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Author Affiliation: Dr Horton is Editor of The Lancet, London, England.
Context To determine whether the views expressed in a research paper are accurate
representations of contributors' opinions about the research being reported.
Methods Purposive sampling of 10 research articles published in The Lancet; qualitative analysis of answers to 6 questions about the
meaning of the study put to contributors who were listed on the byline of
these articles. Fifty-four contributors listed on the bylines of the 10 articles
were evaluated, and answers to questions were compared between contributors
within research groups and against the published research report.
Results A total of 36 (67%) of 54 contributors replied to this survey. Important
weaknesses were often admitted on direct questioning but were not included
in the published article. Contributors frequently disagreed about the importance
of their findings, implications, and directions for future research. I could
find no effort to study systematically past evidence relating to the investigators'
own findings in either survey responses or the published article. Overall,
the diversity of contributor opinion was commonly excluded from the published
report. I found that discussion sections were haphazardly organized and did
not deal systematically with important questions about the study.
Conclusions A research paper rarely represents the opinions of those scientists
whose work it reports. The findings described herein reveal evidence of (self-)censored
criticism, obscured meanings, confused assessment of implications, and failures
to indicate directions for future research. There is now empirical support
for the introduction of structured discussion sections in research papers.
Editors might also explore ways to recover the plurality of contributors'
What happens when scientists disagree? Most times, readers of research
papers never know. However, in 1995, a dispute among the writing committee
of the Italian Multicentre Acute Stroke Trial spilled out onto the pages of The Lancet.1,2
During peer review, it became clear that 2 committee members interpreted the
results of the trial very differently from their colleagues. They had, for
the good of the collaboration, self-censored their own views. However, this
fragile truce broke down once an editor asked for signatures confirming each
contributor's assent for the paper to be published. Tognoni and Roncaglioni2 described their disagreement as "unfortunate."
Such disagreements have come to light before. For example, divided interpretations
about a polio outbreak in Israel led to separate commentaries in The Lancet.3 In an even more protracted
dispute, a competing manuscript based on the same study was eventually published
4 years after the original article appeared.4
Harmony among authors cannot be relied on.
A crisis over definitions of authorship during recent years has led
several medical journals to discard rigid rules for who can or who cannot
be an author. Instead, the idea of the contributor has emerged.5
In place of the assumption that scientists named on the byline of an article
are true authors, journals such as The Lancet, BMJ, and Annals of Internal Medicine now require contributors to state explicitly what part they played
in the research being reported. This conceptual shift was best summarized
by Rennie et al5: "Contribution is the activity
of science that is most relevant to publication because its disclosure can
identify who is accountable for what part of the research and allows the reader
to assign credit fairly."
However, important as contributorship is, this mechanism of disclosure
does not take account of the ideas or interpretations contributed to the research
being reported. I wanted to know whether the views expressed in a research
paper are accurate representations of contributors' opinions.
I selected 10 articles published in The Lancet
during 2000 (Table 1). This study
had a qualitative design: articles were selected purposively with varying
numbers of contributors, across a range of subject areas, and including a
spectrum of research methods. I wrote to the corresponding author of each
research article to secure permission to contact contributors on the article's
byline and to explain the background and nature of the study. Once permission
had been granted, I wrote to all contributors and asked 6 questions about
their work (BOX 1). Contributors were written to twice after that and telephoned
once to obtain replies.
Box 1. Questions Asked of Contributors of 10 Selected Research Papers
In your own words, how would you:
1. Summarize the results of your study?
2. Define the strengths of your study?
3. Define the weaknesses of your study?
4. Interpret the results of your study in the context of the totality
of available evidence?
5. Assess the implications of your results?
6. Plan further research into the question under investigation?
Once available replies had been collected, individual answers to questions
were compared with one another among contributors for each research paper.
These answers were also compared with the contents of the published article.
Finally, contributor sections were examined to discover if there were any
identifiable connections between stated contributions and the answers to these
All corresponding authors gave permission for me to contact their co-contributors.
However, one corresponding author, although agreeing that "the results of
your project will shed light on whether the true strength of a collaborative
research group is being fully achieved," declined permission for me to contact
more junior members of her research team. She wrote, " I would ask that you
refrain from contacting three of the authors on our paper . . . since they
are still under my supervision." In all, 36 (67%) of 54 contributors contacted
replied to the survey.
In reporting these results, I will take one study and describe the responses
of the contributors in detail. The study I will focus on is a randomized trial,
and I do so because it is this study design that is central to establishing
evidence for or against interventions in clinical practice. Supportive or
contradictory findings, together with further issues, will be explored by
describing the remaining replies.
The trial concerned the efficacy of ondansetron, a peripherally active
serotonin antagonist, in patients with an eating disorder. Forty-three patients
were screened and 26 were randomized to receive either ondansetron or placebo.
The primary outcome measure was a composite of the number of bingeing and
vomiting episodes per week. For patients receiving ondansetron, at 4 weeks
the mean number of episodes was 6.5 (SD, 3.9) per week. For patients receiving
placebo, the mean number was 13.2 (SD, 11.6) per week.
When asked to summarize the paper, contributors seemed to reply according
to their underlying interest in the research question. At the extremes, for
example, one contributor took a purely clinical view: "Our study found that
ondansetron significantly reduced binge eating and vomiting compared to pill
placebo in women with severe bulimia nervosa." Another took a more pathophysiologic
perspective: "Blocking vagal neurotransmission primarily at the gastric level
by ondansetron produces a statistically significant reduction in bulimia symptoms
in a group of severely ill bulimic patients." Different summaries suggest
different interests and perhaps different motivations for doing this work.
The published article, especially the discussion section, did not clearly
separate these interests.
The strengths of the research were identified as follows: study design
(by 6 contributors), an identified mechanism of action (4), the double-blind
nature of the trial (3), daily patient contact (3), well-matched controls
(2), cyclicity of symptoms taken into account (2), the large treatment response
(2), and the interpretation (2). The first 3 of these strengths were clearly
identified as such in the article.
Similar transparency was not found for weaknesses. In the published
report, highlighted weaknesses were self-reporting of symptoms and the risk
of a higher motivation to succeed among study participants. However, on direct
questioning, small sample size (7 contributors), short duration of study (4),
no long-term follow-up (2), and poor generalizability (2) were emphasized.
Concerns about the study, freely stated by the scientists undertaking this
research, had not been incorporated into the article.
The views about interpretation in the context of the totality of available
evidence matched those found for the summary of findings. That is, contributors
ranged between strongly clinical ("ondansetron is effective in the treatment
of bulimia nervosa") and more pathophysiologic conclusions. Again, these distinctions,
although clear from individual replies, were not made in the published article,
where clinical and mechanistic issues were mixed together in the discussion
The implications of the study findings were also poorly expressed in
the published report of the trial, according to the responses of individual
authors. The main implications concerned vagal nerve research (3 contributors),
vagal influences over psychiatric symptoms (3), ondansetron as a treatment
for bulimia (2), the therapeutic value of vagal blockade (2), and the need
for a broader vision for research into bulimia (2). Only ondansetron as a
treatment was highlighted in the final article. Indeed, according to a senior
author, "the most important implication" of the trial was that the results
"would help remove the negative social connotations associated with this disorder."
Nowhere was this implication mentioned in the article published in The Lancet.
Finally, in considering lines for future research, several possibilities
were identified: the physiology of bulimia (4 contributors), comparisons of
ondansetron with other treatments (3), the inclusion of patients with less
severe conditions in subsequent trials (2), and a longer study duration (2).
None of these ideas was discussed in the published article.
Many of these omissions and patterns of reporting were found in the
other articles studied (data not shown). However, there were exceptions. For
example, in a randomized trial of folic acid plus vitamin B6 to
lower plasma homocysteine concentrations and perhaps to ameliorate atherosclerosis,
the weaknesses cited in the survey responses (small size, use of surrogate
measures, and short study duration) were all discussed in the published article.
The striking fact, therefore, was the inconsistency across this sample of
articles. For instance, in a study of how El Niño affects diarrheal
diseases in Peruvian children, several contributors pointed out that only
one El Niño event had been studied. This weakness was not discussed
in the article. Similarly, although wide confidence intervals were cited as
a weakness in a study of cancer in individuals with Down syndrome, this weakness
was not highlighted in the article published in The Lancet.
The question that yielded the most uniformly disappointing response
concerned interpretation in the context of the totality of available evidence.
In neither the survey responses nor the published articles were any efforts
made to describe systematically evidence that related to the investigators'
own findings. Anecdotal reporting of other work was the norm in both settings.
The consistent failure by scientists to provide a more rigorous overview of
past evidence when considering their own findings has been pointed out before.6
Confusion was also common when implications of new research were being
considered. For example, in the folate and vitamin B6 randomized
trial, one contributor concluded that the results "provide some justification"
for treating patients at high risk of atherothrombotic disease with folic
acid. Another contributor simply considered that this "first (little) piece
of evidence . . . should be seen as an encouragement for other trials" only.
In a systematic review of stress hyperglycemia and risk of death after myocardial
infarction, one contributor drew a diagnostic conclusion: "a simple, early
available, and cheap plasma glucose identifies patients at a high risk for
in hospital complications and death." Another drew a treatment lesson: "clinicians
should recognise hyperglycaemia as an important prognostic marker and take
an aggressive therapeutic approach for patients who have elevated blood glucose
readings at the time of [myocardial infarction]." The article itself does
not explore this range of opinion and takes a more conservative line, emphasizing
glucose as a risk factor only.
Contributors differed in their views about future research. In response
to a direct question, contributors to a paper on risk factors for suicide
suggested looking at sex, family history of illness, age, socioeconomic background,
psychiatric diagnosis, and life events. Yet none of these ideas was discussed
in the published report. In a study of Helicobacter pylori transmission among siblings, readers were given no direction about
where future research might be directed. However, in their survey responses,
the contributors suggested work on the natural history of the infection, factors
(especially those in the family) that influence the dynamics of infection,
and a focus on early childhood years.
The Lancet introduced contributors' descriptions
of the parts each person played in the research being reported in 1997. These
descriptions are written by the authors themselves. In this study, I relied
on these self-reports to find links between stated contributions and survey
responses. No such associations could be made, mostly because contributor
statements lacked sufficient descriptive detail.
In reviewing these 10 published articles, the most frustrating aspect
of comparing survey responses with published reports was the chaotic nature
of discussion sections. There was no clear or consistent approach by contributors
to the discussion of their results. Limitations were frequently omitted, clinical
interpretations were often mixed with mechanistic reflections, and repetition
of key results was common.
The results of this qualitative study show that a research paper rarely
represents the full range of opinions of those scientists whose work it claims
to report. I have found evidence of censored criticism; obscured views about
the meaning of research findings; incomplete, confused, and sometimes biased
assessment of the implications of a study; and frequent failure to indicate
directions for future research. Some papers have more complete evaluations
of findings than others. What was striking was the inconsistency in published
evaluations, especially regarding weaknesses. The strengths of this work are
its qualitative design, which produced a rich data set, and a purposive sampling
technique that confirmed the findings across a range of subject areas and
This work also had several limitations. First, these data are preliminary.
The sample of articles was small and came from one journal only. The risk
of bias is substantial. Second, since I surveyed contributors after publication
of their studies, I could not rule out the possibility that contributors discussed
their responses with one another before replying. Third, variance of opinion
was determined by one person (R.H.) using a nonvalidated survey instrument.
Multiple independent assessments, perhaps adopting a quantitative scale, could
improve the validity of these findings.
A scientific research paper is an exercise in rhetoric7;
that is, the paper is designed to persuade or at least convey to the reader
a particular point of view. When one probes beneath the surface of the published
report, one will find a hidden research paper that reveals the true diversity
of opinion among contributors about the meaning of their research findings.
For both readers and editors, the views expressed in a research paper are
governed by forces that are clear to nobody, perhaps not even to the contributors
themselves. Who determines what is written and why? Despite the introduction
of contributors' sections to research reports,8
this question remains unanswered.
The gaps identified in published research reports reveal not only the
range of opinions among contributors, but also the weaknesses of editorial
procedures. In particular, the omission of limitations from the discussion
sections must be judged a potential failure of journal peer review.
What more could editors do to recover the plurality of contributors'
opinions? The discussion section is a neglected part of the research paper.9 The 6 questions I asked in the survey described herein
seem to set a minimum standard for addressing the central scientific issues
concerning the validity and meaning of a piece of research. A first step would
be to ensure that all 6 questions are answered explicitly in the discussion
section, with the full range of contributors' opinions being offered. To enable
authors to answer these questions satisfactorily, longer papers may be necessary.
Editors should probably relax their usual word limits for research papers
or consider publishing expanded versions of the paper on the Web. Indeed,
one could go further. These data provide empirical support for structured
discussions. I have raised this possibility before,7
and other editors have substantially supported and developed this proposal.10,11 The results reported herein indicate
that more careful organization of the discussion section of a research paper
might provide the framework for not only a fairer and more accurate representation
of contributors' views, but also a more complete analysis of the data being
presented. The importance of omissions in research reports has been described.12 A proposal for the elements to be considered in a
structured discussion is shown in BOX 2.
Box 2. Proposal for Structured Discussion in Medical Research Papers
Summary of Key FindingsPrimary outcome measure(s)
Secondary outcome measure(s)
Results as they relate to a prior hypothesis
Strengths and Limitations of the StudyStudy question
Interpretation and Implications in the Context of
the Totality of EvidenceIs there a systematic review to refer to?
If not, could one be reasonably done here and now?
What this study adds to the mavailable evidence
Effects on patient care and health policy
Controversies Raised by This StudyFuture Research DirectionsFor this particular research collaboration
Future research might aim to confirm these findings in a larger sample
from multiple clinical and nonclinical journals, perhaps using a quantitative
scale or a more formal method of linguistic analysis.13
More interestingly, an ethnographic approach14
would reveal how papers are actively put together. Whatever route this work
takes, current definitions of "contributor" should be widened to include the
appraisal and interpretation of research—what is thought as well as
what is done.
Horton R. The Hidden Research Paper. JAMA. 2002;287(21):2775–2778. doi:10.1001/jama.287.21.2775
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