Know why manuscripts are rejected and what each reason lets you do
Journals reject many of the research manuscripts they receive, and the grounds recur: a study that adds nothing new, a weak or poorly described design, parts of the manuscript that do not connect, conclusions that outrun the results, poor language, the wrong journal, a poor abstract or neglected instructions for authors, and a failed ethical screen. Some of these grounds are under the writer's control and some are not.
How often and at which stage manuscripts are rejected
Rejection is common, and authors, particularly inexperienced ones, may take comfort in knowing it: rejection rates run above 50% for many journals and can be above 90% for top-tier ones. Most authors have had a manuscript rejected by journal editors at least once. Rejection is becoming more common and acceptance at the first attempt less likely. The most common reasons are lack of new or useful information, study design and methodology problems, logic problems, language problems, the wrong journal, a badly written abstract, and failure to format to the instructions for authors. Some of the reasons for rejection are under the writer's control and others are not, and a writer should know the main ones, both to minimise them and to give the authors and other contributors practical advice. Three common reasons for rejection are within the authors' control: failing to explain the significance of the study, integrating its results insufficiently with the existing literature, and poor grammar and sentence construction.
A manuscript can be rejected at the editor's initial screening, which is a desk reject, or after peer review. The common reasons for a desk reject are lack of sufficient novelty, being out of scope, ethical problems, and poor English or manuscript structure. Each reason for rejection, at either stage, has potential underlying meanings.
The World Health Organization's ten reasons
The World Health Organization names ten most common reasons for rejecting a manuscript submitted to its bulletin: content not suitable for an international journal of public health; study design not appropriate for the question asked; lack of novelty or timeliness; lack of ethics committee approval or informed consent; lack of an appropriate search strategy; conclusions not justified by the results; lack of a feedback step in descriptions of audit; insufficient sample size; lack of a clear message for the public health community; and secondary analyses of demographic surveys or simple prevalence studies that are difficult to generalise.
Lack of novelty
Lack of new or useful information is the most common reason of all: the manuscript does not add to the current literature, or lacks originality. At the desk, insufficient novelty or impact can mean novelty below the journal's expectations or none at all, a confirmation of earlier results or an incremental advance, too few expected online reads or downloads for a top-tier journal, enough manuscripts already accepted on the topic for coming issues or similar findings recently published, a duplicate publication, or a topic of low priority. Limited clinical relevance at the desk can mean work restricted to a geographical area outside the journal's expectations, or a minimal effect on the standard of care. After peer review the reasons include low novelty and nothing new. The potential underlying meanings of these reasons include findings specific to one geographic area, similar findings for separate populations, a significance in the field that is not evident, and a subtle novelty that was not highlighted.
A writer cannot always do much about a study that adds nothing, but should be familiar and up to date with the literature, so as to advise the contributors when the novelty or importance of the results is in doubt, and in some cases can encourage them to include or focus on the data that are novel or especially interesting. The study needs a hook for the reviewers' attention: that it fills a gap in the existing literature or contributes significantly towards addressing an existing problem. It should also be folded into the fabric of the published literature, because there is always a body of published work that serves as its starting point, and placing the study in that context adds enormously to its richness, depth and value. A missing citation of important articles is itself a reason for rejection after peer review.
Weak or poorly described design and methods
Whether the study has an appropriate, rigorous and comprehensive design is cited as the most or second-most important factor deciding a manuscript's fate. The main design and methods problems include a fundamentally weak hypothesis or question, poor methodology, inadequate description of the methods including the study design and the technical methods, results that do not address the hypothesis, question or stated objectives, and questionable results arising from inappropriate methods or statistical analysis. After peer review, the common causes include flaws in methodology and study design, inadequate description of the methods, poor statistical analysis, and problems with controls, case groups, covariates or outcomes. The potential underlying meanings include no power analysis, group sizes too small, inadequate controls, important covariates ignored, unsound science, inadequate outcome measures, old assays where more detailed ones are readily available, unusual or inappropriate analyses that result in significant bias, and too few outcomes.
A writer cannot do much about poor study design or methodology, but should ensure that the hypothesis or question, the objective, the study design and the technical methods are easy to find, complete, clear and consistent with the experimental findings. The methods section needs particular attention, because it is where mistakes most often occur and the section most often responsible for rejection.
Logic and structure
After novelty and design, the most important aspect deciding a manuscript's fate is whether it is logical and well written. How the design, results and conclusion interconnect is of the utmost importance to peer reviewers commenting on a manuscript and deciding its fate. The manuscript writer's most important job is to tell the story of what happened in the study logically: present the study problem, then take the reader gradually through the study, its results and its implications. One tip for a logical flow is to answer one question in each of the four sections: why the study started, what was done, what was found and what it means. Another is to break the writing into manageable pieces, by subdividing the methods and results, keeping one idea per paragraph and one thought per sentence, and breaking up a sentence or paragraph that gets too long.
One experienced reviewer finds that in manuscripts by fellows and doctoral and medical students, the most common mistakes are that the perspective of the reader is ignored and the manuscript is not structured logically and coherently, which is much more a basic lack of structure and logic than a matter of fancy statistics, and that this may apply less, or not at all, to medical writers. The same reviewer holds that the introduction should clearly lead to the main question, the main question should then be reflected in the methodology, including the statistical section, and all descriptions should be transparent, consistent and easy to understand.
Information placed in the wrong section, such as results in the methods or essential background in the discussion, is a potential underlying meaning of a desk reject for poor writing or manuscript structure. After peer review, the potential underlying meanings include speculation that belongs in the discussion, a rambling discussion and unacceptable figure quality.
Overstated conclusions and bias
Inadequate reporting of results and excessive enthusiasm about their implications can be major reasons for rejection. Obvious bias is a reason for a desk reject, and its potential meaning is a one-sided description or discussion, such as advantages given only for the new medication and adverse events only for its competitors. After peer review the common causes include overstatement of conclusions and major flaws in the interpretation of results, and the reasons include bias or a lack of neutrality and data that do not support the conclusion. The potential underlying meanings include vague or overreaching statements of conclusions, or no meaningful conclusions at all; a one-sided discussion, a missing discussion of alternate interpretations and missing citations of opposing views; potential bias, and industrial bias towards the sponsor's compound, where both the efficacy data and the safety profile are needed; overstated significance, with statistical significance set against clinical significance; conclusions extended to additional populations that were not tested; and unjustified superlatives such as robust, rapid or dramatic.
Authors should avoid commercialism: acknowledge any negative findings, discuss the findings objectively without regard to a personal or company-based agenda, and include the pros and cons of any particular product the manuscript discusses.
Language
The language problems editors and reviewers commonly identify are excessive wordiness, poor syntax, poor grammar, redundancy and deliberately complicated writing. They are not usually an important reason for rejection in themselves, but reviewers may become critical of a study when the manuscript contains too many language errors. English too difficult to understand to be sent for peer review is a potential meaning of a desk reject for poor English. Authors should "be reasonable" about grammar and sentence construction, since reviewers are not supposed to serve as grammar police but poor grammar and sentence construction can impede comprehension and frustrate them.
Writing well is a professional medical writer's job, and language problems should definitely not limit the acceptance of a manuscript the writer has written. The writing should be clear and concise, in good English spelling, grammar and syntax, and above all written for the reader, with information easy to find and easy to understand. A manuscript is not a place to show an ability to write poetically or with big words. If a reader, editor or reviewer misunderstands something or finds the manuscript hard to read, the fault is the writer's and not theirs.
The writer should always run a spelling and grammar check before submitting, always have a colleague proofread, and not expect the authors to catch language problems. A writer who is not a native English speaker should, if possible, have the manuscript read and corrected by one, and a writer who is should have the courage to correct the writing of non-native speakers, even well-known or experienced researchers. The writer must also read the manuscript from the standpoint of the reader, who here is the reviewer, stop assuming that the reader knows as much as the writer does, and if possible get a colleague's critique before submitting.
Manuscripts have to be crisp, with sharp messages, because the demand for journal pages is great and the standards keep going up.
The wrong journal
Content irrelevant to the journal is an important reason editors reject manuscripts. Editors usually have limited space and must select by priority, judging whether a manuscript is appropriate for their journal and readership and whether it is sufficiently novel and interesting for the journal's standing. Contributors sometimes feel the manuscript deserves a premier journal, but such journals can have rejection rates above 90%. At the desk, being out of scope can mean a topic incongruent with the readership, a type of paper, such as a case series, that the journal does not publish, or a type, such as a review, that is usually written by an invited author. The author instructions should be examined closely to make sure the study fits the journal's scope and criteria.
The abstract and the instructions for authors
A confusing or boring abstract can cause a manuscript to be rejected without entering the review process at all, so the writer should take the time to put together a good abstract that captures the reader's attention. To avoid a desk reject, the abstract and the manuscript should explain the rationale, the methods and the novel, significant findings clearly and concisely, followed by fully supported conclusions.
Authors often underestimate the power of the beginning of a manuscript, and the mistake can send it to the rejection pile. To hook editors at the beginning of the review, authors should pick an important research question and write a great title, a succinct abstract and a clear, compelling hypothesis or purpose statement. The cover letter is also a good place to hook them.
Few manuscripts are rejected because they do not perfectly meet the instructions for authors, but a manuscript has to comply with them to be published, and getting this right at the beginning puts the manuscript in a good light and helps ease its acceptance. The journal's instructions and guidelines for authors should be followed carefully, and its format kept.
Ethics and trial registration
A desk reject can follow from a lack of ethical compliance, which can mean no description of approval for animal experiments, of the compliance protocols for human clinical trials, or of informed consent, or from a clinical trial that is not registered in an acceptable registry. After peer review, ethical considerations are among the reasons, and their potential underlying meanings include plagiarism and evident self-plagiarism in the introduction, results or discussion, failure to disclose a conflict of interest, a manuscript that reaches the same reviewer who saw it at an earlier journal with no revisions made to address that review, and outcomes from one trial or piece of research split among too many manuscripts in an attempt at salami science. Writers are urged to verify that the images pasted into figures are correct and not a placeholder image from a previous manuscript, because this is a common ethical mistake.
Reporting guidelines
Reporting guidelines can help ensure the study design is fully described and the technical methods are complete. Professional medical writers often use the reporting guidelines for specific types of human trials and for methods to make sure the abstract and the body of the manuscript include the salient points.