“In Press” or “Forthcoming”: Issues of Naiveté and Experiences for Medical Student Publishing

By J. Michael Homan, MA, Director of Libraries, Mayo Clinic

Two articles in Academic Medicine’s November issue underscored issues of integrity and professionalism based on the misrepresentation of unpublished manuscripts in residency applications. Although the Grimm and Maxfield study on the ultimate publication rate of unpublished manuscripts listed in residency applications did not include potential scientific misconduct such as plagiarism or image manipulation in their scope, one might logically conclude that some of these issues may have been present in the context of the general increase in instances of plagiarism and other examples of scientific misconduct in academic institutions. Mushlin and Katz noted that residency program directors may choose to overlook certain problems in residency applications by attributing any errors to naiveté.

There is undoubtedly some if not a significant amount of naiveté represented in the cohorts of medical students applying for residency programs. Applicants who have not had sufficient scholarly writing experience may not completely understand the language of scholarly publication, including the publication terms expressing a manuscript’s status in the peer review process. For inexperienced writers, terms in the Electronic Residency Application Service (ERAS) system like “in press” and “accepted” may mean approximately the same thing.

Further, style manuals differ on publication status terminology. While ERAS uses the term “in press,” the National Library of Medicine recommends using “forthcoming” to mean accepted for publication but not yet published:

Forthcoming material consists of journal articles or books accepted for publication but not yet published. “Forthcoming” has replaced the former “in press” because changes in the publishing industry make the latter term obsolete. 

Unintended errors like publication misrepresentation in the residency application process due to inexperience, or instances of plagiarism, could be addressed in the medical school curriculum by including additional opportunities for:

  • Writing experiences;
  • Instruction and drills in writing originally;
  • Experience strategizing on journal submission routes;
  • Experience uploading manuscripts to text-matching software to detect potential problems;
  • Experience reviewing and interpreting author guidelines in key journals;
  • Preparation of manuscripts for submission to journal publishers.

Text-matching programs in particular can be very instructive and powerful teaching tools by uncovering instances of matches caused by sloppy writing habits (e.g., forgetting to add quotation marks around direct quotes) or self-plagiarism – and in advance of manuscript submission. Professionalism and trust are the key concepts in Grimm and Maxfield’s study and highlighted in Mushlin and Katz’s commentary, but nothing trumps actual experience with original writing and participation in the scholarly publication process as potential solutions, particularly when guided by a trusted  mentor or experienced peer.

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One Comment

  1. Kemi Tomobi
    November 4, 2013 at 3:34 PM

    I have come to appreciate librarians as part of the interprofessional healthcare team, as they offer a unique perspective that is much needed  in healthcare.  I appreciate the comment on misrepresentation.  There seems to be so much emphasis on research experience.  I would agree that fabrication of personal statements for the ERAS application should not be tolerated; as a matter of fact, using a non-original personal statement for ERAS actually defeats the purpose of a “personal” statement and is part of what will be addressed later.  However, I would disagree with the commentaries and the research report that attempts to link misrepresentation of manuscript publication status with plagiarism.

    Faith I would disagree, firstly, because of the virtue of faith.  What is faith?  Faith is the substance of things hoped for, and the evidence of things not seen (Bible: New Testament, Hebrews 11:1).  Faith requires trust and commitment.  Does the medical profession encourage faith?  Doctors are trained to not instill too much hope in a patient’s prognosis.  This way, a doctor does not have to feel like he or she let the patient down should bad news arrive, but if good news happens, then it can be a pleasant surprise for both doctor and patient.  But patients need hope.  Attending to a patient’s spiritual needs is just as important as attending to their physiological needs.  When we neglect the virtue of faith, we neglect our spiritual roots.  Faith requires us all to think and plan ahead, not merely based on what was, or what is, but also on what will be, and what should be.    For example, if an applicant was filling out a FAFSA form for financial aid before being accepted to a program, would that applicant be misrepresenting himself or herself because of acting without a letter of acceptance?  Also there are catchy slogans saying “dress for the job that you want.”  So if someone dresses for the job that they want, instead of the job they have, is that person considered to be misrepresenting himself or herself, or is the person acting in faith?

    Humility; Know your roots, embrace differences Faith is but one of the spiritual issues raised in this response.  Another is raised in the discussion on competitiveness.  Yes, getting into medical school is competitive.  And certainly, it is competitive to mach into radiology residency as mentioned in the research report, and based on match results in GME funding in recent years, it is becoming competitive to match into ANY residency program.  Certainly research experiences can convey to residency programs that the applicant has taken initiative to learn a topic in depth, attach meaning to what they learn, and to network with faculty, as well contribute to medical advances.  Regardless of one’s manuscript status, these experiences are valuable and should be considered by residency programs.  However, the pressure exists to become a more attractive candidate because the medical community praises research publications, and these publications do positively influence match rates.  So anyone who does not feel competitive will strive to make themselves competitive by whatever means necessary.  This promotes a deficit mindset, in that something has to be wrong with the applicant if the applicant does not meet a standard model of a competitive applicant.  So the applicant may find legitimate ways to become more competitive, or less legitimate ways to become competitive.

    But we are all human, and instead of promoting a deficit mindset, there should be a celebration of differences.  Diversity is valuable.  Why should all radiology residents have pre-residency publications in high impact journals before applying?  Why not have some with varied experiences that they can bring to their residency program?  Instead of looking at the shortcomings as deficits, why not look at them as opportunities to one day become the publication superstar when the time is appropriate, or why not accentuate other aspects of the application that makes them strong future practitioners in the chosen specialty?  there needs to be a culture of “it is OK to be who you are, as you are” and “it is OK to be unique”.  If I was a residency program director, I would look for the applicant that best portrayed the best of themselves in the application and in the interview.  If you are not passionate about research, I would not bother to see that as a strength in an applicant, and would hope that the culture would be forgiving to allow the applicant to be themselves and see such deficits as merely variations and welcome differences to be embraced.

    Poorly defined categories AS the discussion now turns away from the spiritual issues concerning misrepresentation, there is the issue of the categories in the ERAS application.  Poorly defined categories = poorly defined problems.  Think of the nightmare associated with taking a the multiple choice exam.  Now it is on an ERAS application.  there are so many ways to represent one’s research experience.  thus this part of the application brings so much stress and anxiety, as applicants may not know how to appropriately represent their research on these applications.  For example,

    “If I worked with one person, but another person presented the poster, then which category does it belong in?”


    “What if my PI allowed me to be in charge of one section, and then changed his or her mind? How can I account for such an experience on ERAS so that it means something on the application?”

    Unfortunately, there is very little to guide applicants.  Therefore, there is ample room for things to be confusing, misleading or suspicious.  The door becomes wide open for fraud to occur.  One solution to the poorly defined categories is to make sure there are clear instructions, definitions, and explanations for the applicants to follow.  Another solution is to give the applicant a chance to respond, either in a mock residency interview or a real one.  In networking, one learns that “great things can begin with a one-on-one conversation” because they open the lines of communication and are the best opportunities to network.  These “great things” may begin with an interview.  Therefore, these poorly defined categories perpetuate the problem, but there are solutions to help reduce misrepresentation.

    Education In addition, better and timely education on the research categories and getting better quality research experiences from medical institutions may help to reduce misrepresentation.  Applicants should learn more about the steps to take to reach publication.  The post is right on in stating that there should be opportunities to discuss strategy to achieve the most coveted manuscript publication status.  the applicant should not have to go at this process alone.    Imagine if the mentorship was solid – and there was great faculty and research team follow through . . . would as many of these problems of misrepresentation exist on the ERAS application? No.  And even if there was potential for misrepresentation, they should be opportunities for “open and meaningful” experiences for student to learn from.  Applicant and research team should be on the same page concerning research goals.  These experiences should be encouraged by academic leaders at the home medical institution, and allow applicants to become more educated about the manuscript submission status. It should not get to the point where some outsider, less familiar with the applicant, and likely less familiar with the complexities of medical education are providing detrimental feedback to the applicant.


    In conclusion, misrepresentation is a problem, though it does not necessarily mean plagiarism.  Based on the spiritual elements, poorly defined elements, and naiveté, there are other factors that account for misrepresentation, and all of the above should be addressed.  Further studies are needed to discover why some applicants start a research or other manuscript publication experience, expect to complete it at a certain time, and are not able to complete it at the time of residency interviews.

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