Comment From the Editor

Authorship: Who Should Be Included and How Should It Be Determined?

ublication is an important metric to gauge academic success. We are all too familiar with the saying publish or perish. The importance of publications as a criterion for promotion varies among academic institutions. In most instances, quality is more important than quantity. There is, however, no objective or standardized measure of quality. Therefore, quantity or total number of publications still matters. The International Committee of Medical Journal Editors (ICMJE), that comprises editors from major journals (including GASTROENTEROLOGY), develops Uniform Requirements for Manuscripts1 including criteria for authorship: A) Authorship credit should be based on (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) nal approval of the version to be published. Authors should meet all three conditions. B) When a large, multicenter group has conducted the work, the group should identify the individuals who accept direct responsibility for the manuscript and these individuals should fully meet the criteria for authorship. C) Acquisition of funding, collection of data, or general supervision of the research group alone does not constitute authorship. D) All persons designated as authors should qualify for authorship, and all those who qualify should be listed. E) Each author should have participated sufciently in the work to
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take public responsibility for appropriate portions of the content. F) All contributors who do not meet the criteria for authorship should be listed in an acknowledgment section. As authors, we have all signed agreements verifying that we meet the authorship criteria. For those of us who have been senior authors, there is an added responsibility of making sure that all of the authors listed meet the criteria and that no one who meets those criteria are left out. Senior authors also have the power or burden to determine the sequence of authors, which can be contentious, particularly in institutions or countries where credit is given to the rst and last authors only. In this commentary, I discuss my own experience and perspective which may be biasedand invite comments from our readers. The focus of this article is publications on original research because, in general, there is less controversy regarding authorship of review articles. Although the issues discussed are more relevant to clinical research, most also apply to basic science research. There seems to be more manuscripts from basic science investigators that have joint rst authors, although this trend also seems to be the case in clinical manuscripts.2

Who Should Be on the Author List?

This seems to be a redundant question because a majority of the journals we wish to publish with follow the ICMJE guidelines. Interpreting and implementing these guidelines are more complicated.

Single-Center Studies
Determining who should be on the author list in manuscripts on research emanating from a single clinical site or laboratory is the simplest, but by no means simple. Take,

for example, a retrospective study of the clinical experience in managing disease X. A fellow develops the research plan with guidance from a mentor. The research plan is sent to other faculty for comments. Some faculty provided constructive comments and others merely indicated interesting study. The fellow completes the chart review with guidance from the mentor. The data are analyzed by the fellow alone or with the assistance of the mentor or a statistician. The fellow drafts the manuscript, which is then edited by the mentor. The revised manuscript is circulated to other faculty who participated in the management of the patients that are the subject of this research. Some faculty provided valuable suggestions on data interpretation and substantive editorial comments, whereas others simply respond looks good. The nal manuscript is sent around and every one approves it. Who should be on the author list in this manuscript? Everyone who provided a response at each stage in the process no matter how supercial it is or only those who provided substantive contributions and critical review? And how should substantive and critical be dened? Over the years, I have had to take potential authors off the nal author list on more than one occasion. It is not pleasant, but if the policies are clearly stated and consistently applied, this can be achieved without any fanfare. This may be more difcult if a junior faculty has to eliminate a senior faculty, particularly in countries where it is customary for the head of department to be listed on every manuscript. The notion of granting authorship simply based on having contributed to the care of patients in retrospective clinical studies or to the management of patients in prospective clinical studies or provision of a reagent or performance of an assay in laboratory-based research

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is over. Under the current guidelines, these individuals would be recognized in the acknowledgment section. I have, on occasions declined authorship because my contribution was minimal or because I disagreed with the data interpretation. It may be more difcult for a young investigator to turn down authorship when he/she needs to boost their curriculum vitae or out of fear of alienating other colleagues. On the other hand, there are times when an investigators contribution did not meet all the ICMJE criteria, but the study could not have been completed without that contribution or the contribution may have necessitated substantial commitment of time, expertise, and cost. Should authorship be denied because the investigator failed to meet all 3 criteria in the ICMJE guidelines, and what would be the incentive for these collaborators to contribute? To promote team science or collaboration, I would argue that these investigators merit authorship. mal numerical system that had been proposed by some study groups.3 Since the inception of HALT-C in 1999, 55 papers have been published with another 10 15 papers in press, under review, or in the nal stages of submission. Although there had been discussions regarding the merits of certain papers and the worthiness of merely having contributed to the study design and data collection, the group was amazingly cohesive and productive because the publication policies were transparent and assignment of writing groups and progress of manuscripts were regularly reviewed. Understanding the dynamics of each study group and monitoring equitya ne balance between equal distribution and involvementare critical to the success of the group. With HALT-C, all investigators participated in designing the study, enrolling patients, and collecting data. It was not practical to have everyone involved in data analyses or drafting of the manuscript; hence, fulllment of authorship criteria in study-wide papers hinged on critical review of the manuscript. Similar to single-center studies, comments from co-authors had varied from looks ne to several pages of comments or innumerable tracked changes. What should a critical review of a polished manuscript that had gone through multiple revisions entail? Multicenter studies that are less structured or have fewer resources may not have the luxury of oversight committees. Nonetheless, having ground rules upfront avoids ill feelings later on. Another concern with multicenter studies is the number of authors. During the last 20 years, the number of authors per article has been increasing among all journals at a mean SD rate of 0.078 0.057 authors per article per year.4 Although multicenter studies necessarily involve multiple authors, it does beg the question whether all authors in manuscripts with 40 authors met all the criteria for authorship.

Industry-Funded Multicenter Studies

Determining who should be on the author list in industry-funded multicenter studies remains a mystery to me. Although the clinical trial agreement clearly states that authorship is based on contribution to the study, how contribution is measured is seldom spelled out. Some, but not all, industry-funded studies involve investigators in the study design. In most instances, data analyses are performed by statisticians working for or commissioned by the company. Thus, an investigators major contribution is patient enrollment and data collection. These investigators are generally listed in the acknowledgments section. Investigators listed as authors are selected for a variety of reasons: status in the eld, involvement in study design and/or data analyses, high enrollment, and relationship with the sponsor. Over the years, I have participated in many industry-funded clinical trials and have been included in the author list in a handful of papers from these trials. For me, authorship is not important; what matters is making sure the results (positive and negative) are shared with the scientic community and presented objectively. When I am approached for authorship of a report on an industry-funded study, I ensure that the company is aware of my principles being involved in every stage, having access to raw data, and having the nal say (when I am listed as the rst author) in data interpretation and conclusions. Some sponsors I worked with only once, others came back because they want to have involvement authors. A major concern with industryfunded studies is the involvement of ghost authors. These professional medical writers are paid by the sponsor to prepare the drafts of the manuscript and shepherd it through to
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Multicenter Studies
Determining who should be on the author list in multicenter clinical studies is much more complicated. Authorships in multicenter clinical studies sponsored by government agencies such as the NIH are usually determined by publication policies of the study group. In general, a publication committee is established early on to develop the policies. The criteria for authorship are transparent and a process for arbitration is established. Ideas for data analyses and manuscripts are solicited and the writing group and sequence of authors are determined at the start of manuscript planning. These policies have worked well for many NIHfunded clinical research networks including the Hepatitis C Antiviral Long-term Treatment against Cirrhosis (HALT-C) Trial that I have the privilege to be a member of, even though we did not employ a for-

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submission. They can be a great help in developing an outline of the manuscript, collecting and compiling comments from numerous other authors, formatting tables, gures and references, and collecting author disclosures. When their role and funding source are declared, and the authors have fullled their obligations in participating in data interpretation and critical review and approval of the manuscript, professional medical writers are legitimate.5 My personal experience with professional medical writers is that, although they help with certain tasks, their knowledge about the disease is often limited and they have a tendency to put a positive spin on the results. It is therefore important that all listed authors (not just the rst author) are willing to take charge and push back if necessary.
References
1. ICMJE: authorship and contributorship. Available: http://www.icmje.org. 2. Akhabue E, Lautenbach E. Equal contributions and credit: an emerging trend in the characterization of authorship. Ann Epidemiol 2010;20:868 871. 3. Whellan DJ, Ellis SJ, Kraus WE, et al. Method for establishing authorship in a multicenter clinical trial. Ann Intern Med 2009;151:414 420. 4. McDonald RJ, Neff KL, Rethlefsen ML, et al. Effects of author contribution disclosures and numeric limitations on authorship trends. Mayo Clin Proc 2010;85: 920 927. 5. Hamilton CW. Dont get spooked! How to collaborate with a professional medical communicator (and avoid ghostwriting). Arch Immunol Ther Exp 2010;58:255 261. doi:10.1053/j.gastro.2011.07.007

Conclusion
Authorship of peer-reviewed publications is one of the primary metrics of academic success. The ICMJE guidelines provide a useful framework but interpretation and implementation of these guidelines are more complicated. Having early discussion and agreement about authorship and author order is critical and can save subsequent agony.
ANNA S. LOK Senior Associate Editor Division of Gastroenterology & Hepatology University of Michigan Health System Ann Arbor, Michigan

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