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In addition to the changes that may be needed in the text of an article, I also send each client a section of notes dealing with problems too complex to be discussed on the copy itself. These are from a paper I worked on recently.

LAPAROSCOPIC BENCH MODELS

     The very small amount of respelling necessary here was done in accordance with Dorland's Medical Dictionary, which I have found to be much the most trustworthy authority.

By page, paragraph, and line number . . .

1-1-1 I'm afraid I don't feel that the title:

"INTENSE LAPAROSCOPIC SKILLS TRAINING IMPROVES
OPERATIVE PERFORMANCE OF SURGERY RESIDENTS"

comes anywhere near doing justice to this exceedingly important article. It's a self-obvious statement: training can be assumed to improve performance. But that's not what the study is really about at all, is it? I would like to suggest something on the order of:

"LAPAROSCOPIC TRAINING ON BENCH MODELS: BETTER AND
MORE COST-EFFECTIVE THAN OPERATING ROOM EXPERIENCE ?"

     Also, according to the Information for Authors from J Am Coll Surg, the funding statement now at 16-2-1 should go here on the title page instead, at the bottom.

     2-1-1 Make sub-heads ("Background" etc) capital letters and lower case, not all caps, and make whole page bold face.

     3-1-1 Make "Key Words" caps and lower case, and run the words themselves out into lines one after another, separated by commas. All the above is for conformity with this particular journal's compositional style.

     5-1-1 I'm sorry to say that Reference citation 19 is incorrect. The highest number we've had before it was 11 (which was at 4-2-3), so the one here would have to be 12. But this problem makes it seem likely that all our other Ref citations should be checked for accuracy, too. Unfortunately I do not have the files I would need in order to do this for you, so I can only suggest that someone in your office follow through on it.

     9-1-1 J Am Coll Surg uses a lower case, nonitalicized "p." Also, note indicated separations; these two problems appear throughout the paper.

     9-5-2 The copy here originally read as if "Residents who underwent formal training" were a different bunch from "The training group" in the next sentence. The rewrite was done to correct that misapprehension.

     10-6-2 I'm afraid that I compute 77 out of 139 as 55.4%, not 53.9.

     10-7-1 Likewise, 128 out of 139 as 92.1%, not 90.8. If your calculator agrees with mine in these two cases, I fear that entire paragraph should be re-examined. Once more I don't have the information I would need to check those other percentages for you myself.

     11-1-7 The author of the article cited here is given as Karathanasis. But in the Reference list, at 18-Ref 27, that's spelled Karathannasis. Please check.

     11-3-2 An Arabic figure can never begin a sentence; it must be spelled out when used there ("One hundred and twenty-eight"). However, I prefer to rephrase, putting a word or two ahead of the figure, rather than having to go through all that verbiage. In my experience, readers grasp a concept expressed in numbers far more easily than one in words, especially when it is compared with others expressed in numbers.

     13-3-2 These Ref citations are problematic; the 5 is out of order, and 13,14,15,16 should read 13-16. But as noted before, it would be better if they were all checked.

     15-3 This paragraph starting "The old adage . . . " is certainly adequate. But I'd say that we already have a very much better wrap-up that is now buried deep in the text, and should be used here, in this considerably more important place in the article. So I would suggest killing the present last paragraph, and replacing it with one beginning, "A final note concerning costs." Then we go to your paragraph starting at 12-1-1, "The list price . . . "

     Following that, we add one more sentence, "Video trainers like the GEM would appear to be most exceedingly cost effective, and as we have already seen, considerably superior in training efficacy as well." A boil-down of the same information should appear on p. 3 in the Conclusions section of the Abstract, after " . . . operative performance." (The rest of the Editor's Notes concern J Am Coll Surg's preferred style in the Reference list.)


EDITED COPY

     This is an introductory section of the article itself. The editorial changes necessary to bring it up to a publishable standard are printed in red.

     Developing technical skills is essential to the training of surgical residents.  About a century ago William Halsted 1,2 introduced in the United States the system by which residents learn through graded responsibility under direct supervision in the operating room.  This arrangement is effective, but it may be inefficient, is certainly costly, and worst of all can potentially result in patient morbidity.3-5   Besides that, managed care has in recent years placed increasing financial constraints on hospital and physician reimbursement.  With more pressure on doctors to maximize efficiency, faculty may have less time available for teaching.  And money considerations can further compromise the use of OR time for teaching purposes, the cost of which is estimated at $53 million per year in this country alone.3

     Laparoscopy has emerged as a highly useful surgical modality, but it additionally complicates the problems of teaching residents in the operating room,6,7 for a significant amount of experience is required before competence can be achieved. 8-11 Depth perception is altered by a two-dimensional video imaging system, and new cues must be learned before spatial relationships can be reliably established.  Long instruments diminish tactile feedback, making them awkward to use.  Range of motion is limited by trocars, and video eye-hand coordination must be developed to position instruments in the operative field correctly.

UNEDITED COPY

     This is the same section in its original version.

     Developing technical skills is essential to surgical resident training. William Halsted1,2 introduced the surgical residency system in the United States about a century ago, whereby residents learn in the operating room through graded responsibility under direct supervision. Teaching residents in the operating room is effective, but may be inefficient, costly, and may increase patient morbidity. 3-5 Managed care has placed increasing financial constraints on hospital and physician reimbursements. With more pressure on physicians to maximize efficiency, faculty may have less time available for teaching. Financial constraints may further compromise the availability of operating room time for teaching purposes. The cost of using operating room time for teaching surgical residents in the United States is an estimated $53 million per year.3

     Laparoscopy has emerged as a very useful surgical modality but complicates the problems of teaching residents in the operating room.6,7 Laparoscopy poses a new obstacle to skill acquisition since significant experience is required before competency is achieved.8,9,10,11 Depth perception is altered by a two-dimensional video imaging system and new cues must be learned before spatial relationships can be reliably established. Long instruments diminish tactile feedback and can be awkward to use. Range of motion is limited by trocars and video-eye-hand coordination must be developed to correctly position instruments in the operative field.

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