The following excerpt is reprinted with permission from The Trouble With Medical Journals (Taylor & Francis, 2000).
When Anthony Trollope sat down at 5.30 in the morning day after day to write his 47 novels he wrote every word. Editors and publishers no doubt proposed ideas and suggested changes. But the work was his. He was a true author. Mostly it doesn’t work like that in research. Many people with different skills are essential. Writing the paper may be one of the easiest parts of the process, and sometimes may be undertaken by a professional writer who has had nothing to do with the research. Authorship is thus, I will argue, the wrong concept for research studies, but it’s a concept with great tenacity. It is the coinage of academia, and academics have proved reluctant to move away from it to something [I] call contributorship.
Authorship is about credit and accountability. Authors are most interested in the credit, whereas editors are most concerned about accountability. Publishing papers in important journals is the main way to progress in the academic world. Those who publish the most will be promoted the fastest, win the most grants, get paid the most, and find their way to the best universities and departments. Increasingly departments and institutions are themselves judged on the amount they publish and where they publish. The cliche ‘publish or perish’ is known beyond the academic world — and is largely true. It’s often also more a matter of quantity than quality. So there are huge incentives to publish as much as possible.
The number of authors on papers has increased steadily in recent years. Some studies in molecular biology have over a hundred authors. Some of this increase is no doubt legitimate in that it reflects the increasing complexity of science and the need for teams of people with different skills. But some of this increase is probably illegitimate, driven by the need of individuals and institutions for publications: authors are included who have done little or nothing, a practice that has been called ‘gift authorship’ (164-166).
Putting your name to a paper should be like signing a cheque, a major undertaking, but often it isn’t (167). Gift authorship is a form of deception. It’s particularly troublesome to editors when there turn out to be serious problems with the paper and yet the gift authors will not accept any responsibility. I described several florid cases in chapter 8.
So who should be an author? Some academic institutions have attempted definitions, but the best known definition is that produced by the International Committee of Medical Journal Editors (which is widely known as the Vancouver group because it first met in that city in 1979) (168).
What is the legitimacy of this group to define something so important for academic life? One answer might be ‘none’. The group, of which I’ve been a member, is self-appointed and comprises the editors of the major general medical journals from the United States and Britain. There are some editors from other countries but very few, and only one or two editors are from journals not published in English. International is a misnomer. It has no constitution, no clear mission, no secretariat, no funds and no leaders. It was started by Stephen Lock, my predecessor as the editor of the BMJ, and Ed Huth, the editor of the Annals of Internal Medicine. And its great achievement was to get these major journals (and subsequently many others) to agree to use one system of referencing. This meant — in the days before word processing — that authors (or in reality their secretaries) did not have to keep retyping manuscripts as they worked their way down the food chain of journals. The group has continued to meet every one or two years and has now produced guidance on many aspects of publishing medical research. Some of this guidance has been used in institutions like the Supreme Court in the United States.
The legitimacy of the group to produce a definition of authorship (and other statements) stems partly from the fact that nobody else was doing so and partly from its potential ability to enforce the definition. Its initial definition of authorship was produced by the editors without any consultation. This meant, I judge, that it produced a definition that didn’t work in the real world. It has now, however, moved substantially towards supporting a policy of contributorship, but it continues to offer guidance on when a contributor might qualify as an author.
This is its current position (168):
‘An “author” is generally considered to be someone who has made substantive intellectual contributions to a published study, and biomedical authorship continues to have important academic, social, and financial implications. In the past, readers were rarely provided with information about contributions to studies from those listed as authors and in acknowledgments. Some journals now request and publish information about the contributions of each person named as having participated in a submitted study, at least for original research. Editors are strongly encouraged to develop and implement a contributorship policy, as well as a policy on identifying who is responsible for the integrity of the work as a whole.’
While contributorship and guarantorship policies obviously remove much of the ambiguity surrounding contributions, it leaves unresolved the question of the quantity and quality of contribution that qualify for authorship. The International Committee of Medical Journal Editors has recommended the following criteria for authorship; these criteria are still appropriate for those journals that distinguish authors from other contributors.
- Authorship credit should be based on 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. Authors should meet conditions 1, 2 and 3.
- Acquisition of funding, collection of data, or general supervision of the research group, alone, does not justify authorship.
- All persons designated as authors should qualify for authorship, and all those who qualify should be listed.
- Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content.
One important change introduced by these criteria is that authors are now publicly accountable for ‘appropriate portions of the content’. It used to be that authors were expected to be publicly accountable for the whole document. Indeed, the way that I remembered the definition and explained it to others was by the story of the lead author who was about to fly to Acapulco to present the results of the study and then was suddenly taken ill. If you could get on the plane to Acapulco that day, present the paper and answer all questions you were an author. If you couldn’t, you weren’t.
Raj Bhopal, at that time a professor at Newcastle Medical School, and others conducted a study in 1996 of what academics from every part and every level of the medical school thought about the Vancouver group’s earlier definition of authorship (169). They approached 70 academics and achieved a 94% response rate. Three-quarters of those they interviewed thought that there should be criteria for authorship, but few knew of any criteria. Only 16 knew of the Vancouver group, and only five knew the three criteria, which survive in the definition quoted above. One academic of the 76 knew that you had to satisfy all the criteria in order to qualify for authorship.
Most of the academics agreed with the individual criteria of the Vancouver group, but most thought it unreasonable to expect all three to be fulfilled. The need to fulfil all three criteria was viewed as inflexible and restrictive — and prejudicial to junior researchers. Many thought that the (then) requirement to be publicly accountable for the whole study failed to recognize the real world of multidisciplinary research.
More than half of those interviewed thought that the criteria were not usually adhered to, which fits with what is now a large body of evidence that shows that only a minority of authors of studies meet all three criteria (164-166). Indeed, something like one-fifth don’t meet any of them. The Vancouver group criteria just don’t fly in the real world. Many of those interviewed in Newcastle thought it inevitable that the criteria would be breached — often for reasons of ‘power, status, and “nepotism”‘. Some didn’t recognize the authority of the Vancouver group to produce a definition of authorship.
Many of those from Newcastle — and particularly the junior researchers — thought that the Vancouver definition gave too much emphasis to intellectual input and too little to practical work. Indeed, the Vancouver definition has been called ‘a senior author’s charter’. I know about this because, although I hesitate to describe myself as a researcher, I have conducted research on aspects of medical publishing with colleagues and medical students. Often the idea is mine, and I have a rough proposal for an experimental design. But it is the others who do all the hard work, sticking stamps on envelopes, chasing those who don’t respond, and compiling and analysing the data. Without them there would be no research.
One of those interviewed in Newcastle put it this way: ‘There needs to be a difference between intellectual contribution and the execution of work. You need to have made a contribution to one or the other but it may not be realistic to have both. The criteria seem to overlook the practical, doing the experiments. They seem to say if you have ideas you become an author, if you work in the laboratory 12 hours a day you don’t get on. It should be teamwork.’
Gift authorship was seen by those in Newcastle as ‘unethical, dishonest and unacceptable’, and yet it was thought to happen commonly. The reasons given for gift authorship were (in order of importance) pressure to publish, enhancing the chances of publication (by including a ‘big name’), to repay favours, to motivate a team and encourage collaboration, and to maintain good relationships. The ‘solution’ that was most favoured was to require researchers to sign a statement justifying authorship and to specify the actual contribution of each author. Limiting the number of publications listed in a curriculum vitae or a system of fixed credits per publication found less favour.
An important aspect of the Newcastle study was to show that problems with authorship are common. Two-thirds of the academics had experienced problems, most commonly being excluded from authorship when they felt that they deserved it. Many had vivid and bitter memories of disputes over authorship. At Harvard disputes about authorship accounted for 2.3% of 355 complaints brought to the Ombuds Office in 1991-2 and 10.7% of 551 complaints in 1996-7 (170). One-third of 51 German students who had published papers reported honorary authorship of the department head, and 16 among 201 students who had done research reported that they had been omitted as author from a publication despite having contributed (171). Disputes over authorship are often the origin of the long running feuds for which the academic world is notorious. Despite most respondents in Newcastle disapproving of gift authorship, one-third of the academics had included as authors people who had done little. Gifting authorship is one of the currencies of academic life.
The overall conclusion of the Newcastle study was that: ‘The strategy for communicating and implementing the criteria of the International Committee of Medical Journal Editors has largely failed. New initiatives should engage researchers and meet their legitimate needs. Future guidelines should be developed collaboratively and not be imposed on researchers by editors.’
So the academic community and medical journals have a problem. Authorship is of fundamental importance in the academic world and yet it is corrupted. Many people appear as authors when they have done very little, but at the same time people who have done a great deal of work, usually the practical work, are excluded. How can journals respond?
One response — tried by the American journal, Obstetrics and Gynecology — was to limit the number of authors. If your paper had more than six authors you were asked to justify why. One result was that a great many papers had six authors but another was that authors submitted studies that had more than six authors elsewhere. This may have damaged the journal because major studies — like randomized controlled trials — often have more than six authors. It was a crude response to a complex problem.
Another solution suggested by the Newcastle researchers and tried by us at the BMJ was to ask everybody to sign to say that they met the Vancouver group criteria. We also tried to respond to the problem of people being excluded from authorship by asking the authors to sign to say that there wasn’t somebody who met the criteria but hadn’t been included. This solution hasn’t worked. The number of authors has not changed and later research has shown that many people who appear as authors do not meet the criteria. Editors can go only so far in ‘enforcing’ a solution, and it doesn’t feel comfortable to be operating like a policeman.
Something much more radical was suggested in JAMA in 1997 by Drummond Rennie, Veronica Yank and Linda Emmanuel (172). They suggested abandoning the concept of authorship and moving instead to contributorship. Instead of making an inevitably arbitrary decision on who was and was not an author people would simply describe their contribution. It should be possible for people to agree on who did what. It’s simply a descriptive not a judgemental exercise. The sorting of people into the sheep of authors and the goats of the merely acknowledged seems to be based, unsurprisingly, on power. The powerful even if they have done little become sheep, while hardworking goats are excluded.
The great benefit of the contributorship system in my mind is that it can be informative, precise and honest. Contributors describe exactly what they did, and readers make up their mind on the value of the contribution. By making people either authors or not lots of information is lost, and there is a pressure to be dishonest. You want to include as an author somebody who has done a great deal of work but who doesn’t feel comfortable with being publicly accountable for even part of the work. So currently they are included as an author, but readers are deceived.
One immediate problem with such a system is the need to ascertain who will take overall responsibility. Otherwise, we may be left with the problem of a dishonest paper and only ‘honest’ authors. Rennie and others suggested that all papers should have guarantors, people who accept responsibility for the full paper (172). ‘Guarantors,’ they wrote, ‘are those people who have contributed substantially, but who have also made added efforts to ensure the integrity of the entire project. They organize, oversee and double check, and must be prepared to be accountable for all parts of the completed manuscript, before and after publication.’
At the BMJ we were convinced that we needed guarantors, but we were not convinced that they had to have double checked every aspect of the research. Would this be possible if the study includes molecular biology, statistics and economics? More controversially, did the guarantor necessarily have to have contributed substantially? Mightn’t the guarantor sometimes be the person who hired all the researchers even if he or she hasn’t contributed much to the particular study? In other words, guarantorship might be akin to the responsibility of a government minister. While sat in Venice writing this book I was the guarantor of the BMJ. The buck stopped with me. I fulfilled this role not through double checking every word in the BMJ and every decision taken, but by hiring good people and creating good systems. The BMJ thus adopted the ‘ministerial’ version of the guarantor, and, interestingly, it potentially revived in some way the tradition of heads of department putting their names on papers just as people countersign cheques.
The idea of Rennie and others was radical — and so naturally there were objections. People have described the contributorship system as being like ‘film credits’, and one anxiety was that studies would accumulate enormous lists of contributors — down to the ‘principal lady’s baggage carrier’. This has not happened. In fact the opposite has happened in that the sum of the contributions turns out to be less than the work that clearly had to be done. For example, papers have been published that nobody has written. Those journals — like the Lancet and the BMJ — that have adopted the system have so far allowed contributors to produce their own statement in straight text. The BMJ did plan to experiment with a matrix system, where the journal would list the activities that we knew had to be undertaken to complete and publish a study (conception, design, data collection and analysis, writing and correcting the paper) and then ask for an indication of which author did what. We didn’t want to be restrictive and would have allowed authors to add tasks that were not in our routine list.
Another objection is that the contributorship devalues authorship. All sorts of ragamuffins are now included. But the beauty of the system in my mind is that there should be no pretence, no deceit. If the ragamuffins simply made the tea then the contributorship statement will say so. Disclosure is once again a panacea.
One problem that is potentially solved by the system of contributorship is the problem of the ‘ghost author’, somebody who simply writes the paper. Such people are often employed by pharmaceutical companies, which has prompted great anxiety. Clearly nobody can be happy with a distinguished doctor receiving a ready written review article that is to be submitted to a major journal and being asked to append his name in exchange for $10,000. A bold doctor might be willing to declare that his contribution was to sign his name and bank the cheque, but this is a degree of deception that cannot be tolerated. Unfortunately, it happens, although I know of no data that say how often.
I did, however, recently meet a professor who told me that he sat next to a woman on a plane — in business class — who boasted that she had published more papers in major medical journals, including the BMJ, than any other living author. Yet her name, she said, never appeared. She was a champion ghostwriter and employed by pharmaceutical companies.
What is known to happen commonly is that a professional writer writes the paper. The other contributors will read the paper and make changes, but the professional writer does the donkey work of getting the first draft written. To my mind, this is no different from using a statistician, somebody with special skills, and is perfectly acceptable so long as it’s declared. Others differ. They think that the process of writing creates ideas and allows bias to suffuse through the paper. Professional writers should thus be banned. If a scientific paper were a novel or a poem I would agree, but it’s not. It should be as clear a statement as possible of what was done and found. Those parts of a scientific paper that are closest to a novel — the introduction and discussion — should be cut back ruthlessly. Furthermore, the other contributors — and particularly the guarantor — must approve every word of the final study. They are, I keep repeating, signing a cheque.
A more important objection to the system of contributorship is that the academic system of credit depends on authorship, and some journals moving away from authorship messes up the academic system. People who have contributed small amounts to a study will be seen as authors by a system that simply counts the names attached to a study. I can see the problem, but for me it is an argument not for editors abandoning contributorship but for academics adopting a more sophisticated system.
The information included in contributorship statements should be very useful to those awarding credits or making appointments. Do you want to appoint an ‘ideas’ person or somebody who is better at implementation? Contributorship statements will give you this information in a way that lists of authors will not.
Despite my enthusiasm for the concept of contributorship it has not been widely adopted. This is, I think, mainly a matter of time and conservatism — and there has been steady movement in the direction of contributorship by the International Committee of Medical Journal Editors. It can’t, however, take the logical step of abandoning authorship and moving wholesale to contributorship. Nor, I have to say, did the BMJ while I was editor. Academic medicine is stultifyingly conservative. It’s something to do with fear. Those academics who have fought their way to the top of the pile have done so through the present system. Any change in the system might expose the fragility they feel in their hearts.
A subject that I must discuss despite its unimportance is the order of contributors — because, although unimportant, it causes great distress. When correcting the first draft of this chapter I was in correspondence with a contributor ready to take extreme steps in a dispute over order of contributorship. I argued that she was fighting a battle without meaning, but she didn’t agree. I argued that the battle was meaningless because order of contributorship is uninterpretable. The traditions over order vary among disciplines, specialties, institutions and departments. Sometimes the ‘senior’ contributor (in itself a phrase with little meaning) is first, sometimes last, sometimes in the middle. Unless readers have the traditions explained to them they can’t infer anything from the order.
The Vancouver group has this to say (168):
‘The order of authorship on the byline should be a joint decision of the co-authors. Authors should be prepared to explain the order in which authors are listed.’
The adoption of contributorship statements would make the debate over the order of contributorship irrelevant. The information a reader might need is in the statement. But Rennie and others suggest that contributors meet together and agree on the relative sizes of their contributions and then list themselves in order of size of contribution. This is of course a matter of comparing apples and oranges (how does having the idea while in the bath compare with six weeks of data collection in the street?), and with such processes the powerful are likely to come out on top.
I want to end this chapter by commenting on an interesting paper by Richard Horton, the editor of the Lancet, that suggests that the idea that all the contributors to a study agree with its conclusions is often false. He builds on the insight of the French philosopher Simone Weill that, ‘All sentences that begin with “we” are lies.’ We can never know exactly what each other thinks. I use the quote whenever I talk about the media, a plural noun. The same might be said of sentences that begin ‘Doctors…’ or ‘Medical journals…’ There are probably many such sentences in this book. They are inescapable.
Horton began with the observation that there have been some high profile studies — for example, an Italian trial on the treatment of acute stroke — where contributors have disagreed openly, and sometimes bitterly, about the meaning of their study. (173-175). He selected 10 papers published in the Lancet in 2000 and wrote to the 54 contributors asking about the studies’ results, strengths and weaknesses, interpretation, implications, and meaning for further research. Overall he found substantial disagreement among contributors, but this diversity of views was not reflected in the published papers. Weaknesses of the study were played down, and the discussion section of papers was poorly organized and didn’t address many scientific questions that they should have addressed.
Perhaps we shouldn’t be surprised by this. Simone Weill has pointed out the problem, and we know that many people describing a comparatively simple event will give very different descriptions. As the film maker Robert Evans said, ‘There are three sides to every story: yours, mine, and the truth.’ This might be extended upwards to any number of people, and the only version that I would disbelieve completely would be that labelled ‘the truth’. Who would produce it?
One response to the problem Horton has identified might be to require structured discussions, a suggestion that I made together with Mike Doherty, who was at the time the editor of the Annals of Rheumatic Diseases (176). But a more interesting response might be to make discussions exactly what the word implies. Instead of presenting one discussion contributors might display their different views.
Moves away from authorship towards contributorship, and possible future moves to reflect the diversity of views of contributors, all help to move us beyond the illusion of a scientific paper as an objective artefact to a living, human and therefore imperfect document.
More From The Trouble With Medical Journals
- Introduction: Medical Journals Are Probably a Force for Good but Need Considerable Reform
- Why Bother With Medical Journals and Whether They Are Honest?
- What and Who Are Medical Journals For?
- Can Medical Journals Lead or Must They Follow?
- What Are and What Should Be the Values of Medical Journals?
- The Complexities and Confusions of Medical Science
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