Are any editors aware of support groups for authors who have something original and important to say but suffer from obsessive anxiety that inhibits their ability to pursue their ideas to fruition? I have been working with such an author for many months. The ideas are exciting, original and important. The author can set out logically and clearly all the necessary facts and inferences, has an excellent literary style, but has repeatedly baulked at the final stage, cannot and will not submit a paper for publication because of an obsessive and groundless fear that the work will be judged worthless by peers in the discipline. My admittedly rather superficial inquiries about the prevalence of this condition suggest that it is not uncommon among creative artists and writers, which leads me to wonder whether there is/are support group(s) for victims. If so, the location of afflicted individuals would not be an impediment in this electronic age. Any helpful ideas will be gratefully received.

John Last
Emeritus professor of epidemiology, University of Ottawa

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John Last asks, "Are any editors aware of support groups for authors who have something original and important to say but suffer from obsessive anxiety that inhibits their ability to pursue their ideas to fruition?"

The peer review "system" can be seen as distant, omnipotent, inaccessible and not open to appeal. John's author may have had bad experiences with earlier manuscripts that reinforced his anxieties.

The article by Juan Miguel Campanario "Rejecting Nobel class papers and resisting Nobel class discoveries" (available at http://www2.uah.es/jmc/) contains short narratives by a number of Nobel prize winners about their experiences with rejection and incomprehension. It may not be much of a consolation to the insecure author, but then again it may help him understand that rejection is a normal and inevitable part of peer review for highly original ideas.

Best wishes,
Karen Shashok

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I deal with blocked scientific authors fairly often-being blocked is among the reasons an author might seek out an author's editor like me. Being a non-native English speaker isn't the only reason.

I'm surprised by your description of an author that "can set logically and clearly all the necessary facts and inferences, [and] has an excellent literary style." I'm confused because that implies the author has submitted the paper to you already. Otherwise, how can you tell that that's true? Through conversation or e-mail? Being able to explain ideas in conversation or in e-mail—for an interlocutor who gives immediate verbal and nonverbal feedback—is very far from being able to write a good paper for remote readers who may come in all shapes and sizes.

In fact, for novice authors—who are not unintelligent persons or persons with no ideas or persons who can't express themselves well—drafting a paper is far from the final stage. It's more like a brave first step in coming out and exposing oneself to criticism or just lack of interest. Speaking as a "recovering blocked writer," I know.

The persons charged with helping a novice author, traditionally, are wise mentors and supportive colleagues. Unfortunately, not all authors find those. I don't know of any self-help groups for writers. Arty book store/cafes sometimes have literary circles, but I can't imagine a young scientist there, can you?

So, to start unblocking a scientific writer, I get him or her to talk about why the work is important on the phone. As soon as I see s/he has a clear idea, I cut off the stream of information. (No time for long conversations, but besides, I want to leave him/her hungry to tell the story.) Asking why the work is important is just a litmus test to see if the author has enough passion and a grasp of what the research was really about—you'd be surprised how many doctoral students have had their hands held throughout their research experience and don't have clear thoughts. Then I switch to a new question: Can you describe the research design for me? If I get another confident barrage of information (usually the case) I again cut him/her short once more and say something like, "Yes, why don't you write that down, more or less the way you've told me. Just tell the story chronologically in the first draft. Then imagine you have to explain it to an intelligent undergraduate—make sure enough detail is there. Then look at the target journal and mold your draft of the research design story so it resembles the Methods section in that journal. When you've done that, call me again."

When the author calls again, I explain how to draft the Results section—often s/he has already taken that step, enthusiastic about being unblocked! If s/he seems to have more confidence, I ask questions designed to focus the approach to the Introduction. And so on until there's the makings of a paper I can begin to "author's edit".

There are variations on that process, but the key to unblocking scientific writers for me has been not to start at the beginning. Not from the Introduction and never from the Abstract. Work from the Methods section forwards and backwards. Later, through revision rounds of the full paper, different sections are perfected at different rates.

At some point the author clearly feels pretty good about the paper, even exhilarated. Then s/he's generally eager for the opinion of whatever peer reviewers a journal editor feels like throwing at it!

It may seem inefficient to fluent writers, but it seems to work. It's certainly no less efficient than weekly support groups!

M.E. Kerans
Barcelona, Spain

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I agree with M. E. Kerans. I think one point to start unblocking scientific writers is to educate them. For that reason since some years ago, at a Latin American congress of medical students (www.felsocem.org), we include a workshop dealing with these matters (with participation of med students and medical editors; eg, David Sharp, Deputy Editor, The Lancet, Paraguay 2000) and trying to educate those medical students how to write a scientific paper with a high quality to be published at any peer-reviewed international biomedical journal. We have also a Latin American med students' journal that is peer-reviewed, indexed at Imbiomed, called CIMEL, that serves an option to publish for these med students.

This is an important activity that should be followed by many organizations, specially professional ones.

Most people don't know it, but in these medical congresses we encourage students to submit their research papers with the similar guidelines or instructions to authors used by most medical journals, which we consider better than just submit a brief abstract. Then, those papers are more easily adaptable to any journal.

In one med students journal where I serve as Editorial Advisor we strongly support any student who needs to be helped in the final stage of his/her research, just previously to submission to the journal. And additionally the med student scientific society to which belongs the journal, also help in early stages, including planning of medical research and referral to scientific mentors or advisors.

I think this could be also implemented in some scientific societies' journals.

A. J. Rodriguez-Morales
Caracas, Venezuela

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I have found that those with deep-seated fears of rejection, so deep that they cannot mail a manuscript, almost never become productive scholars. However, in the work I have done in Kenya, I have found that the problem is not necessarily fear of rejection, but rather not understanding the structure of a manuscript. They often write in a stream-of-consciousness way that is almost impossible to edit into a decent manuscript.

To overcome that, I have tried to tell them that a scientific article is not creative writing; it is a structured report, and the structure can be learned. To facilitate that process, I have created the table below that I ask them to fill out. I then cut and paste the contents of the table's cells as the paragraphs which can then be edited into a serviceable manuscript. This has not been used a lot yet, so I can't tell you how useful it is, but I've had a lot of people (both Kenyan and American) ask me for it.

TITLE PAGE
Write the paper's title below:
List the study's authors (one to a line, including middle initials and highest degrees):
List the paper's authors' institutions (in the same order as the authors):

INTRODUCTION
Provide a brief discussion of the general topic: Why is it important?
Provide a brief discussion of prior work by you and/or others:
Provide an explicit statement of your study question/hypothesis:

METHODS
Describe your study site:
Describe your study population (source, inclusion and exclusion criteria):
Describe your recruitment methods in detail:
Describe your intervention (if an interventional study):
Describe the data you collected and how you collected them:
Describe your data analysis in detail (dependent variables, independent variables, comparisons, primary and secondary analyses, statistical methods used, p value accepted as significant, etc):

RESULTS
Describe your subjects: numbers approached, enrolled, excluded, characteristics (do not repeat table data—describe the table data in qualitative terms, where possible)
Describe main analysis results (again, do not repeat table data):
Describe secondary analysis results (again, do not repeat table data):

DISCUSSION
Write down the most important take-home point you want the reader to remember. Do not merely repeat the results. Then provide commentary based on what prior relevant studies have found.
Write down the second most important take-home point and discuss it.
Write down the third most important take-home point and discuss it. (Some papers will not have 3 take-home points.)
List and discuss the study's limitations:
Write down your conclusions (usually a repeat of take-home point #1):
Give future directions (often the next study you want to do following this one):

Bill Tierney
Co-Editor-in-Chief, Journal of General Internal Medicine

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Tierney, William M wrote: I have found that those with deep-seated fears of rejection, so deep that they cannot mail a manuscript, almost never become productive scholars.

Many years ago, I read a very interesting and then quite popular book called Women in Academe. One of the things it discussed was that many women tended to wait to publish until they had completed a large enough body of research that would be intellectually complete. The author argued that men tended more towards the 'salami science' model, publishing a series of small pieces along the way to a similarly ambitious project. The former strategy is not only problematic because it delays publication and interferes with the tenure process, but also because these more monolithic manuscripts tend to have a much harder time in review when they are eventually submitted because they are harder to understand and require the new model to be accepted as a block. I would imagine that with so much more riding on it, they would also produce greater anxiety before sending out.

One of my senior colleagues referred to this non-productive strategy as 'pretender syndrome'. You are afraid that you just aren't as good as everyone else, try to hide it by not publishing. and try to prove it's not true by taking on large, ambitious (and potentially undoable) projects.

Trying to help junior faculty avoid this and provide them with support in breaking off smaller pieces that could be reviewed and published was a major function that several support groups for junior women faculty that had been started at different institutions I have worked for. Similar non-gendered publication support groups have been organized where I am now to get people out of that rut. If one is not available for people having problems churning papers out, they aren't hard to start and almost always get the support of the administration. After all, the administration wants you to publish.

Nancy Darling

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This has been an interesting thread and I would like to offer the following classification of writer's block, which people might find helpful.

(1) Early onset writer's block: this is when writers can't get going. Part of the problem is that they have too much data and too many references and don't seem to have a grip on where they should start. My preferred solution is to send them off on a long walk—the goal of which is to get them to define their key message in one simple sentence. They find this incredibly difficult, but once they have done it they can start moving forward.

(2) Mid-stream writer's block. This is when writers start off promisingly, but come to a sudden halt. The problem here is that they haven't really worked out what they are writing—and for which journal. Like the previous state, the cause is lack of clarity, and the answer is having a clear message—plus a plan.

(3) Writer's block by proxy. This one is caused by anxiety. Writers spend happy hours fiddling with the data, or churning through the databases because it gives them the illusion of making progress while ensuring that they do not have to commit to paper - and endure the heap of criticism that inevitably follows. The answer, as previous contributors have said, is to try to have a genuinely supportive environment.

Tim
Tim Albert Training

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I want to express my opinion regarding the issue I have been reading with great interest. Being a scientist, teaching professor and author of many articles on medical issue I concur completely with the first 2 points of your writer's block classification. Indeed, before starting scientific manuscript writing, it's necessary at first to work out a detailed plan of what you want to write, like planning the scientific research. Naturally, there may be certain cases, and they are numerous, e.g. other urgent matter businesses, professional, family or private affairs, muse absence or laziness, and, as you notice, an extremely large volume of basic information, that can interfere with your work. In such a case it's better to leave this work and do something else, to return to it when muse comes or, to be more correct, when the aims and purposes of your manuscript are matured in you completely.

What could be advised to junior staff before starting the work?

1. To realize self-critically whether everything you consider urgent, new, and practically significant is really such for medical science in general.
2. To work out a minute plan of the work
3. To carry out detailed search of the literature. Maybe what you want to write was written long ago.
4. To write in competent literary medical language. You can't be sure that phrases and words that are clear for you are as such for the reader.
5. To give the manuscript to the most authoritative scientific opponent in your given sphere for informal private review before publication.

In conclusion I want to note that such discussions are very useful both for junior colleagues and for us too.

Rouben Hovanesyan
Chief Editor, Armenian Medical Review Journal

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