Perception and attitudes versus medical writing skills.

This issue contains two original articles focusing on the knowledge, perceptions, attitudes and thoughts among undergraduate healthcare students.[12] This editorial is aimed at two broad groups, our journal readers who will learn from these articles and the authors who conduct and report such surveys. I must, therefore, begin with a cautionary note that my comments are simply to improve the quality of such work and better understanding of how to use this knowledge in daily practice. What this editorial will focus on is the perception and attitudes of the authors as well as how it will influence (empower or mislead) the readers.

Introduction: This section should be brief and to the point. It should be limited to purpose and objective of the study. Specific statements that are pertinent should be supported by up to date references. Latha et al. have stated that there are “less than 100 pediatric oncologists” in India and “India is still far behind current international standards.”[1] These are very strong statements and must be supported by references. Their second paragraph in the introduction describes the rationale for their study, again without a single reference. The second study among dental students of Shimla fails to specify that several such surveys have already been conducted from India, – including among dentists.[23456] This conveys a misleading impression to the readers and should be avoided

Methods (and Materials): This should not duplicate what is already said in the introduction and should not contain results - data that are to be included in next section. The first sentence in Sneha Latha's methods is not necessary.[1] So also statements that the conference was attended by 240 students of which 206 participated belongs to the results section. In the Shimla article, whether the questionnaire used was developed by them or did they use a published one has not been clearly specified.[2] The reference cited have used different questionnaires.[378] Hence, it can be claimed that the Shimla questionnaire has been previously validated only if they used a previously published questionnaire without change, in which case due credit should be given by citing the reference of the original publication

Results: Use of adjectives like “only,” “few,” “never,” ‘overwhelming” and “huge cost” should be avoided as a general rule and especially in the results section. The data should be provided in a neutral manner in this section without introduction author bias or perception. Also inserting words (huge) which are not part of the questionnaire betrays the bias of the authors and can be considered as flaw in the development and validation process.[1] Vague statements like “answered correctly the basic questions about childhood cancer” should also be avoided. Whether the answers are correct or not are the interpretation/conclusion of the authors and cannot be part of the results section. Therefore careful attention paid during proper design of the questionnaire is vital to prevent bias. For instance, the question “in which way are you interested in supporting the pediatric oncology patients” presumes that the student being surveyed is, in fact, interested in doing so. There is no option for him/her to answer that there is no interest. As a result, there is misleading conclusion in the second last paragraph in this section in the article by Latha et al[1]

Discussions: This section should start immediately by discussing the results of their own study. What is described in the introduction should neither be repeated nor be elaborated here. Other common issues in this section includes:

Statement about developing countries without any reference from India[910]

Making comparisons to non-Indian studies, even when Indian data is available[91011121314151617181920]

Making conclusions not supported by own results

Failure to point out contradiction (especially as related to the results). – Knowledge lacking, but they are still able to teach their subjects

Unnecessary and irrelevant discussion on data from other studies[152021]

Using superlatives unnecessarily

Now I will give specific examples from these two survey manuscripts.

“Smoking and alcohol consumption were correctly reported as risk factors by 63.5% of subjects, which is <92.4% as reported by Soares et al. and 94% as reported by Lachlan M Carter and 79.2% as reported by Omolara.” There are several Indian references on alcohol and tobacco as risk factors which were not cited[910]

“92.5% of the subjects educate their patients on the adverse effects of alcohol and tobacco and assist them in cessation, which is higher than 82.1% as reported by Soares et al.” There are several Indian references on adverse effects of alcohol and tobacco which were not cited.[910111516] Furthermore, the contrast to the 31% of dentists educated their patients on the adverse effects of these habits as reported in the survey paper by Vijay Kumar and Suresan, should have been cited in comparison[3]

At one place it is mentioned, “about 1/3rd of the population disagreed that their knowledge about prevention and detection of oral cancer is current and adequate” whereas at another place in the same manuscript the authors state, “only 7.5% of the subjects reported that their knowledge regarding the prevention and detection of oral cancer is current and adequate.”[2] Such discrepancies must be avoided by careful whetting of the manuscript before submission.

In the same manuscript, regarding additional training and information about oral cancer, the figures is 99% at one place and 99.1% at another place. I wonder why change from zero to one decimal place was thought to be necessary by the authors[2]

“Out of total 118 questionnaires that were distributed only 107 were received back which means the response rate of the study was 90.6%.” in this statement the word “only” reflects the “modesty” of the authors. In any survey, a 90% response rate is commendable and quite impressive

“This study is the first to assess the knowledge, attitude and practices about oral cancers ….” Such claims about “firsts” are usually incorrect and frowned upon by most editorial teams – with very rare exceptions

“Worryingly low exposure” and “very few dedicated lecture classes” are subjective words, which should only be used if backed by substantial data, quoting the proper reference[1]

“Policy makers should make use of such studies to quantify the burden of childhood cancers in India.” The survey cannot be considered as robust data to quantify the burden of childhood cancer in India.[1] Besides, there actually exists solid data that shows the author's statement to be factually incorrect[22232425]

“Preventive activities through educating patients about the risks associated with etiological factors and smoking cessation need to be emphasized in the school curriculum to enable students to help their patients make choices for healthier lifestyles.” This conclusion is not based on the survey results or the objective of the study. How is this statement made in relation to the “school curriculum” when the survey is involving undergraduate healthcare students?

“We in developing countries are still striving to bridge the gap between the need and availability in various sectors such as infrastructure, trained staff personnel and fund resources.” The gap of unmet need with relation to infrastructure, trained staff as well as funding exists in all countries – developed or undeveloped. There are several references to this effect.[1819202627] Such a statement would be relevant only if specific gaps are identified by the survey and then discussed

“More than 50% of medical colleges have no facilities or expertise for treating cancer children.” Such an important statement cannot be made without citing a proper reference. There are more than 300 allopathic medical colleges and each one has a specified curriculum that is available with the concerned health university. They also require infrastructure and facilities as per norms of Medical Council of India. On the other hand, what percentage of these has facilities or expertise for treating pediatric oncology is open to conjecture. The fact may be that such facilities are not available in more than 90% of such medical colleges

“Most of the countries have started short summer training programs for their undergraduate students to make them more knowledgeable in the field of medical oncology.” This is one more example of citing a European reference when there exists literature about such training from within India[212228]

One of the article also refers to the need for “teaching undergraduate communication skills.” Here again there is no reference cited, whereas there exists a large body of work done in this subject from India[29]

References: Incomplete and outdated references are the common problem faced by the editorial team. The two survey reports in this issue are a very good example of contrasting styles. The first one has almost half (7/15) the references from India and two more are from developing countries. On the other hand, the Shimla article has only 2 of the 16 references are from India, and 6 of these were published before 2009. There are at least 20 articles from India on oral cancer and surveys in the last 4 years in PubMed – only one of which is cited.[4567] Furthermore, there exists at least 400 articles on tobacco and oral cancer from India in PubMed in the last 4 years, including two special issues of Indian Journal of Cancer on smokeless tobacco – only one if which is cited[910]

Tables, Figures, Graphs, Photographs, Images: The two survey articles do not have any figures, graphs, photographs or images. Their aspects will be dealt separately in a future editorial.[30]

In summary, medical writing is a vital component of skills required in healthcare professionals. It's formal training is often found lacking. Young healthcare professionals and students must give it the adequate attention and nurture their skills to be successful academically. The casual attitude of yesteryear is no longer acceptable.