgery and your department has a particularly robust esthesioneuroblastoma referral network, then work with a mentor to determine if there is a unique angle or new spin that would be worth evaluating. Conversely, if you are interested in looking at outcomes of EXIT procedures in neonates with aerodigestive lymphovenous malformations and you don’t have an associated tertiary pediatric hospital, then this project is likely unrealistic.  Look at the literature for at least a good hour before moving forward with a project. If you have a killer idea, chances are, it’s already been done before. This does not mean you can’t do it, as reproducibility is an essential aspect of clinical research, but if there is not a unique angle or if the “N” is smaller than previous studies, the chances of publication in a high impact factor journal decrease.

On a cautionary note, anything you publish stays with you. If you are researching a hot topic that generates hundreds of publications each year such as cleft palate surgery, cochlear implantation, or transoral robotic surgery, you may have to publish 50 papers before you are recognized for your contribution. However, if you are the first author on a single paper about chronic pain in histrionic patients with skull base osteoradionecrosis, you may end up receiving international referrals for patients with this problem and be asked to speak at meetings on it. Be careful (strategic) about what you publish on.

IDENTIFYING A MENTOR
Find someone in your area of interest. The most well-known person is not always the best individual to ask. They are often busy, or have less time or interest in hand holding. If you know what you are doing and feel you need little input, then this may be less critical. Go to someone who is productive. It is unlikely that the productivity of your mentor will double when you are working with them. If they only publish one paper every couple years, it is unlikely that you are going to have a prolific spell during your time with them.

WHAT TYPE OF RESEARCH TO CONSIDER?
When deciding what to study and devising a research plan, it is extremely important to balance scientific merit with feasibility. Of course, a randomized double-blinded prospective study with 10,000 patients comparing coblation and electrocautery tonsillectomy is better than an observational study with only 200 patients… BUT the latter is much more likely to get done during your residency (or your lifetime). And frankly, no one really cares that you had a great idea or a perfect study design if you don’t execute. There is a plethora of good ideas, but the numbers of projects that are brought to fruition are few. The process of research is important for personal development, but ultimately, the primary goal is to have data for others to read, evaluate, repeat and build upon. If it is not published, unfortunately it is as though it didn’t happen.

So, to address this question more directly, the best answer is that it’s helpful to have a well-rounded application. Have a couple projects that you can finish more easily (case reports, case series, etc.) and a couple more involved endeavors. Basic science and animal studies are frequently weighted more heavily than retrospective clinical studies; however, the effort requirement and potential frustrations are also greater. If you are planning on working on a basic science study, it is very important to start early since it may take twice as long to finish than anticipated.

It is a common misconception that having a lot of ongoing research projects makes you a productive researcher. Ironically, the most successful people often take on no more than 1 to 3 projects at a time and work on them until they are finished. If you have too much going on, your energy and attention will be divided and you may not finish any.

AUTHORSHIP ORDER
The most desirable position on any paper is first author. Most journals allow you and a co-author to share first authorship (indicated by an asterisk) if you feel that the contributions were very similar, although this is not commonly utilized. The next best position, after first author, is controversial. Most believe that last authorship is the second most desirable position. Usually, the PI or head of the lab is granted this position. Interestingly however, some centers count second authorship as second most desirable. Third through second to last authors are essentially equivalent. 

If you are working with peers, it is helpful to establish authorship position and distribution of workload from the beginning. Two seconds of awkward conversation upfront often prevents significant problems at the end. It can be very frustrating for a young researcher to contribute 80% of the work only to have first author taken by a more senior author. While not uncommon, this scenario is extremely unfortunate since it often injures professional relationships, but even more importantly, discourages young investigators from participating in future projects. As a general rule, the person who contributes the most work directly to the publication, regardless of academic rank, should be first author.  

WHAT JOURNAL TO TARGET?
If you have a home run paper (level one evidence) that has broad audience appeal, you can aim for very high impact journals such as Lancet, JAMA, or NEJM. But for the most part, clinical papers will be submitted to specialty specific journals. While not perfect, as a general rule, the quality of the journal is measured by impact factor score -- the higher the score the better. Journal impact factor is driven by the number of recent citations that papers within that journal have received, and therefore, it is an indirect measure of the relative worth of the journal to the specialty. Because the specialty of otolaryngology is small compared to most other fields, our journals are naturally cited less frequently, which drives the impact factor down even if the research is of decent quality. The effect of this imbalance is demonstrated well by comparing lower end internal medicine journals, which still often have impact factors of 3 or 4, to even the highest scoring ENT journals, which commonly settle around 2. Estimate the quality of your research and submit accordingly, and it never hurts to aim a little high. A list of Otolaryngology journals can be found here.

WRITING THE PAPER
It is always amazing to me that writing the paper often becomes the bottleneck for many projects. The only way to get something done is to do it. Just start writing and work on it until you are done with your goal for the day. You do not have to write a final draft the first time. In fact, it’s common to have several dozen revisions before having a final draft. This point introduces a very important habit to develop. Keep resaving you work with a new name (e.g., Title YYYY-MM-DD) every 30 minutes or less. That goes for excel or word documents. This sounds neurotic, but you will be very happy you followed this rule. If anything happens to the file, you will be able to retrieve the file at various stages of development.

Your manuscript submission is a package deal and the wrapping matters as much as the gift. Any one part you are sloppy on will hurt the rest. When you submit your manuscript, make sure the grammar, punctuation, spelling and flow are perfect. Read, set aside and read again, set aside and read again, set aside and read again. Have someone else read once, then set aside and read again, set aside and read again. What makes sense when you are deep in thought might not make sense later. If you have any errors, the reviewers will assume you are sloppy and that other more important areas such as data collection and statistics are wrong, even if they are not.

Review the author guidelines for the journal to which you are submitting thoroughly.  For most journals, failure to adhere to their specific guidelines is a fast-track to having your manuscript sent back to you.  Furthermore, if you have previously un-successfully submitted the paper to one journal and are now submitting to a competing journal, make sure the manuscript is 100% adherent to author guidelines for journal #2.  Nothing guarantees a rejection more than accidentally showing a journal you have previously sent your manuscript to their competition and are now “settling” on submitting to them.

Everyone develops a unique style of writing. The outline below provides a good example that you can consider using when writing a manuscript for the first time.

• Total length: 2000-3500 words depending on content. Each paper should not have more than 1 or 2 primary objectives. Determine what these points are from the beginning so that the outline is structured to support your conclusions. Create an outline with a logical flow. Each paragraph should convey one (or at most 2) idea(s). Each paragraph should generally build upon the last. Avoid saying the same thing over and over in the same section.

• Introduction: Introduction to the subject. Identifying a knowledge gap. Delivering a sales pitch. Usually about 3 paragraphs long.

• Materials and methods: Should be able to reproduce study based on description. Can shorten by referencing other papers. Include statistical methods. When determining variables to collect, do a literature review. Sit back and think about it. Run it by others and re-evaluate. It is painful to go back more than once to collect data.

• Results: Do not explain your findings. Provide structured paragraphs that move from one data set to the next. Data are rarely “perfect” – variables are sometimes missing, incomplete or difficult to interpret. You have to do the best with what you have and be honest. If you have any questions regarding data collection or interpretation, review with your co-investigators.

• Discussion: No more than 2-3 pages. Your first paragraph should be a brief summary of the study findings. Then, compare your findings to what has been published previously. Review clinical significance of your results. Identify potential areas for future study. Review the strengths and weaknesses. Before writing the discussion read ~10 strong papers on the subject to make sure you touch on the important issues. Make sure to wait a bit before writing to avoid accidental plagiarism.

• Conclusion: 1-2 paragraphs. Only make conclusions that are directly supported by the data.

• Bibliography: One word, “ENDNOTE”! The first couple times you use this program it’s a little clumsy, but after you get the hang of it, you will save yourself a ton of time.

THE REVIEW PROCESS
Do not take a long response to suggest the paper will be accepted or rejected -- there is no correlation. It just means that one of the reviewers is tardy with their review. Most reviews for good journals take about 1-2 months. If it’s been a while and you are wondering about the status, you may check online. In general, don’t call or email the journal until at least 2 or 3 months have passed.

It is a common misconception that all reviewers are seasoned researchers who have received extensive training on manuscript review and grade papers on a rigid point scheme to determine acceptance. If your paper is rejected, that does not necessarily mean it is a bad paper. There is never a perfect study and the review process is very subjective. The paper may be a flop, but it is also possible that the reviewer got a flat tire earlier in the day and that is why your paper was rejected. Five percent of papers are awesome, 20% are really bad and all the rest are in the middle. If you receive a rejection, you need to critically evaluate the reviewer comments (if they are provided with the rejection notice). If you feel that your paper is good, then resubmit to another journal after making appropriate revisions.

A request for revision is a safe way of saying “acceptance with revision”. With revision requests the journal does not want to be married to the paper yet, but if you satisfy most of the concerns, they will generally accept with the next round. You don’t have to agree or concede to all requests to have your paper accepted. If you disagree, be very polite and explain your reasoning. Some reviewers will try to steer the paper towards their bias. If you disagree, don’t let this happen. Unfortunately, it’s probably wise to kiss a little butt with review responses. It is a subjective process. If they like you, they will take it. If they don’t like you, even if it’s good research, it may get rejected.

In summary, successful research is 1% inspiration and 99% perspiration. Plan your work and work your plan. Completing a project from conception to publication is attainable. Your hard work and persistence will pay off.