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1 How to reply to peer review comments when submittin g papers for publication HC Williams PhD Manuscript to be considered as a “special article” for JAAD e-blue or Corresponding author: Prof. Hywel Williams Centre of Evidence Based Dermatology Queen’s Medical Centre Nottingham NG7 2UH Tel: +44 115 924 9924 x43000 Fax: +44 115 970 9003 [email protected] e-mail: Conflict of interest: None 1

2 Abstract Background ific journals is a fairly complex and The publication of articles in peer-reviewed scient ees’ comments. Little guidance is step-wise process that involves responding to refer available in the biomedical literature on how to de al with such comments Objective To provide guidance to novice writers on dealing wi th peer review comments in a way that maximises chance of subsequent acceptance Methods Literature review and review of the author’s experi ence as a writer and referee Results Where possible the author should consider revising and resubmitting rather than sending their article elsewhere. A structured layout for re sponding to referees’ comments is suggested that includes the three “golden rules” of (i) responding completely (ii) responding politely and (iii) responding with evide nce. Conclusion Responding to referees’ comments requires the write r to overcome any feelings of personal attack, and to instead concentrate on addr essing referees’ concerns in a courteous, objective and evidence-based way. Word count 147 Key words: Referee comments, reviewer comments, res ponse 2

3 Introduction 1,2 , and websites of most Plenty of guidance is available on conducting good research ions on what is suitable for submission scientific journals give clear and helpful instruct ce on replying to referees’ (peer and how to submit. Yet where does one obtain guidan reviewer) comments once the manuscript is returned? I could find little in the literature 3-7 . dealing with this important topic This article attempts to address this gap by provid ing some helpful tips on how to reply to c research to determine which referees’ comments. In the absence of any systemati the tips suggested below are based strategies are “best” in terms of acceptance rates, simply on my personal experience of publishing arou nd 200 papers and of refereeing over 500 papers, as well as working as an editor fo r 3 dermatology journalsI have presented some aspects of the work previously in tw o workshops with groups of British Specialist Registrars in dermatology, and I am grat eful to them for helping me to develop the learning themes. 8 s on the of peer review I have deliberately not entered into any discussion quality or the value of peer review in publication since it is still ho tly debated if peer review really helps to discriminate between good and bad research or whether it simply improves the 9 readability and quality of accepted papers . Instead, I have decided to stick to providing n the system that already exists . what I hope is helpful and practical guidance withi That letter arrives from the journal... 3

4 After labouring for many months or years on your re search project and having written many manuscript drafts in order to send off your fi nal journal submission, a letter or e- mail from the journal arrives several weeks later i ndicating whether the journal editor is interested in your paper or not. At this stage, it is every author’s hope that the paper is accepted with no changes, yet such an experience is incredibly rare – it has happened to me only twice, and these were both commissioned rev iews. More commonly, one of the following scenarios ensues: ACCEPT WITH MINOR REVISION If you are lucky, the letter will ask for only mino r revisions. In such circumstances, it is probably best to simply get on with these without i nvoking too much argument. If you send the revised paper back to the editor quickly, it is still likely to be fresh in his/her mind, and you will probably get a speedy acceptance . MAJOR REVISIONS NEEDED The commonest form of letter is one that lists 2 or 3 sets of referees’ comments, some of which are quite major. In such circumstances, you w ill need to work hard at reading and replying to each referee in turn following the layo ut and three golden rules (Box 1) that I will develop later in this paper. Such a process ca n take days to complete, so do not underestimate the task. Only you can decide whether such an investment of time is worthwhile. My advice is always to revise and resub mit to the same journal if the a lot of time. Some authors go weak comments are fair, even if responding to them takes and instead simply send the paper at the knees when requested to do a major revision, 4

5 elsewhere. This is understandable, but the authors should still try and make comments. Authors should also be improvements to the paper in light of the referees’ k is likely to end up with the same aware that in certain fields of research, their wor referee when they send their paper to another major specialty journal. It will not go down well with that referee if they see that the authors have completely ignored the referees’ is to put in the time needed to previous comments. So generally speaking, my advice , and resubmit along the lines make a better paper based on the referees’ comments suggested. If you do submit to another journal, you should consider showing the “new” journal the previous referees’ comments and how you have improved the article in response to such comments – some journal editors fe el positively about such honesty (Bernhard JD, personal written communication, Novem ber 2003). JOURNAL REQUESTS A COMPLETE REWRITE Only you can decide if the effort of a complete rew rite is worth it. If it is clear that the referees and editor are interested in your paper an d they are doing everything they can to make detailed and constructive suggestions to help you get the paper published, it might be a safer bet to follow their wishes of a complete rewrite. It might be difficult for the editor to then turn you down if you have done exact ly what was asked of you. If on the other hand, the request for a complete rewrite is a cold one, ie without suggestions as to exactly what needs to be done and where, then it mi ght be better to reflect on the other comments and submit elsewhere. Sometimes, referees may recommend splitting a paper if the paper is part of a large study that tries to cram in too many different results. Such a request from one of the referees may appear like a gift to the author – two for the price of 5

6 one. But a word of warning - if you are going to r edraft the original paper into two related papers, there is no guarantee that both wil l be accepted. The best thing under such circumstances is to have a dialogue with your edito r to test how receptive they would be to having the paper split into two. UNSURE IF REJECT OR POSSIBLE RESUBMISSION? The wording of some journal response letters can be difficult to interpret. For example, phrases such as “we cannot accept your paper in its current form, but if you do decide to resubmit, then we would only consider a substantial revision”, may sound like a reject, yet in reality, it may indicate an opportunity to r esubmit. If you are unsure on how to “read between the lines”, ask an experienced collea gue, or better still someone who works as a referee for that journal. Failing that, you could simply just write back to the editor to ask for clarification. Sometimes, a journ al will ask you to resubmit your article in letter format rather than as an original paper. You then have to decide if the effort versus reward for resubmission elsewhere is worth i t, or if you are content to accept the “bird in the hand” principle and resubmit your orig inal paper as a letter. THE OUTRIGHT REJECTION Usually this type of letter is quite short, with ve ry little in the way of allowing you an opportunity to resubmit. Outright rejection may be due to the manuscript being unsuitable for the journal or because of “lethal” methodologic al concerns raised by the referees that l trial on lentigo maligna with an are non-salvageable eg by doing a crossover clinica ffect on patient outcomes in the first intervention such as surgery that has a permanent e 6

7 , who are always pushed for phase of the crossover study. Sometimes the editors publication space, simply did not find your article interesting, novel or important enough to warrant inclusion. You will just have to live wi th that and submit elsewhere. eat and toil may not be easy, Dealing with outright rejection of your precious sw especially if the journal has taken ages to get bac k to you. You have two main choices at this stage. If you feel that the referees’ comments are grossly unfair or just plain wrong, you can write to the editor to appeal the decision and ask for new referees. The success of such appeals depend on how confident you are that t heir decision was “out of order” and those comments transferred to you. whether the real decision for rejection was indeed Appeals such as this are rarely successful – I have done it twice with the BMJ, and both have failed. The other (better) option is to stop snivelling, pi ck yourself up and resubmit elsewhere. If you do this, it is important that you read and obje ctively assess the referees’ comments from the journal that has turned down your paper. T his is for two reasons (i) those comments may improve the article and (ii) as stated earlier, your paper may end up with the same referee even if you send it to another jou rnal. If you are really convinced that your paper is earth shattering, then you should not automatically resubmit to a journal that might be easier to get your paper accepted int o. Sometimes, it has been my experience that a paper that was rejected by a medi um-ranking dermatology journal is h is the unpredictability of peer subsequently accepted by a higher-ranking one – suc 9 review and journal editor preferences . 7

8 The three golden rules of structuring your response letter RULE ONE: ANSWER COMPLETELY It important that all of the referees’ comments are responded to in sequ ence, however irritating or vague they may appear to you. Number them, and repeat them in your covering letter using the headings such as “Reviewe r 1” then “Comment 1” followed by “Response”. What you are doing here is making the e ditor’s and referees’ jobs easy for ence lots of scripts in order to discover them – they will not have to search and cross refer what you have done – it will all be there in one cl ean document. Typing out or paraphrasing the referees comments as a means of itemising the points also achieves two other things (i) it forces you to list en to what the referees actually said, en you first read their comments and rather than what you though they might have said wh (ii) it helps you to understand how many separate p oints are being made by the referee. Quite often, you will just receive a paragraph with several comments mixed up together. In such a situation, you can split the paragraph in to 2 or 3 separate comments (comment 1.1, 1.2, 1.3) and then answer them in turn. Even i f some of the comments are just compliments, then repeat these in your cover letter followed by a phrase such as “we thank the referee for these comments”. RULE TWO: ANSWER POLITELY 8

9 Remember that nearly all referees have spent at lea st an hour of their personal/family time in refereeing your paper without being paid fo r it. If you (as a lead author) receive a huge list of comments, it usually means that the re feree is trying very hard to help you improve the paper to get it accepted. Reject statem ents are usually short, and do not allow you an open door to resubmit. It is quite all right to disagree with referees whe n replying, but do it in a way that makes your referees feel valued. Avoid pompous or arrogant remarks. Whilst it is onl y human nature to feel slightly offended when someone else dares to criticise your precious work, this must not come across in your reply. Your reply should be scientific and systematic. Get someone else to read your responses before sending them off. sagree” or “the referee obviously does Try to avoid opening phrases such as “we totally di not know this field”. Instead try and identify some common ground and use phrases starting with words such as “We agree with the refe ree...but...”. A list of helpful phrases that I have developed over the years is giv en in Box 2 for guidance. RULE THREE: ANSWER WITH EVIDENCE If you disagree with the referee’s comments, don’t just say, “we disagree” and then move ill, back it up with some on. Say why you disagree with a coherent argument, or better st your reply. Sometimes those extra facts supported by references that you can cite in 9

10 our covering letter, but occasionally references are just to back the point you make in y you may add them to the revised article. Some kind referees go to the trouble of suggesting missed references or how you might rewor d important areas of your document. Providing the references or rewording makes sense t o you, just go ahead and incorporate omments to add some extra text and data them. It is quite legitimate to use the referee’s c if their comments require it, although if this amou nts to more than a page, you would be wise to suggest it as an option to the editor. Anot her option is to suggest that the extensive additions would be better placed in anoth er subsequent article. Sometimes, if there is no clear published data to s trongly support your methodological approaches, you can discuss this with an expert in the field. If he/she agrees with your hough other approaches have been approach, then you can say so in your reply eg “Alt used in the past, we have discussed this statistica l methods with Prof Teufelsdröch who agrees that it was the appropriate analysis”. 10

11 Tips on dealing with other scenarios REFEREES WITH CONFLICTING VIEWPOINTS At first, this scenario might appear very difficult to the novice, yet it should be viewed as a gift. You, the author, have the choice of which v iewpoint you agree with the most (or better still, the one which is right!). Then it is simply a question of playing one referee off against the other in your reply. You can always app eal to the editor by asking him/her to make the final decision, but give them your preferr ed option with reasons. THE REFEREE IS WRONG Referees are not Gods, but human beings who make mi stakes. Sometimes they do not read your paper properly, and instead go on at leng th about their hobbyhorse whereas in fact you have dealt with their concerns elsewhere i n the paper. Try to resist the temptation of rubbing their nose in it with lofty s arcastic phrases such as “If the referee had bothered to read our paper, ...”,. but instead sa y something like “We agree that this is an important point and we have already addressed it on page A, paragraph B, line C”. Sometimes the referee is just plain wrong about som ething. If so, it is silly to agree with the referee, and you are entitled to a good argumen t. If you are confident that you are right, then simply argue back with facts that can b e referenced - the editor can then adjudicate who has the best evidence on their side. 11

12 THE REFEREE IS JUST PLAIN RUDE just how difficult it can be, and there Anyone who has done clinical research will realise ad that senior academics can sometimes is no place for rudeness from referees. I find it s forget their humble beginnings when they referee ot her’s work. Nearly all journals provide clear guidance to their referees to avoid r emarks which they would find hurtful if applied to their own work, yet some ignore such adv ice and delight in rude or sarcastic comments, possibly as a result of envy or insecurit y. In such circumstances, all you need to do is to complain to the editor and ask for anot her non-hostile review. THE DREADED “REDUCE THE PAPER BY 30%” REQUEST Such a request typically comes form the editor who is pushed for space in his/her journal. I have to confess that for me, this is the comment that I dread most of all because it is often accompanied by 3 referees’ comments, the resp onse to which usually involves making the article longer than the original submission. A general reduction in text by 30% basically requires a total rewrite (which is sl ow and painful). It is usually easier to make a brave decision to drop an entire section tha t adds little to the paper. Ask a colleague who is not involved in the paper to take out their editing knife and suggest non- essential areas that can go – even though the proce ss of losing your precious words may seem very painful to you. Discussion sections are u sually the best place to look for radical excisions of entire paragraphs. Background sections should be just one to two paragraphs long – just long enough to say why the s tudy was done, rather than an 12

13 exhaustive review of all previous literature. Pleas e do not skimp on the methods section unless you are referring to a technique which can b e put on a website or referenced. Conclusion Referees are human beings. The secret of a successf ul resubmission is to make your referees feel valued without compromising your own standards. Make your referees’ and editor’s life easy by presenting them with a clear numbered and structured response letter. Provided you have made a good attempt at answering all of the referees’ comments in a many referees and editors are too reasonable way by following the three golden rules, weak at the stage of resubmission to open another r ound of arguments and resubmission. ial refereeing of a manuscript, but In my experience, I spend up 90 minutes on the init only around 20 minutes on a resubmission. But if yo u miss out some comments completely or your manuscript changes do not corres pond with what you said you have done in your covering letter, this you will entice your referee to spend hours going through your paper with a fine toothcomb and a poss ible deserved rejection. Like a good marriage, resubmitting your manuscript in light of your referees’ comments is a process of give and take. Acknowledgement his constructive comments and for The author wishes to thank Dr. Jeffrey Bernhard for references 5 to 7. 13

14 References 1. Lowe D. Planning for medical research: a practical guide to research methods. Astraglobe Ltd., Cheshire, England, 1993. 2. Altman DG. Practical statistics for medical researc h. Chapman and Hall, London, 1991 Cummings P, Rivara FP. Responding to reviewers' com ments on submitted 3. articles. Arch Pediatr Adolesc Med. 2002;156:105-7. 4. DeBehnke DJ, Kline JA, Shih RD. Research Committee of the Society for choosing an appropriate Academic Emergency Medicine. Research fundamentals: journal, manuscript preparation, and interactions w ith editors. Acad Emerg Med. 2001;8:844-50. 5. Byrne DW. Publishing your medical research paper. W illiams & Wilkins, Baltimore, 1998. rd ed). Williams & Wilkins, 6. Huth EJ. Writing and publishing in medicine (3 Baltimore, 1999 7. Rothman KJ. Writing for epidemiology. Epidemiology 1998;9:333-37. 8. Jefferson T, Wager E, Davidoff F. Measuring the qua lity of editorial peer review. JAMA. 2002;287:2786-90 Jefferson T, Alderson P, Wager E, Davidoff F. Effec ts of editorial peer review: a 9. systematic review. JAMA. 2002;287:2784-6. 14

15 Box 1: 3 golden rules of responding to referees’ comments Rule 1: Answer completely Rule 2: Answer politely Rule 3: Answer with evidence Box 2: Some useful phrases to start your replies to critical comments We agree with the referee that ..., but The referee is right to point out ..., yet In accordance with the referees’ wishes, we have no w changed this sentence to ... Whilst we agree with the referee that... It is true that ..., but We acknowledge that our paper might have been..., bu t We too were disappointed by the low response rate... We agree that this is an important area that requir es further research... We support the referee’s assertion that ..., althoug h With all due respect to the reviewer, we felt that this point is not correct... 15

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