Authors of articles published in medical journals are often busy researchers who cannot afford time devoted to writing. Though they are experts in their own therapeutic area, more often than not, researchers find it difficult to actually write and publish their research. Professional medical writers with their expertise in writing clear, concise, comprehensible, and coherent content are often a great support to researchers. Their contribution to the manuscript is usually focused on getting a manuscript ready for publication. They are not authors unless they make substantial contribution to the study according to the guidelines of the International Committee of Medical Journal Editors (ICMJE). However, medical writing is not the same as ghostwriting. Ghostwriting is unethical. Medical writers can be legitimate contributors to the medical manuscript. Several international guidelines including the ICMJE guidelines require authors to acknowledge the contribution of medical writers in the published article. Medical writers whose name is publicly associated with the article in turn make an extra effort to ensure that all applicable publication ethics and style guidelines are adhered to. This article discusses the current international guidelines about the acknowledgement of writing assistance. It also emphasizes on how acknowledging medical writing support can go a long way in curbing the menace of scientific misconduct including ghostwriting.
Keywords: medical writer, ghostwriter, authorship, ethics in publishing, acknowledgement
Medical authors try to communicate the results of their research, clinical practice or thinking to their colleagues by writing about it in medical journals. Generally, they are amateurs in the field of writing. Not all amateurs do a poor job when writing for medical journals. Yet, professional medical writers are more likely to do a better job since that is their forte. Specialization always helps. Medical writers specialize in writing for the medical domain.
Way back in 1963, McVeagh had suggested making the medical writer a member of the research team in such a way that the medical writer’s responsibility is “the presentation of the researcher’s results” (1). However, several questions need to be answered before thinking of hiring a professional medical writer.
Is it not necessary that the researcher should write his own paper?
Clinical practice and lives of patients depend on what is published in medical journals. Is it not necessary that the paper should be written by an expert in the therapeutic area? Are professional medical writers also therapeutic area experts?
How does a professional writer improve the quality of the paper?
Should the writer be included as an author of the paper? Who should be included as authors?
Will not including the writer as an author because he has not contributed substantially to the research, amount to ghostwriting?
Is there an ethical method by which the expertise of a medical writer can be used in order to enhance the chances of acceptance of the manuscript?
This paper attempts to answer such queries regarding professional medical writers. In this paper, we try to explore the role of professional writers in the medical publication process. We also try to find out if there is an ethical method of using the expertise of a medical writer without being accused of promoting ghostwriting.
Writing your own papers
For a researcher, there is possibly nothing as perfect as writing and publishing his own research results. Nobody understands the research and its results as clearly as those who did the research. Yet many physicians do not publish a single paper in their lifetime. There are many who publish a couple of papers but do not publish all of their research. They have a lot to report but end up reporting only a few cases or studies.
What impedes publishing in a medical journal?
Many physicians do not write a paper simply because they believe their research is not worthy of publication. Unless the results are published, the research remains incomplete. All research needs to be published. Many physicians, at least in the developing countries, are overloaded with clinical work and have very little time to write their own papers and publish them. They cannot afford time that is devoted to writing. Some others are unaware of how to choose the right journal and how to carry out the entire process of publishing an article. In situations such as these, hiring a writer comes in handy.
Experts in their own fields
Does it help if the medical writer is a therapeutic area expert? Yes, in many cases, it does. Is it necessary for the medical writer to be an expert in the therapeutic area? No.
The responsibility of the content of the published article lies on the authors. The authors are experts in their therapeutic area. Medical writers are experts in their own field, i.e., writing. They help in making the communication timely and compliant with universally accepted standards or according to the specific style that the targeted journal follows.
The international competency model for medical writers does not suggest therapeutic area expertise as a requirement (2,3). Instead, it lists several other competencies for being an effective science communicator, e.g., knowledge of publication and style guidelines, knowledge of publication ethics, language and grammar skills, computer skills, project management skills, etc.
Professional medical writers come from diverse backgrounds. They usually have advanced degrees in life sciences and many may even be physicians, dentists, nurses, pharmacists and PhDs. They combine their understanding of science with an ability to communicate the message clearly through their writing skills.
The medical writer integrates inputs, expertise and opinions of the authoring team into the document and communicates the information in such a way that it satisfies the readers’ needs (3). Sometimes, it may be advantageous if the writer is a non-expert in the concerned therapeutic area. A therapeutic area expert may subconsciously leave gaps in the writing because he may feel others will understand the content as well as he does. As a result, the content may not be clear and logically presented.
How a professional writer helps
Because of the interdisciplinary nature of medicine and the wide access to journal articles, articles on a highly technical topic may ultimately be read by experts in the niche field as well as by people from other disciplines. For example, an article about a clinical trial on the use of ruboxistaurin mesylate in diabetic retinopathy may be read by clinical research professionals, endocrinologists, ophthalmologists, pharmocologists as well as general physicians. Today, even patients and their caretakers reach out to articles published in medical journals to enhance their understanding of the health conditions, the treatment options available and the potential complications of the disease or the therapy. The professional writer is at times a non-expert in the therapeutic area. Yet, he or she understands the need for the content to be concise, comprehensible, clear and coherent (the four Cs for an effective communication). The medical writer, through his or her expertise in writing, adds logic and flow and improves the style of writing making high end research articles comprehensible to the reader. A good professional writer identifies and fills any gaps in clarity and flow. This ensures that the end product is a clearly written manuscript with no ambiguity in the content. If a document lacks in clarity, the actual thought that the authors want to communicate may be lost (4,5).
Each year, reviewers and editors return several manuscripts for revision or even reject them because of poor writing styles, poor organization of the content and even poor English and grammar (6,7). The writers organize the author’s thoughts in such a way that the sentences and paragraphs are connected to each other in a logical sequence. They help putting medical jargon into plain, reader-friendly language so that the readership is increased. Professional medical writers are aware of and adhere to ethical publication practices. They ensure that all relevant guidelines and style formats are followed. This reduces the number of review cycles and enhances chances of acceptance and publication.
The authorship dilemma
Considering the amount of contribution medical writers make to the preparation of the draft and even of the final manuscript, should they be listed as coauthors?
It is not mandatory to include medical writers as authors as they may not make substantial intellectual contribution to the article. According to the International Committee of Medical Journal Editors (ICMJE) Guidelines, an author apart from contributing to the preparation of the manuscript, also contributes to the concept and design of the study as well as to the data acquisition and/or analysis (8). Even the European Medical Writers Association (EMWA) insists in the guidelines for its members that medical writers who do not qualify the authorship criteria of a target journal should not agree to be listed as authors (9). EMWA guidelines point out that “professional writers are unlikely to be named as authors on primary research articles”. However, in case of review article, writers may qualify as authors if they have done an extensive literature search (9). Only those who agree to take public responsibility of the content should become authors (8,9).
The interaction between the professional writers and the authors can be clearly defined using the GATE principles (10). Do the authors agree to Guarantee the article? Did they Advise the writer before as well as after starting the assignment? Is there Transparency about the contribution of a professional writer? Does the writer have sufficient Expertise or knowledge about the field or topic?
Most journal policies recommend that professional medical writers whose contribution to a manuscript qualifies them as authors according to the ICMJE criteria should be listed as authors. If their contribution does not qualify them to be authors, they should be adequately acknowledged in the Acknowledgement or the Contributors sections (11,12).
In countries where hierarchy plays a significant role in professional life, some physicians seek supportive assistance from their subordinates to undertake the entire process of publishing their own data. Any writing assistance of this nature should also go into the Acknowledgement section.
How the medical writers work along with the named authors
The named authors are responsible for all stages of the publication. In studies involving many investigators, the sponsoring company is encouraged to identify a ‘writing group’ or the named authors who collaborate with the professional writer in developing the manuscript for publication (9). The publication outline and the key message are first approved by the named authors and then the writer gets down to the detailed process of writing. Thus, the writer facilitates the writing of the manuscript while the named authors are responsible for its content.
‘Medical writers’, ‘ghostwriters’ and ‘honorary authors’
It is a myth that medical writing is the same as ghostwriting. It is not the same. When the people who write the article are not acknowledged as authors or otherwise in the published version of the article, they are called ‘ghostwriters’. They remain as ‘ghosts’, invisible to the reader.
There are marginal differences between the terms ‘guest authors’ and ‘gift authors’. These are included under a broader term called ‘honorary authors’ (13). By and large, this term includes all those who are mentioned as authors, despite minor or negligible contributions, if any. Ghostwriters are ‘unnamed writers’ of the article while honorary authors are named authors who make negligible or no contribution to the article. Both ghostwriting and honorary authorship are considered unethical practices.
What is unethical about honorary authorship? The honorary authors do not fulfil the ICMJE criteria for authorship. They may, in some cases, review the draft of the manuscript, make suggestions for improvement, and approve the final version of the manuscript. Yet, this contribution does not qualify them as authors according to the ICMJE criteria. They ought to have made significant contribution to the concept and design of the study and data collection and/or analysis, in addition to reviewing an important draft and approving the final version of the manuscript (14).
Why is ghostwriting considered unethical? Ghost-writers can at times be biased. An explicitly biased article can be harmful to the patients when clinical decision making is based on the article. Even when not biased, ghostwriting puts all the public blame of the writing on the authors. This hampers the public trust in the pharmaceutical industry as well as the medical profession. Most journals insist on saying ‘no’ to ghostwriting.
Since ghostwriting is not declared, there is a high chance that many of the articles published in journals are still being ghostwritten, a practice that is widely viewed as dishonest, unethical and unacceptable.
This dishonesty can be curbed by encouraging authors to declare any writing support sought. Professional medical writers are legitimate contributors to the article (15,16). They are a blessing while ghostwriters are a curse (17).
Legitimate contributors to manuscripts
By declaring the medical writing help they receive, authors save their own skins. Their article is not accused of being ghostwritten. Writers whose names are disclosed, in turn, are accountable for what they write and hence, ensure all steps are taken to avoid possible misconduct. A retrospective systematic study of retracted publications showed that publications retracted because of misconduct rather than mistakes rarely involved declared medical writers (18). Undisclosed medical writers, based on the fact that their name is never associated with the published article and they have no real or implied public responsibility of what goes into the article, may possibly be less ethically minded than the disclosed medical writers.
Several guidelines today encourage transparency about the use of professional medical writers.
The ICMJE guideline says (15): “All contributors who do not meet the criteria for authorship should be listed in an acknowledgements section. Examples of those who might be acknowledged include a person who provided … writing assistance…. Editors should ask corresponding authors to declare whether they had assistance with …manuscript preparation. If such assistance was available, the authors should disclose the identity of the individuals who provided this assistance and the entity that supported it in the published article.”
The World Association of Medical Editors (WAME) recommends journal editors to modify their Instructions for Authors to mention that medical writers’ contributions can be legitimate and should be mentioned in the acknowledgement section (16). Their role in the preparation of the manuscript and their affiliations should be clearly mentioned too. The Council of Science Editors (CSE) also encourages acknowledgement of any writing assistance (19).
The Committee on Publication Ethics (COPE) provides impartial advice to editors on cases they find difficult to resolve. It advises editors to encourage authors to acknowledge the contribution of professional writers and their funding source (20). COPE also guides editors on how to detect a contributor has not been adequately acknowledged.
The Good Publication Practice (GPP2) guidelines for communicating company sponsored medical research insist that all articles and presentations prepared with medical writing assistance should include an acknowledgement, “even if not requested by the journal or congress”(21). If the submission requirements do not allow the authors to include this information within the article or presentation, the GPP2 guidelines recommend inclusion of the information about writing assistance “in a letter that accompanies the submission”. It encourages authors to use a published checklist to avoid ghostwriting (21,22). This checklist has been developed by a group of medical writers (22). They hope that if journal editors ask authors to complete this checklist, it will discourage ghostwriting. In this checklist, authors are required to acknowledge professional medical writing assistance and its funding source, to confirm that the main points, outcomes and all data reported in the manuscript was controlled by the authors directly, and to verify that if needed the medical writers could prove that ethical writing guidelines were followed.
The European Association of Science Editors (EASE) has also published a checklist for authors of scientific manuscripts (23). The checklist requires authors to declare the contribution of medical writers in the acknowledgements. It is considered an obligatory declaration that applies to all manuscripts.
Many journals that adhere to the ICMJE, WAME, CSE, COPE and GPP2 guidelines or GATE principles encourage authors to declare medical writing assistance and state that ghostwriting is unacceptable.
Ensuring a fair and appropriate acknowledgement of medical writers
Some biomedical editors predict a gradual shift from the traditional authorship system to a model of contributorship (24). With a shift to the contributorship model, even medical writers who do not always qualify as authors will receive adequate acknowledgement for their contribution.
Stakeholders at each level need to ensure that there is total transparency about writing assistance and its funding (24). Research institutions that wish to publish honest articles should train their researchers on updated guidelines and policies in publication ethics. Authors must familiarize themselves with the journal’s instructions to authors as more and more journals today encourage adequate acknowledgement of writing assistance. When reviewers suspect the involvement of a ghostwriter, they should report the same. Editors must ensure that the authors submit statement about contributorship. Publishers should make sure proper guidance is provided about authorship and acknowledgement in their instructions to authors.
It is the ethical responsibility of all the stakeholders of the medical publishing process to encourage transparency so that they can bring an end to the practice of ghostwriting. A medical writer who is not adequately acknowledged remains a ghost-writer.
Potential conflict of interest
Dr. Natasha Das reports receiving personal fees from medical writing, editing, training and revenues from a book on medical writing. She is also the Secretary of All lndia Medical Writers Association. This is not a paid position.
Dr. Saurendra Das reports being an Advisor to All lndia Medical Writers Association. This is not a paid position.
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Articles from Biochemia Medica are provided here courtesy of Croatian Society for Medical Biochemistry and Laboratory Medicine
How to set your prices as a freelancer or consultant
April 1, 2012
Tags: fees, rates, pricing, freelance rates, per diem
"How much should I charge? ask writers and editors." The answer: That depends (among other things) on
� how good, how fast, and how reliable you are ("Cost. Quality. Speed. Pick any two.")
� how rare or specialized your set of skills (how valued the hairdresser who knows just how to do your hair)
� how deep or specialized your knowledge of the subject (and audience)
� what the market will bear, which varies regionally and by industry (book publishing is dirt cheap)
� how much the client can afford
� how easy you are to work with.
You can learn a great deal from the many following pieces (and books) on how much to charge, and whether to charge by the project, by the hour or day, or by the word or page?
� How Much Should I Charge for My Freelance Services? (Lifehacker 8-17-11)
� Ghostwriter (Wikipedia--see section on Remuneration and Credits, credits being a factor in pricing on collaborations)
� Pricing 101:How To Increase Your Income with Three-Tiered Pricing (Jake Jorgovan, Career Foundry, 11-13-14) "Clients don�t care if it takes you 20 minutes or 20 hours to complete the project. Clients care that the work is done and it is done well."
� How much should I charge? By the hour or by the project? (Allena Tapia, About.com) There is also "per diem."
� How much should I charge? (Lynn Wasnak, NJ Creatives Network, 2011). Lynn provides ranges of fees for various types of work
� How Much Should I Charge? (Lynn Wasnak, Writers Market, PDF of easy-to-read chart, based on summary of 2005-2006 fees)
� Freelance Fee Setting: Quick Guide for When a Client Demands a Price NOW (Kindle edition, 2012) by Laurie Lewis, author of What to Charge: Pricing Strategies for Freelancers and Consultants (see below)
� Tip of the Week: What a Copyeditor Earns (Erin Brenner, Copyediting, 3-13-12). Includes rates for Content Development & Management, 2012, copyediting rates, 2012.
� Tip of the Week: More Copyeditor Earn Rates (Brenner, Copyediting, 3-20-12). Discusses rates in England, Ireland, and Canada.
� Common editorial rates (Editorial Freelancers Association), and common pace of editing, too. Rates are on the low side, reflecting the low rates book publishing traditionally pays--now more than ever.
� Bay Areas Editors' Forum (PDF, summary of results from 2005 member survey of rates and types of work done)
� How to Charge: By the Project, by the Hour, or by the Word or Page? (Katharine O'Moore-Klopf, KOK Edit, 1-24-11)
� Tips for Putting a Price on Your Work (Alina Tugend, New York Times, 1-27-12)
� Freelancers, Here's How To Set Your Rates (Laura Shin, Forbes, 10-27-14) "For instance, writers for content mills may earn as little as $15 a post, writers for esteemed magazines could earn $20,000 for a lengthy story, and some authors can receive millions for a book advance. Even for articles of the same length � say, 1,000 words � some outlets pay as little as $100 and others pay as much as $2,000 (or more)....Three factors will affect how much you can or should charge: Your budget, how good you are at what you do/the price you can fetch, and how much time you have."
� Freelancers, Here's How To Negotiate Raises With Clients (Laura Shin, Forbes, 10-27-14) Track your time. Compare the per-hour rates of various projects and clients. Analyze the spreadsheet to see if there are any clients that could pay more. Use your numbers to negotiate yourself a higher rate. Analyze your time spent to see if you can become more efficient. See if it makes sense for you to outsource any tasks. With examples.
� Graphic Artist's Guild Handbook of Pricing and Ethical Guidelines (13th edition, free when you join the Guild
� How to Set Rates FAQ (HTML Writers Guild, but principles applicable to all entrepreneurs). See also, from the same group: Discussing prices (HTML Writers' Guild FAQ, explaining the organization's rules against discussing prices online, in view of federal regulations against price-fixing)
� The Designer's Guide To Marketing And Pricing: How To Win Clients And What To Charge Them by Ilise Benun and Peleq Top
� Services and fees at Story Circle Editorial Circle (affiliated with Story Circle Network, by, for, and about women)
� Freelance Fees Guide (National Union of Journalists, UK)
� SfEP suggested minimum freelance rates (Society for Editors and Proofreaders, UK)
� Pay rates for technical, business, and trade editing (Megan B. Wyatt, Suite101.com, 8-23-09). Average payment for medical, science and corporate editors (the ones who get paid a decent amount, by contrast with those who work in trade book publishing)
� Thinking About Money: What Freelancers Need to Understand. How to calculate your effective hourly rate, or EHR (American Editor, 10-6-10)
� How to Set Your Copywriting Fees and Earn What You�re Worth (Dean Rieck, Men With Pens). Many comments!
� What to Charge: Pricing Strategies for Freelancers and Consultants, interview with Laurie Lewis for National Association of Independent Writers and Editors
� What to Charge: Pricing Strategies for Freelancers and Consultants by Laurie Lewis (a book about pricing as part of a career strategy, not just a job strategy--solid practical advice and templates)
� Go Ahead, Raise Your Business's Prices (Jason Fried, Inc., 11-1-10). "Sure, some customers will complain, and others might take their business elsewhere. But there�s a good chance you don�t want those kinds of customers, anyway."
� Ghostwriting Prices (Writers for Hire, with fee range on the low side--the ghostwriters of bestsellers are paid more than that)
� Professional Genealogy: A Manual for Researchers, Writers, Editors, Lecturers, and Librarians . Read chapters 9 (Structuring a Business) and 10 (Set Realistic Fees)
� Avoid Pricing and Discounting Mistakes (Karyn Greenstreet, Self-Employed Success, 2-14-13)
� Pricing strategies and cost factors (Encyclopedia of Business)
� What to charge and how to get it (Walt Kania, The Freelancery) See various pieces on website. "...instead of quoting $400, make it $435. It sounds more rational, more acceptable, as if it�s based on something. Instead of quoting $1000 (made up) say $1280. More money, but more reasonable to clients.�ricing?
� Seth Godin's pricing formula (S&S). Substitute & Story. Is there no good substitute for your product? Does your price tell a story?
� Pricing Strategies for Resume Writers (Resume Writers' Digest, 9-7-07)
� What to say to your low-balling clients (Laura Spencer, FreelanceFolder 9-3-09)
� Why should writers work for no pay? Contributors to the Huffington Post have begun to chafe at its no-pay policy. They could take a lesson from stand-up comedians who faced a similar insult in the 1970s. (Michael Walker, OpEd, Los Angeles Times, 4-1-11)
� Should I work for free? (Jessica Hische's amusing and realistic chart)
� When to work for nothing (Michelle Goodman, New York Times, Shifting Careers, 11-9-08)
� Per diem rates, U.S. Department of State. If you're estimating travel costs abroad, these might help.The foreign travel per diem allowances (which vary by country and within a country) provide for lodging, meals, and incidental expenses when an employee is on temporary duty overseas.
� Benchmarks for Estimating Editing Speed by David W. McClintock (originally published in Corrigo: Newsletter of the STC's Technical Editing SIG (June 2002), pp. 1, 3.
� How long does editing take? (Jean Weber Hollis, Technical Editors' Eyre: Resources for technical editors)
Organizations may not set or recommend rates (they can get in trouble for price-fixing), but many (such as EFA and ASJA) do member surveys of rates charged, fees earned, how difficult particular clients were (this can save you hours of grief, particularly regarding the "hassle factor" -- e.g., editors who don't know what they want, change their minds, or who must run everything through a committee which has a preconceived idea what the writer should be saying) and how slow a client is to pay).
The content on this topic also appears on this website (where it is regularly updated) as
How Much Should I Charge? What can a writer or editor expect? under Freelancing, contracting, telecommuting. Let me know if anything helpful is interesting. And feel free to comment below.