The top 5 reasons manuscripts get rejected – and how you can prevent them

We have exciting news to share! I have been recently published in the Swiss Medical Journal on how to prevent manuscript rejection. The Swiss Medical Journal is a top-notch publication and is the main source for information on the medical field and healthcare system among Swiss healthcare professionals. Since our article has been published in German, I am happy to share an English version with you here on our blog.

There are many reasons why manuscripts are rejected and many struggle with getting their findings published. As a professional medical communications agency, we are often contracted by clinicians and researchers who need professional guidance for their manuscripts. It can be both a scientific and an ethical problem when manuscripts containing high-quality, clinically relevant research fail to receive due recognition.

The advice offered in the article below, draws upon the shared experiences and expertise of our large team of qualified medical writers and I hope you enjoy it.

swissmedicaljournal-cover The following article is an English version of the article “Abgelehnte Manuskripte – wenn hochwertige Forschung aus den falschen Gründen verloren geht” published in the Swiss Medical Journal:

Rejected manuscripts — quality research lost for all the wrong reasons

If you have ever submitted a manuscript to a biomedical journal and it has been rejected, take heart: you are not alone. In fact, you are in the majority: one study reported that 62% of published manuscripts have been rejected at least once by other journals before eventually being published1, and top journals have an overall rejection rate of around 90-95%2-4. With the number of submissions increasing every year, that makes getting published even more difficult. However, the reasons for rejection are not always what you might think; more often than not, manuscripts are turned away for reasons that are easily fixable — and entirely in your control. Here is an overview of some of the reasons journal editors reject papers, along with advice and solutions for helping your paper to be accepted.


1. The manuscript is out of scope of the journal

As of December 2016, 5,633 journals are currently indexed in MEDLINE5. Choosing one can seem a daunting and imposing task. In addition, many manuscripts are rejected by the editors before they ever make it to peer review, simply because the research does not fit the aim and scope of the journal. Take the time to carefully research and consider journal options. Often a “top down” approach is favoured, particularly in academia; this means journals with high impact factors are often chosen over more appropriate, lower impact factor journals. As such, it may be tempting to submit to a journal with a high impact factor like the Lancet (44.002), Journal of the American Medical Association (37.7), or the New England Journal of Medicine (59.558)2-4. However, with rejection rates of around 95% and scopes which include “original contribution that advances or illuminates medical science or practice (The Lancet)” and “offer new information about the biology of disease (NEJM)”, another journal may be more appropriate.

Indeed, the most common reason for rejection is lack of new or useful information.6 Thus it pays to find a journal whose scope and readership are appropriate for your manuscript.

When choosing a journal, consider the following:

  • What is the topic? Is it, for example, novel and ground-breaking medicine, worthy of media coverage, or is it a surgical technique, a systematic review, a local clinical trial, or guidelines stemming from an expert group?
  • Who should be reading your manuscript? This could be surgeons, general practitioners, travel clinics, nurses, radiographers, pharmacists and so on.
  • What is the appropriate geographic region? Would the data be best presented to a US audience, a European audience, or is a local, regional journal more suitable?
  • What is the format of your manuscript? Is it a review, a case study or a clinical study?

Then create a list of journals and select where to submit. Large, international publishers such as Elsevier, Springer, and Taylor and Francis, offer journal finders, which let authors match manuscript criteria to journal criteria, helping to streamline the process. In addition, there are independent databases such as JournalGuide and open-access publishers such as BioMed Central, which help guide you in selecting from a broader range of journals.

Looking at the author guidelines and requirements of the journal can also impact your choice. Limits on type of manuscript, length, number of tables and figures and numbers of allowed references and even authors on the manuscript, are deciding factors.


2. The quality of writing is below publishable standards

If good research is poorly communicated, whether due to the authors having English as a second language, or simply due to linguistic style, then knowledge is lost if it is not published because of these reasons. Poor writing, manuscript structure and preparation are all key reasons for rejecting papers, even with strong results.6,8–15. Some common problems include: 6,8–15

  • Failure to clearly state the problem and context of the study, to describe the issues, and to explain and interpret results
  • Unclear, overly long or complicated, ungrammatical sentences
  • Typographical, spelling and syntax errors
  • Overuse of jargon, unnecessarily technical terms or regional idioms (e.g. A&E versus ER)
  • Inefficient communication that leads to wordiness
  • Inappropriate or unpersuasive title, abstract or cover letter
  • Poor design of tables, graphs or figures

“I have been involved in some clinical trials and I have written some articles,” says Dr Alessandro Diana, chief medical officer at the Clinique des Grangettes in Geneva and associate physician in paediatric infectious disease at the University Hospitals of Geneva. “I am peer reviewer of two journals, so I often review scientific articles. I have come to the conclusion that there are many articles with important scientific contributions that are not published.” The reasons for this are many, but it is a major problem when articles are refused because of poor language.

Most major publishing houses provide links to English language services, companies that specialise in English language checks. However, this is sometimes not enough to ensure that a manuscript will be accepted. To correct linguistic and particularly stylistic, content or formatting issues, it is important to perform several rounds of revisions prior to submission, and to seek help from people who have excellent English writing skills, who possess advanced medical vocabulary, who have a keen eye for detail, and who are experienced in publishing in multiple journals. Often an English language check is not enough – a professional Medical Writer can also check the formatting, content and presentation of the data, errors in manuscript preparation can be corrected before being picked up by the editors of the journal.


3. The manuscript is not formatted correctly

One of the main reasons for an immediate return of a manuscript, or a rejection, is because the manuscript is not formatted for the journal. Each journal follows its own style guide, which dictates everything from use of compound adjectives, prepositions, and commas in lists, to whether page or line numbers are used, the length of a figure legend, and the overall structure. What may seem trivial can be a reason for an immediate return. Even word counts have paramount importance – one must be aware that different journals require different lengths, for different reasons. If the journal is only available online, then word counts are much less restrictive than for a journal which is still in weekly print circulation. In this case, the journal itself is restricted by the number of pages, which impacts the number articles and type of articles that they can print per issue. Even using colour graphics can become an issue if the manuscript is going to be printed in just black and white. These are all small issues which are actually incredibly important, and which have to be adapted and changed for every resubmission to a different journal in the case of a rejection.


4. The guidelines have not been followed

When it comes to writing a manuscript, it is no longer as simple as making sure your manuscript follows the IMRAD format. A demand for increased transparency has led to initiatives which aim to improve the reporting of clinical and biomedical research. As such, the way a manuscript is written has changed. Nowadays, one manuscript has to abide by a number of different guidelines, for different purposes. For example, manuscripts for publication in medical journals need to follow the ICMJE Uniform Requirements for Manuscripts16, to ensure, amongst others, that authors fulfil authorship criteria. If the manuscript reports on a clinical study, then different guidelines are used, depending on what kind of study it was – for example, CONSORT for randomised controlled trials, CONSORT extensions for equivalence or non-inferiority trials, STROBE for observational studies, ARRIVE for animal preclinical studies17 – and then if it was sponsored by industry, suddenly the Good Publication Practice 3 guidelines come into play. If it is a case report, then CARE guidelines can be used; if a systematic review, then PRISMA17 is used. But that is not all, the journals own guidelines then have to be followed: author guidelines, manuscript templates, statistics guidelines and so on. In this way, for example, an industry-sponsored, randomised controlled, non-inferiority trial for publication can follow 5 or more sets of guidelines – which is often overwhelming for anyone wanting to publish.

It is therefore key that, before a manuscript is submitted, care has been taken to ensure that all the relevant guidelines have been followed. The best way of doing this is to start with the author guidelines of the chosen journal, and to make sure that any additional guidelines to which they refer are consulted.

This is another area in which professional medical writers can easily help. Here at we are often approached by doctors who are publishing their first manuscript in years. The way manuscripts are written, or more importantly, the way research is presented, has changed dramatically since they last published. For researchers, it is useful to be able to work with professionals who stay on top of new developments.


5. The peer reviewers’ comments are not properly answered or go unanswered

After a manuscript is submitted and it undergoes peer review, it will most likely be returned with revisions, be it major or minor ones. For issues that can be fixed, this is the point in the process at which revisions and editing take centre stage.

Major and minor revisions do not automatically mean that the manuscript is rejected, more often than not, the journal allows for resubmission after revision. In fact, 75% of published manuscripts end up appearing in the journal to which they were initially submitted.7 Failure to respond to the comments at resubmission is a lost opportunity. All comments should be carefully answered in a detailed rebuttal letter. If the comment can be implemented, then this should be done, and if not, a detailed explanation as to why this is not possible, should be given.


So your paper got rejected, what now?

If a manuscript is rejected, a careful assessment should be made. The letter from the editor is a starting point. Often they give reasons for the rejection: they may be journal-related, such as being out of scope, or the manuscript may be rejected due to language or formatting issues. Other reasons for rejection may lie in the need for further research. For the former, another journal should be carefully chosen, the manuscript reformatted and, if necessary, rewritten and submitted. If further research is required, then an assessment should be made as to whether this is possible.


New developments: free online preprint servers and archives

However, some papers — for one reason or another — cannot find a publication home.  Sometimes, regardless of how well a manuscript is written, the science is not strong enough, or further research is needed.

There is an increasing trend for publishing a preprint — a manuscript that is either not submitted or has been submitted to a journal, but is not yet accepted for publication — to online archives such as biorXiv18 or PeerJ Preprints19. There is also an example from Switzerland; Dr Diana has developed an online platform called Unpublished Articles in Science (UNAIS)20 to publish abandoned scientific papers along with the reasons given by the reviewers for rejection.

For these online archives, there is no peer review, but the manuscript will be read by other readers who may comment. For authors, this can be advantageous if mistakes are noticed, or feedback is given which may help to improve the manuscript before submission. Furthermore, if the manuscript is not accepted by a journal, the research is still presented in the public domain, making it accessible to other researchers to build upon. The majority of publishing houses accept submissions of manuscripts even when posted to an online archive, but it is still sensible to check each journal’s preprint policy, as there are some for whom uploading of a preprint precludes publication in their journal.


Preventing lost research

It is unethical if good quality research is lost to the public domain because it fails to be published. Following the guidelines presented above may help increase the amount of quality research being published. Fewer rejected papers would help progress medical research. Being aware of the issues surrounding publications can help to ensure that your manuscript is eventually published. In addition, professional medical writing services can offer assistance in developing and refining manuscripts, increasing the chance of a successful publication. They can strengthen both the language and the rationale, improve data presentation in figures and tables, and provide input on guidelines.

Ultimately, the collection of clinical data represents large investments of both time and money, in addition to the goodwill and consent of the patients. Don’t let language or formatting mistakes cause unnecessary rejections.


  1. Hall SA, Wilcox AJ. The fate of epidemiologic manuscripts: a study of papers submitted to epidemiology. Epidemiology. 2007;18:262-5.
  2. The Lancet. How The Lancet handles your paper. Accessed July 2016 at:
  3. The Journal of the Americal Medical Association. About JAMA. Accessed July 2016 at:
  4. The New England Journal of Medicine. Author center. Accessed July 2016 at:
  5. Accessed December 2016 at:
  6. Ehara S, Takahashi K. Reasons for rejection of manuscripts submitted to AJR by international authors. AJR Am J Roentgenol. 2007;188:W113–6.
  7. Calcagno V, Demoinet E, Gollner K, et al. Flows of research manuscripts among scientific journals reveal hidden submission patterns. Science. 2012;338:1065–9.
  8. Coronel R. The role of the reviewer in editorial decision-making. Cardiovasc Res. 1999;43:261–4.
  9. Byrne DW. Common reasons for rejecting manuscripts at medical journals: A survey of editors and peer reviewers. Science Editor. 2000;23:39–44.
  10. Bordage G. Reasons reviewers reject and accept manuscripts: The strengths and weaknesses in medical education reports. Acad Med. 2001;76(9):889–96.
  11. Wyness T, McGhee CN, Patel DV. Manuscript rejection in ophthalmology and visual science journals: Identifying and avoiding the common pitfalls. Clin Experiment Ophthalmol. 2009;37:864–7.
  12. Pierson DJ. The top 10 reasons why manuscripts are not accepted for publication. Respir Care. 2004;49:1246–52.
  13. Ajao OG. Some reasons for manuscript rejection by peer-reviewed journals. Ann Ibadan Postgrad Med. 2005;3:9–12.
  14. Ali J. Manuscript rejection: Causes and remedies. Journal Young Pharmacist. 2010;2:3–6.
  15. Thrower P. Eight reasons I rejected your article. 12 September 2012. Accessed June 2016 at:
  16. ICMJE Recommendations. Accessed July 2016 at:
  17. Equator Network. Essential resources for writing and publishing health research. Accessed July 2016 at:
  18. Accessed July 2016 at:
  19. PeerJ Preprints. Accessed July 2016 at:
  20. Unpublished Articles in Science. Accessed July 2016 at:


Power to the people: Make gains by focusing on health literacy

The concept of health literacy is actually fairly new. The term was first introduced in 1974, when Simonds argued that students could also be literate in health, just as they are in other subjects, such as maths or reading1. By the 1990s, the World Health Organization (WHO) had taken up the cause, culminating in the publishing of its own definition of health literacy in 1998’s Health Promotion Glossary2. As governments and health systems make pushes towards more patient-centered care that empower patients to share in making decisions about their treatments, the concept of health literacy has never been more important. Read on for an overview, as well as why pharmaceutical and medical device makers should be focusing on health literacy as part of an overall medical communications strategy.

Defining health literacy

Since the WHO brought health literacy to the world stage, the concept has continued to evolve, inspiring a multitude of research on health literacy in a variety of health conditions and contexts. Researchers are now seeking to integrate existing definitions and conceptualisations of health literacy “into an encompassing model outlining the main dimensions of health literacy as well as its determinants and the pathways to health outcomes,” so that health literacy can be better promoted and measured3. In 2012, researchers created a model that “identifies 12 dimensions of health literacy, referring to the competencies related to accessing, understanding, appraising and applying health information in the domains of healthcare, disease prevention and health promotion, respectively” (see Figure 1)3. This is a straightforward, comprehensive lens through which to view the concept of health literacy, so it’s what we’re referring to going forward.

Figure 1. Dimensions of health literacy

Fig 1a Dimensions of health literacy

The impact of health literacy

As management of chronic illnesses (e.g. diabetes, vascular disease) in particular has come to dominate the global conversation about healthcare, ongoing therapy is often necessary for optimal outcomes. However, health services and clinicians alone cannot be entirely responsible for this burden — patients must also be fully engaged in their care. If they cannot understand what their care regimen is, why a care decision has been made, how to participate in that care, whom to contact about their care, and when to carry out or pursue care options, health outcomes suffer. More specifically, poor health literacy results in:

  • Errors
  • Poor quality of care
  • Risks to patient safety
  • Inability to communicate in public and private dialogues about health, medicine, scientific knowledge and cultural beliefs
  • Lower quality of life
  • Decreased equity and sustainability in health systems3

Without a system-wide focus on health literacy, people with a variety of acute and chronic conditions may not understand health-related educational materials, making them arduous to self-manage. Without proper self-management, patients have a greater risk of developing many secondary health conditions. This can be a colossal expense for the individual and healthcare systems overall. Health literacy is a core foundation for a patient’s ability to self-manage and should be treated as such.

Approaches to health literacy

Low health literacy levels can broadly be addressed by educating persons to become more resourceful (i.e., increasing their personal health literacy), and by making the task or situation less demanding, (i.e., improving the “readability of the system”)3. That is, patients should have a wide variety of options to choose from, to suit their personal situations and learning styles, and these options must be delivered in a way patients can easily understand. More specific examples ways to improve health literacy for patients include:

Blogs — Written in conversational, easily understandable language, blogs are designed to be quick reads on a single aspect of a bigger topic. This approach allows patients to read about the specific information they’re looking for, and link to other related blogs, if they choose. Patients don’t feel overwhelmed by a paper that tries to do everything at once, which helps enhance information retention. The advantage for pharmaceutical and device-makers is that a regularly updated blog helps SEO optimisation, thus keeping the company at the fore of web search results — and at front of mind for patients and clinicians (who often direct patients towards patient education options).

Websites — A well-organised and well-thought-out website delivers a variety of learning modalities to patients. It’s easy to explain concepts visually (e.g. through infographics, pictures or medical illustrations), provide audio explanations for visually impaired patients, and embed videos that let patients follow step-by-step — or even hear stories from patients just like them. A page with downloadable resources lets patients engage in their education and care even when they’re not online. And a mobile-optimised website means they can check for answers to questions anytime, anywhere on their tablets and phones.

Patient education materials — These can be downloadable or more traditional printed resources. Straightforward language and clear visuals can be integrated to help patients, for example, prepare for surgery with a specific device, self-care after that surgery, how to administer diabetes medication, or how and when to take blood pressure readings.

Apps — Apps have the same anytime-anywhere advantage as websites, but they can take health literacy a step farther by making education interactive. Health literacy is not just about being informed, but about how patients are able to apply that information to their everyday lives and care. Apps can be developed to help guide patients through steps in their care — letting them get ‘hands-on’ experience before actually doing — and to integrate reminders about their care regimens and a place to record their care-related activities, for example.

Engaging patients directly in their own care in one or more of these ways positions companies as more than pharmaceutical and device makers, but as thought leaders concerned about patients’ overall wellbeing.

Health literacy never loses its importance

Too often, patient education materials are written at a readability level too advanced for the average patient. Writing medical information in an easily digestible format is not the same as ‘dumbing it down’. Rather, distilling information for patients requires in-depth knowledge of a therapy area or speciality, so that it can be conveyed in a way that is both technically sound and easy for the average patient to follow. has experts across the healthcare spectrum, experienced in delivering a wide variety of educational materials that can help you lead the way in improving health literacy. Remember: Acute and chronic health conditions can occur in all stages of life, to people of all education levels, and health literacy helps optimise outcomes and save lives.


1. Simonds SK. Health education as social policy. Health Education Monograph. 1998;2:1–25.

2. World Health Organization. Health Promotion Glossary, 1998. Accessed March 2016 at:

3. Kristine Sørensen, Stephan Van den Broucke, James Fullam, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. Accessed March 2016 at:


Make your product the star with medical storytelling

The best content tells a story, and medical writing is no different.

Stories make us sit up and take notice, they help us remember, they provide connections between simple facts and spark creativity in our minds. In medical communications, this means going beyond listing product features and data points to give clinicians and healthcare managers a more rounded view.

Think of your drug or medical device as the main character, and all the ways the product can affect hospitals and clinicians as the stories to be told. Storytelling is the key to creating awareness among customers, delivering value to them, positioning you as an expert, and connecting and engaging with current and potential customers. Read on to find out how.COM0043-2015121. Create awareness
There’s a reason oral storytelling survived so long — long enough, in fact, until the printing press was invented, and we could start recording those stories, many of which still survive today (think Grimm’s Fairytales). That’s because, quite simply, the human brain craves stories. In fact, research has demonstrated this time and again — our brains have to work to decode the meaning of data but, when they processing stories, the brain can skip the work of decoding and go straight to the retention of information. Therefore, it’s far easier for potential customers to remember information told by stories than that conveyed as a list of cold, hard facts, however well-organised. What’s more, 92% of consumers say they want to internalise information via stories. Leading consumer brands such as Coca-Cola have successfully adopted this method of marketing, and medical device and drug-makers can, too.


2. Deliver value
When you tell a story, you’re not just describing the ‘what’ of your device or drug. That is, it’s not, ‘Once upon a time, after many years of R&D, a product was developed.’ Rather, you’re taking the facts about your device or drug and communicating to hospitals and clinicians why the product matters to them. Author, business consultant and university professor Simon Sinek originated this concept, which he calls the ‘Golden Circle’ as a sales and marketing approach. When you focus on the ‘why’ of your product, your marketing plan must be multi-faceted. Journal articles and conference posters alone won’t cut it. You have to extrapolate that data — doing the work for the customer’s brain — and provide avenues by which to implement the desired change (i.e. buying your product) and convincing reasons for doing so. Therefore, your marketing plan should include health-economic data, clinical decision-making mechanisms (such as pocket guides and apps), downloadable tools for education and cost-efficiency calculations, and more. These kinds of medical communication, though slightly outside the norm, add value for customers while going beyond a list of product features or data to create the whole story of your product.

COM0044-2015123. Position yourself as an expert
Do you want to be ‘just’ a device- or drug-maker, or do you want to be a partner to hospitals and clinicians in the delivery of high-value healthcare? When you focus on storytelling and start creating value-added content for customers, you demonstrate that you share their concerns — and that you’re not just in it to sell, sell, sell. Of course, no one goes into business to not make money, and everyone knows that. But custom storytelling actually helps you make more: it’s ‘92% more effective than traditional advertising at increasing awareness, and 168% more powerful at driving purchase preference.’ That’s because, when customers have a problem, they think first about potential problem-solvers. With a story-telling approach to marketing, that would be you.

4. Connect and engage with customers
Storytelling gives you more space to answer your customers’ questions, and lets you be nimble enough to address new issues in healthcare as they arise. For example, adding a regularly updated blog to your website gives you the flexibility to tell various aspects of your drug’s or device’s story on an ongoing basis. Instead of trying to get all the information into one, long document, you can focus on bite-sized topics — such as how your product helps manage changes in healthcare regulations, enhances patient safety or solves a clinical problem — that customers can digest in a quick read. What’s more, because you’ve positioned yourself as the expert, they’ll become engaged with the content you’re delivering and return for updates. In addition, clinician experiences and patient case studies help you connect with customers, because they’ll see themselves in the content and have a ‘character’ to root for. Clinicians want to know how the products work (clinically, time-wise and economically) for people like them and patients like theirs, and storytelling helps you achieve those aims.

Building your strategy
When you consider how to put together all the parts of your drug’s or device’s story, it’s important to take a step back to determine your goals. Sometimes, the perspective of a neutral third-party can help pinpoint your aims — and how to achieve them. can help you craft the components of your product story, delivering storytelling that is straightforward and insightful about your product and industry, that adds a personal touch, and that ensures your audience will want to come back for more.

Patient education – more than meets the eye

Patient education is evolving. It’s no longer enough to simply “tell” patients what to do — healthcare reforms in many countries aim at empowering patients and engaging them in their care. Plus, patients can’t be expected to remember everything they’ve been told in the clinic or hospital, considering the volume of information, medical jargon and differences in clinicians’ communication abilities, not to mention the stress of being in the healthcare environment.

Read more

Getting your research published – 7 tips for healthcare professionals

For the healthcare professional looking to publish the fruits of their research, the task of writing up the findings and getting them published can seem almost as daunting as the research project itself! There are a number of steps you should take to ensure you are successful, and here we look at the most important aspects in detail, from the initial preparation to dealing with rejection.

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