Without publication, science is dead.
Gerard Piel1
We love academic medicine. We have been fortunate to have now spent over 25 years each as academic rheumatologists. The challenge of trying to create and disseminate new knowledge is something we particularly enjoy. But this is not without its frustrations. Let us relate a story—a sequel, in a sense, to a publication in this journal some years ago.2
One of us (NS) has been, and still is, particularly interested in the diagnosis, pathophysiology, and management of gout. Over 20 years ago at the Annual Scientific Session of the American College of Rheumatology (ACR), she and her colleagues presented a study demonstrating the value of topical ice as a treatment for acute gout flares.3 She learned of this treatment from a mentor at the School of Medicine at the University of Pennsylvania who had gout. For every gout flare, he would take 20 mg of oral prednisone and place an ice pack on the involved joint. He experienced significant and immediate relief when the ice pack was applied.
While perhaps an unusual and nonmainstream—or complementary or alternative—treatment, it was not an outlandish or unreasonable notion. Water in its frozen state has been used for millennia to treat inflammation. Indeed, William Harvey, considered to be one of the founders of modern physiology, was described in the 1600s as “much and often troubled with the gowte and his way of cure was thus: he would sitt with his legges bare…putt them into a payle of water till he was almost dead with…and so ’twas gonne.”4 Although it may have lacked the intellectual excitement and appeal of new (and expensive) therapies, the ACR presentation was received with considerable interest. Our study had also shown that patients in certain circumstances benefited from this treatment.
The manuscript was submitted to an important medical journal. It was summarily rejected without review due to “lack of interest.” Given how well the presentation was received at the ACR meeting, we requested reconsideration. Six months later, 10 pages of comments were returned. The reviewers’ critiques were addressed diligently, and we resubmitted the paper. A second set of comments were received, stating that the article was “extremely interesting” but requesting additional data analyses. Before this could be done, the consulting statistician was lost, and the new one insisted that all the data be reformatted, after which he declined to further assist in the study. The journal refused to reconsider the manuscript. Meanwhile, Dr. J, who saw 1 patient in the study, demanded authorship; Dr. H, who provided the hand that was photographed to illustrate the technique, demanded authorship; and Dr. W, who rotated on the wards during the study, also demanded authorship. In addition, the 2 statisticians, who never completed their analyses, demanded authorship. Acquiescence might have led to almost as many authors as study patients, which is never a good sign.
In the following years, there were frequent inquiries about the study and requests for reprints, but, alas, the work remained unpublished and encountered several more rejections. More than 6 years later, the editors of this journal accepted the manuscript for publication, much to our delight.2 It was also reviewed that same year by the NEJM Journal Watch.5
Since then, the results have been included in several gout treatment guidelines, the latest of which was the 2020 ACR clinical practice guidelines for gout,6 and have been used as adjuvant treatment in gout trials.
In the struggles of getting a study published, the tale of William Kaelin is encouraging. He, the recipient of the 2019 Nobel Prize in Physiology or Medicine, received a C– for an undergraduate research project, accompanied by the comment, “‘Mr. Kaelin appears to be a bright young man whose future lies outside the laboratory.’”7 Most of us will fail at something, sometimes. It is how we respond to those instances that is important and, perhaps, defines us.
Academic medicine, as rewarding as it is, is not without its vicissitudes, among them the challenges of publishing. There are many thoughtful essays with expert advice on successful medical writing, but these are beyond the scope of this brief narrative.
Instead, we emphasize the enormous satisfaction in conceiving an idea, formulating a hypothesis, testing it, validating it, and sharing the results and implications with colleagues. However, the process of translating that concept into a peer-reviewed journal sometimes requires uncommon patience, diligence, self-confidence, perseverance, and the ability to accept criticism. More than that, we all need to maintain a sense of humor to keep our journey in perspective. Those who succeed in publishing their work are the better for it, and hopefully, so are our patients.
To get to know, to discover, to publish—this is the destiny of a scientist.
Francois Arago8
Footnotes
NS received research grant funding from Amgen and consulting fees from Horizon Therapeutics, Johnson & Johnson, LG Chem, and Novartis. VSS is a former employee of, consultant to, and stockholder in UCB Pharma. This is personal work by VSS and does not necessarily reflect the opinions of the Peace Corps or the United States Government. RSP declares no conflicts of interest relevant to this article.
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