How to Write a Good Letter to the Editor

Gio Perin – Specialist Registrar, General Surgery, Yorkshire and Humber Deanery
Saba P Balasubramanian – Consultant Surgeon and Honorary Professor, Sheffield

In this short blog entry - and related podcast ( ) - Gio Perin and Prof Saba Balasubramanian discuss the ins and outs of writing letters to the editor. This is not meant for seasoned experts who are asked for their judgement in the form of an editorial or a commentary on an article, but for people less experienced in critical appraisal and scientific writing.

Writing a letter to the editor of a medical or surgical journal is something trainees and students sometimes try to do. It may be a first stop in publishing for many people and of significant value in boosting confidence in writing and having a line in your cv. Others think that it does not add much and that you could spend a lot of time and effort for little value, which could be spent on something more worthwhile, like an original manuscript or a review.
What do you think of writing letters? Is it something you would encourage medical students, trainees and surgeons to do?

In short, yes, I certainly would. I think writing letters, especially at an early stage in your education and training can be an important part of learning and developing your critical appraisal skills. Writing a letter to the editor is not difficult. But, writing a good letter requires a number of things:

an in-depth understanding of the subject
clear goals (why are you writing the letter and what you wish to communicate)
logical and structured thought process and
skills in technical or scientific writing.

Personally, I think it is time well spent and as you say, a couple of letters could well be the boost many people need to crystallize their interest in research and set out to address the gaps they have seen in the study they have critiqued. Writing letters enables you to think in more depth about the paper and the subject and you could take away lessons on both ‘how to do things’ and also ‘how not to do things’ in your own research.

That’s a great point, actually my first publication was a letter to the editor, and I remember being quite thrilled when I received notification of acceptance! So in what circumstances should I (as a trainee) consider writing a letter to the editor?

You could consider writing a letter for a number of reasons.

You may be interested in a particular clinical problem and involved in research addressing the problem. You come across an article relevant to your problem/research and may have questions about the methodology, results, interpretation or validity of research; you may have data that is similar or contradictory to the report; or may have a different perspective on potential explanations for the reported findings.
You may be part of a regular journal club and have discussed a paper on a problem relevant to your practice and may wish to summarize the discussion in your journal club and submit a letter. This helps you crystallize your thoughts and gives feedback to the authors. Even if your letter is critical, the fact that the paper has been of interest and discussed by a group of peers would (should) in itself serve as positive feedback to the authors.

What are the potential benefits in writing a letter?

There are numerous benefits:

Learning and development – you will (should) read around the topic, increase your understanding of the subject, improve your skills in critical appraisal and technical/scientific writing and demonstrate your appraisal/writing skills.
Demonstrate your interest in a particular area within your ‘community’ – for example you may be interested in pancreatic surgery and if you write a letter on a paper evaluating a RCT on a new technique aimed at reducing pancreatic fistula rates, it helps establish your interest.
Of course, you add a line to your CV
Benefit to authors – as mentioned before, it is good to give feedback and if given in the right spirit (and taken in the right spirit), authors benefit from your perspective and critical appraisal. Letters are not written very often and in my experience, most authors like to know that their manuscripts are of interest to readers and appreciate the time/effort you have taken in writing a letter.
And finally, there is a wider benefit to the scientific community – letters are one important way of debating a research question and help perform what some people call a ‘post-publication’ peer review.

Where should I start?

If you have come across a paper (either through personal reading or having discussed it in a ‘journal club’ type setting) and you are thinking of writing a letter, I would suggest you consider the following steps:

The first step is to spend time reading through the manuscript in detail and taking the time to understand the concepts, the methodology and the results. Look carefully at what the authors make of the results and as you read the paper, make a note of the key points, the positive and negative aspects (from a study design and a clinical/domain point of view). That is, if you are critiquing a paper on the ‘conservative management of acute appendicitis’; you should not only consider how the study was designed and conducted, but also whether the research question is appropriate, the inclusion and exclusion criteria was reasonable and if the results are generalisable. Also, note things you are not sure about and terms/concepts you are not familiar with.
Then, spend some time reading any relevant background literature. Is the study important and relevant to the field? Has the research question been addressed before? If so, are the results similar to previously published literature or different and if so, in what way? What does this paper add to existing literature?
Then, consider how you may have approached the same research question? Would you have designed the study differently? If so, in what way? If so, think about why the authors may not have adopted your approach – is it because of time, logistics, expense or other reasons?
Consider if you have a different perspective or explanation for the observed findings. Do you have any supporting evidence (your own experience, research findings or other literature)?
Make a list of what you wish to say and then start writing…

How should I structure the letter?

There is no ‘one size fits all’ approach. However, in general terms, I would suggest the following structure…

A short introduction to explain why you are writing a letter (or the context).
The salient points of the paper itself (this could be just a couple of lines) or in some occasions, just the area you wish to talk about...
The positives – what is interesting about the paper, what has been done well – be magnanimous in your praise!
The issues or questions you wish to raise – if there are several, list them in a logical sequence.
For each issue, explain your suggestion/comment you may have – related findings either from your own research or other literature, alternative explanations for observed findings, suggestions for improving methodology or a way forward (that the authors may not have considered).
Conclusion – A very short summary with an ending expressing hope that your feedback will be of interest or that you are looking forward to the answers to your queries.

Are there any specific rules or guidance?

You should follow instructions given by the journal in question. Different journals have different criteria related to ‘letters to the editor’. Most have restrictions on word count, some restrict comments to a short period after publication, limits on number of tables and figures and so on. In general, be courteous. Avoid being overly critical, unless there are serious ethical concerns regarding the conduct of the study. Remember that if the letter is published, this will potentially be read by many people and even if your arguments and comments make perfect scientific sense, it does not help if it comes across as snobbish or arrogant. Disagreements are common and you do not need to ‘sugar coat’ them, but at the same time, they should not be expressed in a disrespectful way.

Do I need to inlude references?

The short answer is yes. This is especially true if your arguments are based on other observations, facts or figures. These may be from your own publications (but only if they are relevant). Try to keep an open mind when presenting contentious arguments and consider referring to manuscripts that may not agree with your assertions.

Can I write a letter even if I am not an expert in this area?

Often, students or trainees may write a letter along with a supervisor who may be an expert. But, even if this is not the case and you are not an expert, I think that it is reasonable to write a letter. Remember that any critical appraisal has two components. One is the aspect relevant to the ‘domain expert’ and this includes the research question, clinical/biological importance, eligibility criteria, relevance of outcomes and baseline characteristics and generalizability. The other component relates to the study design, scientific rigour and principles of methodology the study is based on. Even if you are a student in the area (and not an expert yet!), you could critique the paper on methodological grounds and ask questions of relevance to any practitioner in the field.

Do you have specific advice or tips on scientific writing?

Scientific or technical writing is different to ‘journalistic’ writing or ‘story’ writing. This in itself could be a blog/topic for discussion. But in brief,

Write using simple words or phrases. It is a misconception that scientific writing should be complicated. Einstein said something along the lines of ‘if you cannot explain an idea in simple terms, you probably do not understand it very well”.
Write in short sentences.
Avoid jargon and what I call ‘dramatic’ adjectives – such as ‘extremely’, ‘extraordinary’, ‘enormous’ and so on… Aim to be precise and provide objective, verifiable, facts and figures.
Avoid words such as ‘absolutely’ and ‘never’; as they will rarely be true.
Unless you are an expert, try not to ‘instruct’ or ‘teach’ in your letter. Present the facts or observations and your explanation or rationale for it. But, avoid the temptation to make inferences you are not able to directly make from your observations.
When providing (what you think) is a logical explanation, think of alternative explanations and discuss them.
Take your time. A letter may be much shorter than a research article, but should not be considered as just a quick addition to your cv. It may well be in print and you should be able to look back at it years down the line and still be proud of it.

If the letter is rejected, does it mean that it was not considered relevant?

Not necessarily. Letters are rejected for many other reasons including lack of space, not meeting criteria laid out by the journal (including the time elapsed since its original publication - remember that time is of the essence here! The more recent the paper the higher the chances of your letter being accepted). There may be no or little explanation for the rejection, but do take time to reflect on the potential reasons for rejection and how you could have improved the manuscript. Take advice from peers or your supervisor. Finally, move on and put it behind you and don’t let it affect your confidence.

In my experience knowing the journal you are sending the letter to and their editorial “habits” does help as well - such as writing about a topic that is particularly relevant to the readership of that particular journal. Do you think that’s true?

Yes, that is quite likely. In general, papers are also selected on that basis. Put yourself in the editor’s shoes and and read your draft letter and see what you think will be relevant and what may be of interest to the readership. Then, edit your letter accordingly...

So why not start by presenting a paper at our CRAMsurg journal club? Presenting a paper with us and writing up a letter to the editor will give you the opportunity to build your experience in critical appraisal as well as scientific writing, have a look at “our publications” page for some examples! If you are thinking of presenting with us just have a look at our present with us page or send an email to info@cramsurg.org! Don’t worry if it is the first time you appraise a paper, we will support you throughout!