How I wrote This: What I learned while writing my first paper for an academic publication

The story behind “Six countries, six individuals: resourceful patients navigating medical records in Australia, Canada, Chile, Japan, Sweden and the USA” in BMJ Open

One of the reasons I created an “emerging researcher” section in this blog was to have a place to share the backstory around the work I am doing. I mean, I love Twitter, but sometimes you just need more than 280 characters to capture the nuance of the research adventure.

This is the case with “Six countries, six individuals: resourceful patients navigating medical records in Australia, Canada, Chile, Japan, Sweden and the USA” which was published earlier this month in BMJ Open.

The origin story

The intro to the paper states the authors met at Salzburg Global Seminar in spring 2017. Those of you who’ve been following me from my early patient blogger days may remember when I quit my stable job to accept a “once-in-a-lifetime opportunity” that might give me an “opportunity to change the world.” This was that opportunity.

During my time in Salzburg I was struck by how as fellows from different countries (all experiencing different models of healthcare with various payment mechanisms) we still had a lot in common around the experience of access to medical records. We were all mired in patriarchal, or “doctor knows best,” models of health care—it did not matter in which country in you lived.

Fast forward a few months to fall 2017 when I began working with Tom Delbanco, MD and Jan Walker, RN, MBA, of OpenNotes at Beth Israel Deaconess Medical Center. As researchers, Jan and Tom urged me to write something about what I had learned in Salzburg. I have since gathered that, to researchers, if you don’t write about something it never happened. I shared with Jan and Tom my ideas about what I might write about, and of eight different concepts they liked “6 patients, 6 individuals” the best.

Do one

In medicine there is a saying: See one, do one, teach one. “Six countries, six individuals” was a do one experience.

I remember when it was time for me to get started writing the paper that I was scared. I had no experience in academic writing; my writing background was a mix of AP Style (press releases) and blogging. It’s only now upon reflection I can pick apart what and how I learned to write based on this experience.

For example, Jan and Tom never told me exactly what to do or where to start. The two of them are leaders in their field and busy with many other projects that it was impossible and inappropriate for me to bug them every day, or even once a week, for feedback. But what they did do was send me clues as to what to do next.

Here is what I learned when writing my first academic publication.

1. Don’t start writing until you pick a target journal 

Right away I learned from Jan and Tom that you need to be strategic about which journal you hope your paper will be published in. They suggested I aim to publish this paper in the BMJ family of journals because the BMJ attracts an international community of readers, and this paper would reflect an international story.

2. Collect intel from the journal

Before putting fingers to the keyboard I spent a good amount of time looking at the BMJ journals and sub-journals to understand what kind of papers they accept. For example, a journal focused on cats is not likely to publish a paper about dogs (unless, it was a study of cat’s views on dogs, and so on).

2.b. Get invited to write the paper

After reviewing the journal’s website I learned the kind of paper I wanted to write might fit into a category of “analysis” papers the BMJ publishes… and to write that kind of paper you have to first ask the journal to invite you to write the paper.

Wait, what?

Yes, you have to write to the journal and essentially say, “We have an idea to write a paper about X and we want to publish this as an analysis paper in your journal. This paper will be awesome because A, B, and C. Will you invite us to write this?”

This is what I did, and I heard back from BMJ about a week later saying they were interested. The ball was back in my court.

Side note: This learning has come in handy many times since then.

3. Read the instructions for authors, then read them again… and again

All journals have sections on their website called “instructions for authors.” The instructions tell hopeful authors “the rules” of their publication such as word limits, structure, and how many authors are allowed to be involved. If you want to write a scholarly paper, you have to play by the rules of the journal.

As a person with a communications background, the rules for authors did not seem intimidating to me. If anything, I recognized the rules were similar in concept to sticking with Associated Press Style if you do news writing or write press releases, and I appreciated the structure. I have since learned all journals have rules, the rules vary by journal, and they are not nearly as simple as AP Style. 

4. Flesh out the concept/narrative arch for the paper in advance; this is especially tricky when working with patient voices

It was my idea to include first-person patient or care partner narratives in the paper that would feature people from different countries. Jan and Tom brainstormed with me about how that would work in an academic paper; we knew it would be challenging.

Traditionally, the many authors on an academic paper write with one voice. Here I was suggesting we should have three or more voices (we ended up with six), all using first-person perspectives. I also wanted the authors to speak with a group voice using third-person perspective. What were we to do to?

My goal with the first draft (of many, many drafts) was to write the introduction and the conclusion in third person (group voice), and to write one example of a first-person patient story (using my own story). My story eventually became “The USA: even the activist struggles” in the final paper.

With the intro, one story and conclusion drafted, Jan and Tom were able to react to the concept and give me feedback.

5. Consider sidebars and data tables 

Tom suggested I think about how I wrote my patient story (format) and to turn the structure of my story into a series of prompts for my fellow patient authors as they drafted their own narratives. The prompts eventually became the Sidebar in the paper. (See: “Sidebar: each patient/care partner author was prompted to think about these 5 questions” in the final paper.)

Then Jan threw me a curveball. She said, “You know what this paper needs? A table. People love tables with data.”

In the moment I laughed because it sounded like the nerdiest thing to say. A table? Snooze. However, the 2020 me knows this is true: the comms-trained, emerging researcher in me can draw a direct parallel to how much more interesting it is for people to read a paper with a table to how much more interesting it is for people to read a story that’s accompanied by pictures. Researchers love those tables.

The question was, what data did we even have? Jan had the idea for us to create a table featuring a short blurb about the status of electronic health records in each of the countries for each author. A brilliant idea! But it required more work because there was no one resource for that information. 

In order to collect this data, I did my own research on the USA, drafted a blurb, and asked each author to research and write a similar blurb for their country. This was easy for some of the authors, but very challenging for one country in particular: Chile. I had to do a bit of digging for Chile, which required some Googling and reading academic papers about electronic medical records in South America. 

By the way, do you know what all this Googling and reading is called? Research.

6. Editing makes everything better

After I had the main structure together (intro, my story, table, and prompts) I reached out to the prospective co-authors to think about their experiences as patients/care partners in their various countries and write their first person stories. Everything I got back from my co-authors in Australia, Canada, Chile, Japan, and Sweden was incredible. However, if I included their full narratives in the paper we would be well over our word limits. (Remember, we have to follow the rules.)

Then I was faced with the difficult task of determining which parts of the personal narratives would need to be cut, including my own. As a patient advocate I found this really hard to do because the stories and lessons learned were deep and meaningful. How could I be so egotistical to edit someone else’s story? This is how I learned how helpful and necessary it is to work with a co-author who is not emotionally tied to the writing.

Tom Delbanco stepped in and brought everything to the chopping block. As a veteran clinician researcher, Tom’s work has spanned more than five decades. The man’s C/V is nearly 50 pages in length. Tom knows how to write… and he knows which parts of a paper will cut through and land with an audience. His editing was crucial to us meeting the word limit for this paper. If you read “Six countries, six individuals” and marvel at the brevity of each story, this is due in part to precision editing from Tom.

Similarly, it was Jan Walker who took my rudimentary intro and conclusion and molded it into its final form. The spirit of my original drafts are still there, but there are certain words and turns of phrase Jan offered that truly elevated the story we wanted to tell.

If Tom was a scalpel, Jan was a sculptor. The two have decades of experience in working together and it shines through in the final version of this paper.

7. Author order is assigned by how a person contributed to the manuscript

I am listed as the first author of the paper because the idea was originally mine and I took the lead in starting the first drafts, crafting the first-person structure, and in coordinating with all other authors. The authors from Australia, Canada, Chile, Japan, and Sweden were listed next in alpha order by last name because I felt they all contributed equally. (The patient/care partner stories were published in order by who sent me their drafts first.) Jan and Tom are listed as co-senior authors because they mentored me throughout the process, and did a lot of heavy lifting in generating ideas and in editing. This paper could not have happened without them, TBH.

8. Review by a journal might take a long time—be persistent

We submitted this paper via the BMJ online submission site in mid-January 2020. The journal said we’d hear back within a few weeks. And then COVID happened which turned the world of medicine upside down and delayed all journal review processes. I received a message letting me know that publishing priority would be placed first on anything that was related to COVID.

By mid-April I decided to check in with the journal again and see how things were going. The response I received surprised me: the BMJ could not find anyone to peer-review the paper, and they asked me to suggest a few names of potential reviewers. I was shocked they had not told me this sooner because it certainly delayed the review process. I also found it interesting that a journal could not find adequate “peers” to review a paper written mainly by patients and care partners.

To me, this is a sign of changing times. As patients continue stepping into roles where they partner with researchers, and/or have their voices shared in academic journals, who is considered a “peer?” One of the things I like about the BMJ is their commitment to involve patients and the public as reviewers in research papers. If anyone can figure this out, it’s the BMJ.

Timeline

From first ideas to publication, this paper took three years! I heard it can take a long time for academic publications to come together, get reviewed, and hopefully be published. I learned this lesson with my very first attempt.

Much of the delay had to do with my inexperience, with a little to do with a high bar for excellence set by Tom and Jan. Additionally, about a year after starting this paper I realized we could add stories from two additional authors (Canada and Australia) which required us readjust the word count again and edit more. Were I to attempt a paper like this today, I imagine I could make it happen in 3-6 months to a year; although, a journal today would likely want to see this written by people who tested positive or were hospitalized for COVID. (Free idea to those facing COVID!)

“Six countries, six individuals” is the first paper I ever worked on, but the eighth to be published (and my second as first author). I am incredibly proud of this paper for its quality and content, and honored to have worked with patients and care partners from around the world. I could write a whole other blog post about how awesome they are, so please follow them on Twitter: Selina Brudnicki (Canada), Maho Isono (Japan), Sara Riggare (Sweden), Cecilia Rodriguez (Chile), and Louise Schaper (Australia).

I have now been part of writing a handful of academic papers (some published, others in progress) over the last three and a half years. My contributions to all of these works have been influenced largely by the opportunity to collaborate with Jan and Tom on “Six countries, six individuals.” For this I am forever grateful.