An overview of the concept of problem solving in clinical practice, and how to go about writing an article to be submitted.
- Medical Journalism
- Paediatric Practice
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Know the rules well, so you can break them effectively. Dalai Lama XIV
The hell with the rules. If it sounds right, then it is. Eddie Van Halen
Problem solving in clinical practice (PSICP) is an unusual section for a medical journal, albeit in an educational supplement. I have always been a fan of the format we use, but since having taken over as section editor and looking at the submitted articles, I think that an overview of how it works is in order.
Please do not take the following recommendations as being set in stone. The one thing which made me reticent to write this article is the thought that potential authors who may have a novel approach to writing an article may feel that they are constrained by ‘the format’. As with most things, the rules are there to be broken: but to break them you must have a reason. I have received several novel articles, and I love it when authors use an innovative style to get their point across. A recent example1 involved the authors taking us through how they dealt with an unfamiliar situation as it progressed, a refreshing contrast to the omniscient perspective from which most medical articles are written.
The reason for this article is, however, to guide those who feel that a PSICP is just another case report: it certainly is not. The main distinction is that a case report is usually about one disease. PSICP articles try to draw on many aspects of a case to get a variety of learning points across. The case is the glue that holds the article together and keeps the reader's interest. A good rule of thumb is that if more than a third of the space is taken up with the final diagnosis, then it is a case report rather than a PSICP article.
As most of these articles will be about patient cases, then it is vital that consent is gained from patients/families if you are using actual patient information. The consent form can be found online (group.bmj.com/products/journals/patient-consent-forms). We do accept articles that are based on amalgamated patient histories and investigations which are used to stress a point. We would therefore suggest caution for anyone attempting to accrue data for any series using our patients. It should be clearly stated at the start of the article that this is the case, and all steps should be taken to ensure anonymity. We will not be able to accept articles where we feel that confidentiality is compromised in any way, and so a real case with consent given is usually the best option.
Let your imagination run wild. Obviously, the majority of articles will be about clinical cases, but try to think about your working practice. When have you needed to ‘Solve Problems’? I am very keen to receive articles on subjects as diverse as managerial problems; trainee or trainer problems; ethical or legal problems; complaints; language or cultural problems; and so on. As long as it relates to practice as a paediatrician and is educational, then we are happy to receive it. You do not necessarily have to dedicate a whole article to this (although you may if you wish), but do not be afraid to add some points covering these areas to an otherwise clinically focused article.
These are essentially educational articles, and with that in mind it is good to consider who the target audience is. Our hypothetical reader is a jobbing paediatrician working in secondary care, although the format will extend to primary or tertiary care paediatrics. This works as a good baseline for the vast majority of our readership. If you keep this in mind, you will often avoid pitfalls in overexplaining or underexplaining themes as well as keeping your themes relevant.
I think that the main strength in using the PSICP for education is that they are, for want of a better term, entertaining. It is very important to keep the reader's interest as this is what will make the points you are making come across and be remembered.
This is where it all begins, literally. These articles can be the ‘murder mystery’ genre of the medical literature world. If this is the case, then do not give the game away with the title. A somewhat cryptic title is often called for and so please feel free to have some fun here.
The ‘diagnostic odyssey’
The format that usually works best is snippets of case history, with digressions to discussion points brought up by the case as you go along. There is a somewhat delicate balance here, with too much case history leading to the article reading as a case report, and an overwhelming amount of discussion points rendering the case history redundant. The general ratio should usually be about 1 : 2 case history to discussion points.
My strategy for coming up with the framework for an article would be to write the case history down, then go through it and think: ‘where did I need to solve problems here?’ The most useful discussion points can be about some of the most common (and therefore relevant) problems. Some examples may include:
What is my differential diagnosis? How have I arrived at this?
What are the key features of the history: what particular features are important to elicit and why?
What is the best strategy for investigating this problem?
How do I interpret these diagnostic investigations?
What is the best treatment option?
How is it best to communicate with the child, young person or carers?
There are an almost unlimited number of problems to solve that I have not covered here. Imagination is a word not often associated with medical journals, which is why I am so enthusiastic about PSICP articles: they involve a lot of creativity.
The actual rules
The articles are usually between 3000 and 5000 words. Please do not feel the need to use up this allowance, as the majority of articles will not require the maximum amount.
No more than 30 references will be printed. There is the option to have more online, but this would have to be very well justified.
We are now requiring that all articles come with five multiple choice questions concerning the material contained within.
Please put all submissions through the ADC online submission system (mc.manuscriptcentral.com/adc).
Prior to committing pen to paper, I am very happy if potential contributors wish to contact me to discuss ideas for articles (email@example.com). Generally, I would recommend writing a brief outline of the case, and listing any discussion points you would like to include. I will then be able to give some pointers at an early stage.
These articles are frequently quite complex, and the editorial process can take several drafts before articles are ready to print. The review process can also take some time, especially if multiple specialities are involved. My job is to take care of the style of the articles, but we require peer review to ensure that they are factually correct. Please provide details of recommended reviewers in the online submission form to allow the process to run as smoothly as possible.
Reading back over the article, there are three concepts that I have used which stand out: ‘creativity’, ‘imagination’ and ‘entertainment’. These are what make writing and editing these articles fun. I am always open to innovative ideas, and will not reject articles just because they do not strictly adhere to how previous articles have looked. Also, do not feel that you only have to present the weird and wonderful cases in these articles: if you can construct an interesting, entertaining and informative article about the more (superficially) mundane areas of paediatric practice, then I look forward to it being submitted.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.