Michael L.J. Apuzzo, MD
By Michael L.J. Apuzzo, MD
Dr. Apuzzo is one of the pioneers of modern neurosurgery and we are honored to have him on our team as an advisor to our faculty, residents, and medical students. He recently spent an hour with the Weill Cornell Medical College chapter of the AANS, in an event hosted by chapter advisor Dr. Susan Pannullo and moderated by Parsa Nilchian, a student in the Tri-institutional MD-PhD program, to offer perspective and advice on academic publishing. Here are 10 takeaways from his talk, lightly edited from the transcipt.
1. The Idea Is Paramount
The most important thing for progress and movement is an idea. The idea is the genesis of everything. So if you can be creative, be original, that is so important. The people or the person who creates the idea, the reason for the paper, or initiates the activity toward the paper, that person is extremely important — if not the most important person overall. And then there are the worker bees to make it come to fruition. Medical students want to work in labs — you want to become part of the environment and you're getting paid in experience. The experience you get is like money, giving you riches. You’ll learn the difficulty in collecting data and putting things on paper, but the thing that gets everything rolling is the idea — and there are no better catalysts for ideas than high-caliber institutions like Weill Cornell and NewYork-Presbyterian. (See Dr. Apuzzo’s article A Storm of Ideas.)
Dr. Susan Pannullo welcomes Dr. Michael Apuzzo
2. What Makes a Good Paper?
A good paper is one that conveys a novel idea and stimulates thought in a new direction. But it needs good construction, with a sense of order, to make it easily readable and not fatiguing to the reader. Read the good journals, and you’ll see everything is tight, organized, well constructed.
When I review articles I start with the title, then look at the abstract, then the bibliography. The bibliography is a clue to the confidence of the authors, because I can see how well they understand the topic. Remember that forever. If you're familiar with a topic, you're going to know the literature. Keep in mind when you’re writing an article, and the reviewer is going to look at the bibliography and be able to tell the level of sophistication that paper was put together.
When I was editing a journal, with 12 issues a year, 30 articles each issue, we would have probably 6,000 papers submitted. You may not believe me, but it's true that I looked at every paper. I didn't read every paper, not every word, not every sentence. But I got a sense of the originality of it, of the substance of it, by looking at the title. Did the title strike me? Was I excited? Was it a hook? Was it something that I was interested in? Was it something new and novel or not? The title is like the marquis on a theater and catches a reader’s interest — so create a title that entices, that’s appetizing.
Then I'd look at the abstract, and that was the real hook. A good abstract capsulizes the impact of the paper — how did you go about answering the questions, what did you deduce, and what are your recommendations based on findings? A good abstract summarizes your work for those who don’t want to read the whole thing, but it also brings in those who do. The title may be the bait, but abstract starts to show the meat.
And then I'd look at the bibliography, which puts those three things together. A bibliography is like a Rorschach test of the sophistication of the authors. Do they know the field, or are they shooting in the dark?
If those three things worked — title, abstract, bibliography — then I would get into the substance; if they didn't work, that paper was gone. Once I decide to read it, the paper needs to be organized, logical, engaging, well constructed. A good paper draws conclusions that are supported by the fabric of the data, by the findings.
A good paper will also tell the message visually, so you can go through it quickly and get the information. I like to see lots of images, graphs, and other visuals. Another little secret is that I put my own papers together knowing that it could be a talk, so visuals are extremely important.
If you hit the bullseye on all of these, your paper will be accepted.
3. Choose Carefully: What and Where to Publish
I've been in clinical medicine for more than 60 years, and I had many jobs, but the best job I ever had was to be Editor-in-Chief of Neurosurgery, and to found Operative Neurosurgery and the wonderful journal World Neurosurgery. And all of them are different. There are also different kinds of papers: clinical papers, lab papers, case reports. You have clinical studies, technical reports, and so on, and all of these are different in terms of the effort that it takes to put them out.
There are so many totally different journals, with different audiences they reach, so understand who the journals are for. High-impact journals are good for lab guys but you’ll miss clinical guys. Send basic science work to basic science journals. Ask yourself, who do you want to reach?
"First or last authorship is all that matters. If you’re in the middle, you just chalk that up to experience."
There's a legitimate pecking order — when a paper gets turned down for one journal, the authors go down the list to another. Some people like to publish in a particular journal for political reasons, or to satisfy the NIH. You need to look at reach — online publication brings your work to millions of people.
People get excited when their work appears in the big medical journals, but remember the audience there is medical, not neurosurgical. A medical journal with a big reach may not be getting to the right people. For example, if you’re doing papers on ultrasound, meaningful papers would have to go into neurology journals, neurosurgery journals, functional journals. Those are the important places to go to reach the right people.
For your own papers, send them to journals who have the readers you want to reach. You will help patients the most by reaching other neurosurgeons.
4. Pay Attention to Authorship Criteria
There's a lot of flexibility in who plays what role and where you fall in the list of authors and contributors. My feeling is that if you do work on the substance of the paper, you should be recognized, either with authorship or with a note of appreciation at the end of the paper acknowledging the work you did on it. Where you fall is going to be at the discretion of the senior person in the group, who has the responsibility of designating who the important people are, who did what, and who were responsible in large weight.
I recommend a collegial approach of talking this out. Different labs have different styles, and the lab director’s attitude toward authorship is key. In good places like Cornell, whoever does the work gets the credit. The senior guy doesn’t usually need another first authorship! If your name is on a paper, people know you had your fingers in it. Advocate for yourself — discuss what you did and why you should get first authorship. The person who adjudicates is the senior person.
I think it works to sit down at the end and see who did what. If it’s a sensitive matter, there should be a collection of people who come together and really discuss. If it is important for somebody to be named somewhere and they've earned it, then they should be there. I always think it's nice to have the senior person at the end to show that there was some oversight. It’s a certificate of validation, that they're putting their validation on this work and sticking their nose out.
Dr. Apuzzo addresses some of the members of the Weill Cornell Medical Student Chapter of the AANS
5. The Risk of Getting Lost in the Middle
I review student CVs when they're applying for residency, when they are looking for admission to the guild of neurosurgery, and we all like to see first authorship. I'd rather see two first authorships on a CV than 10 where you're in the middle of the chain. Where you are in the middle doesn’t matter, because once you’re in that zone you’re lost. First or last authorship matters. If you’re in the middle, you just chalk that up to experience.
The last author should be the senior person. The first author is the person who not only did the most work, but was most critical in the genesis of the paper. It doesn't mean doing the most work, doesn't mean you're putting in the most hours. But it has to do with your importance in the fabrication of the concept and bringing the concept to reality. How important are you? So much of authorship relates to the congeniality and the sort of paternal feeling or maternal feeling of who's head of the lab or of the projects.
If you work in somebody's lab, you're putting your trust in that person, trust that they're going to do the right thing for you. Lab directors are usually happy that you're there working with them. When you tell somebody you want to work in their lab, it validates them — it’s a two-way street, believe me.
6. The Credit Statement
[CRediT (Contributor Roles Taxonomy) was developed to reduce disputes over authorship and better identify who did what on a paper. More and more publications are requiring a CRediT statement at the time of submission, establishing who on the list of authors performed which role, from conceptualization to data curation and analysis through project supervision and the actual writing/editing.]
At one time there were complaints about some people abusing the privilege of authorship. People were being given authorship when they don't do the work, and that is just horrendous. It was hard to police — there was so much work to get these journals out in my day, and the budget was generous but limited. I did like the idea of the CRediT system, though. Don't take it for granted — when you see the list of who did what, and then you look at the paper and you get a sense of what it took to put that paper together, sometimes it doesn't add up. But CRediT is a step in the right direction.
"Everything you do, every patient you see — the hospital is a crucible and it's full of ideas."
The people at Cornell are really beautiful, kind and supportive. If you do enough to be first author, you will always be the first author, because our job is to make sure that your career gets career going. I want to see you be famous. I want to see you succeed. I want to see you do more than I ever did, because then I feel good at the Congress!
7. When Not to Put Your Name on a Paper
If you can’t answer questions about a paper, about its methodology or conclusions, or about its statistics, then don’t put your name on it! You may be asked about it on your residency interviews, and that can be very uncomfortable. If you put your name on it, you need to be able to discuss it. You may not know every detail, but you need to know the message and conclusions, what the impact on patients is. If you’re the author, you should know what the substance is. Besides, a paper becomes meaningless when I see 80 authors — I don’t take it seriously.
8. How to Get Started
You will be under somebody’s mentorship, then you come up with an idea, and you want to make it work. You take the lead, so you're the point person. Maybe you see something your mentor is doing that makes you excited. You go and tell them, this is so exciting to me — what contribution can I make to this paper? Can I do something to have my name associated with this paper, because it's so exciting to me? And then you'll be an author, you'll be in there somewhere, I promise. That's the way it should be. At the good places, the good people, they want to promote you. And you should do the same when you eventually have the power to do it. That’s coming from a place of congeniality. Authorship is something that means a lot, and it makes you proud. But you got to be careful about when you're applying, certainly to your residency, that you make the effort to be first author.
9. Keeping Up With the Literature
I recommend that every month you should look at the Table of Contents of Neurosurgery, Clinical Neurosurgery, the Journal of Neurosurgery. If you're interested in a subspecialty, the Journal of Neurosurgery Spine is very good. And then World Neurosurgery and Operative Neurosurgery. Every month you should at least look at the table of contents. You've got the time for that. You look at the table of contents, and then if you want to focus on the three of them and look at articles that you're really interested in, look at that. But you can't read everything. There's no way you can do it. But you can look at the TOCs because that gives you a window as to what's hot.
Remember that ideas feed off each other, so don’t only read about your own interest. MIS spine surgery came from endoscopic neurosurgery!
When I was recruited to be the editor, Dr. Laws said to me, don't you want to do this? Don't you want to guide and create the whole mood and the whole tenor and the whole scope of what neurosurgery is during your lifetime? God, first of all, it was frightening. And then secondly, then the ego kicked in and I said, yes, it would be wonderful to do it. And that's really what the editors do. The journals set the conversation and they set the mood. They set what's important to a certain extent in a big way.
10. It Starts in the OR, Where Any Patient Could Be Your Next Paper
Remember, you're going into a residency to learn to operate. How can you call yourself a neurosurgeon if you can't operate? So you begin there and get a sense of what's really important to you, which gets seared into your mind. You can do all the fine tuning later, but while you learn to operate, you pick up the discipline and the foundation that have been created at Cornell, one of the top places to get your medical training. And that’s where the ideas come from. Every time you make rounds, questions and ideas come up. You’re flooded with them, so it’s up to you to be productive.
As a resident I felt completely barren, with no ideas at all. I thought I was dead in the water. But then suddenly the light went on, and I just realized that when I walked through those doors every morning, particularly at the general hospital in Los Angeles, there was always something good about to happen, something that could give me a new avenue to explore. Everything you do, every patient you see — the hospital is a crucible and it's full of ideas.
We did the first cases with the VNS — this fool of a neurologist came into my office, an epileptologist, dangling this coil in my face. I said, I told him to get out and leave me alone, and he left the coil on my desk. I kept looking at it, looking at it, and then I looked in the literature, and there was one patient in Mississippi where they had showed they could technically do it. I called the vendor who was trying to promote it, and then we went to work and we did the first series of cases with the vagal nerve stimulation, showing that modulation peripherally could have an effect on chronic epilepsy. So this is the way that things happen.
See Dr. Apuzzo’s article A Storm of Ideas