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MEdIC Case: The Case of the Honorary Authorship


medic documentWelcome to season 3, episode 9 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Brent Thoma, Sarah Luckett-Gatopoulos, Tamara McColl, Eve Purdy, John Eicken, and Teresa Chan) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine! In this month’s case a junior staff person is unsure of whether or not to include a senior staff on a paper.

MEdIC Series: The Concept

MEdIC: The Case of the Honorary Authorship

by Dr. Brent Thoma

Dr. Keurin was excited for her meeting with her research mentee, Andrei, today. He was a junior emergency medicine resident with a strong interest in research that had just completed his first project! They were just meeting to review the final draft before submission. As she walked into the coffee shop she saw him slumped in his chair, looking a bit dejected. That wasn’t like him at all.

“Hey Andrei, is everything okay?”

He sighed. “I dunno. I just met with Dr. Lee to talk about this whole submission process. You know, which journal we should submit my manuscript to and such.” Dr. Lee was the program’s Research Director and one of the most renowned emergency medicine researchers in the country. She knew that one of the reason’s that Andrei had ranked the program so highly was so that he could work with the illustrious Dr. Lee and he had confided to her in previous meetings that he had been disappointed about their lack of interaction so far in residency.

“Oh, and that didn’t go well?” she asked.

“Well, I dunno. It was the first time that we had discussed the project since I ran into him in the hall at the beginning of the year. You’ll remember that he hadn’t been too impressed with the idea at that time.”

Dr. Keurin remembered. That was actually how she, a much more junior researcher in the Faculty, had come to be Andrei’s mentor. She thought he had a great idea for a research project and had supported it to fruition.

“Anyways, I had met with him to ask for some advice on where we should submit the manuscript and we had a good chat about that. But then he mentioned that I should send it to him to give it a final once over and add him as the senior author. He said that if we added his name it would strengthen the chance of our paper getting published. I was so shocked that I didn’t know what to say. You’ve really mentored me through this project, that should be your spot! But I’m also worried about my future job and research projects if I were to piss him off. What do you think?”

Dr. Keurin pursed her lips. This was putting her in an awkward position. She recalled a similar conversation from when she was a resident. She had just gone along with it because she figured that was how research worked, but it didn’t feel right then and it still doesn’t feel right now. At the same time, it would be horrible for her prospects at her institution to be on Dr. Lee’s bad side. What should she say?

Discussion Questions

  1. What are the requirements for being listed as an author on a manuscript? Does Dr. Lee meet these authorship criteria? How should the authorship order be determined?
  2. How should Dr. Keurin deal with this situation? What advice should she give to Andrei? Should she confront Dr. Lee?
  3. What are some policies that you have seen that are used to protect junior residents and faculty from encountering this problem?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

This time the experts (3 jointly writing a piece from the University of Toronto)

  • Farah Friesen, Lindsay Baker, and Dr. Stella Ng from the University of Toronto’s Centre for Faculty Development
  • Dr. Kerstin De Wit from McMaster University

On July 25, 2016 we will post the expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan
  • swapnil hiremath

    You can add nuances to this discussion, but the easy answer to senior authorship is *NO* in my opinion.

    Let’s see the ICJME criteria for authorship in general (not senior author) from

    The ICMJE recommends that authorship be based on the following 4 criteria:
    1. Substantial contributions to the conception or design of the
    work; or the acquisition, analysis, or interpretation of data for the
    work; AND
    2. Drafting the work or revising it critically for important intellectual content; AND
    3. Final approval of the version to be published; AND
    4. Agreement to be accountable for all aspects of the work in
    ensuring that questions related to the accuracy or integrity of any part
    of the work are appropriately investigated and resolved.

    In this case, Dr Lee could do 2, 3 and 4. For (1) – which to my eyes is one of the most important criteria, he has to actually not just critically revise the draft manuscript (which is part of 2) – but also either help in analysis or interpretation of the data – which is not clear at all if he’s doing from the descriptor (likely not)

    For senior authorship – it is one thing for the basic science labs – where the senior scientist would get funds to run the lab, pay the salaries and supervise the projects – even from a high enough perspective – to justify senior authorship. This case does not seem to be like that at all. My question, however, is how and who will tell this to Dr Lee (I don’t have an easy answer to this). It should be Dr Keurin – and not Andrei. It will create some discomfort – but will save a lot of ongoing pain – and Dr Lee will hopefully think again (for some people, I guess they just don’t think it through – ie giving benefit of doubt).

    Two other issues to consider:

    – the academia/promotion complex incentivizes this behaviour – and is arguably the root cause?

    – Who is the senior author? Second/Last? (I have heard different opinions)

    And of course, Jorge Cham’s viewpoint:

    Interesting case, and I will be happy to hear other opinions,


    • Thanks for your insights Swapnil! You clearly have a lot of strong feelings on this topic! How do you coach junior people to be discriminating about their collaborators? I think as staff people, it’s much easier for us to be super clear about our ethics – but it can be harder when you’re not in a position to walk away (e.g. a Masters student or a Post-doc)! Any advice on how you might broach this if you are less empowered?

  • Riley Golby

    I post this as someone who hopes he can ‘get it right’ when in a more senior position like the docs in the vignette – I certainly don’t claim to have the full perspective as a learner at this time, but here are some thoughts…

    As a med student keen on research I’ve seen a spectrum of high to low functioning research teams in action already this early in my career. At their best, senior authors leverage their experience from previous successes to make the team as a whole better. Practically for me, this has meant they routinely encourage, identify gaps in the study/manuscript for improvement, and most importantly (young or old) act as a sage consultant providing trustworthy advice as needed.

    I think the trust is the key point. Ideally this person understands the amount of work it takes to undertake a project and bring it to the publication process. They have been through it themselves and know the time and effort and sacrifice required.

    To say, “just send it over and I’ll give it a once over” before putting their name on it means that this person is either actively forgetting what is was like to be a budding researcher, or they genuinely believe they are helping you because to them the easiest route to publication is what you are looking for.

    As a student, resident, or new researcher, the cusp of publication – the journal submission – is a very risky point of compromise. You’ve worked so hard for so long on something and you want to share it – you want to publish something you are proud of that is worth sharing to others. I have actually had peers ask me if they can help with a project at this stage and sirens start ringing in my ears with my brain telling me to change the subject. What has been more difficult is when a senior author suggests forwarding the final work to be glossed over by an expert with the expectation of authorship will be provided.

    I don’t have an answer for what is right or wrong, since I know this kind of thing happens all the time in the research community. All I know is that making clear authorship expectations – though it may be awkward – is orders of magnitude easier up front than at the end.

    Three takeaways I’ve learned so far…

    [1] Be intentional about who you contact regarding your work
    • What are their expectations going to be if they assist you?
    • Have you made it clear what you are asking for, and are you willing to acknowledge them in the paper or have them as authors?
    • Don’t expect someone to pour significant amounts of time into your work without receiving some benefit for their expertise.

    [2] Create clear criteria for yourself and starting team about what merits authorship
    • Using the ICMJE framework is useful, but what does that mean as applied to your project? Some team members may be more suited to take more active roles in particular criteria over others.
    • Be flexible with the authorship list and honest. If a team member is not contributing to the work as discussed initially, the conversation needs to happen. Can you imagine trying to convince them they don’t merit authorship at the publication stage if they had thought it would be fine until then?

    [3] Having a senior author who is trustworthy
    • I know this is a challenge faced in the vignette, but if you don’t have “the sage” from the beginning don’t expect them to occupy that role when conflict arises. Finding mentors in research is just as important as finding them for other aspects of your career.

    Cheers! I wish I had a more rich perspective to offer but hopefully I can read more about it in this post 🙂

    • One of the structures that I have begun incorporating into my research papers is a cover letter, which diagrams out the ICMJE criteria for authorship (alongside contact info, credentials, etc..). This clearly outlines how the authors got to become authors, and but also lists the collaborators as well. A nice function of PubMed/MEDLINE now is that they now allow collaborators to be searched via this, giving those who might not meet the stricter authorship criteria the ability to still show their participation. (See details here: The intention behind this is to keep people from listing all those who have participated in research as an author, to create a new category that highlights the contributions of those who have been involved but are not true authors!

      Check out this recent paper in Academic Medicine which supplies an algorithm for determining authorship!

      • Margaret Chisolm

        I’ve heard Laura Roberts speak on the topic of her article in Acad Med. I’ve also learned from experience to offer 1st authorship to trainees only contingent upon them taking ownership of manuscript and actually writing first draft and shepherding through submission/revisions. Most have risen to the occasion but – those who haven’t – understand they no longer met criteria for 1st author. In age of increasing sense of entitlement, these discussions are essential.
        So authorship order is dicussed prospectively but all is tentative until final acceptance after revisions. I’ve had a trainee nearly drop the ball in revision process, and reminded them of responsibility if first authorship was to be retained, which helped them take charge again.

        • I think it is the role of a last author to coach a rookie or trainee first author through the process, no?

          • Margaret Chisolm

            Absolutely – most importantly, I want them to 1) have fun in the sometimes challenging ms prep process & 2) get first author credit as a reward for their hard work.

          • Eve Purdy

            Thanks for your comments!

            Outlining the expectations of first author is very helpful for us newbies. I think this whole case comes down to clarifying expectations and having transparency in the process from an early stage!

            How do you set those expectations with trainees?

          • Margaret Chisolm

            Exactly. Honest and open direct conversations

      • Whoops. I forgot a picture of the grid.

    • Eve Purdy

      Thanks for your comments!

      How do you initiate the conversation about expectations with more senior members of the team? Do you find it awkward – especially if the folks you are working with aren’t used to having such conversations early in the process – if so how do you smooth it all over?

  • Bertha welcome to the conversation! I think that is amazing that you do that! I know that on occasion I have bowed out like this as well. I do think it is important for senior members of a team to role model best practices. Thank you for continuing to be a great role model and teacher!

  • Kory London

    As the first part of question one has been completely answered, allow me to take a devil’s advocate approach to the remainder.

    Clearly, if Dr. Lee truly is implying that he will wave his hand on the manuscript, not contribute to its formation/writing and thinks his contribution is adding his name alone, the entire situation represents a true ethical conflict and would need to be discussed with the department chair and would impugn Dr. Lee and emergency medicine (as one of our renowned researchers) by proxy. A frank discussion about authorship requirements and everyone’s future careers would be required. I would not stay in a shop, as a junior researcher, if that was the way our leader carried himself.

    Saying that, if Dr. Lee is truly one of the preeminent EM researchers, I would heavily doubt he would truly need to act so cravenly. He would likely have multiple high impact projects currently running, this seems like but a trifle. If, instead, he is offering his services, he clearly believes this manuscript is deserving of being published and that he initially misjudged Andrei.

    Therefore, as this vignette is written with Dr. Lee/Andrei’s interaction being second hand to Dr. Keurin, I will assume Andrei is mistaken in Dr. Lee’s intentions. I would approach Dr. Lee as though he has seen the light and wants to significantly improve this project. As I’m a junior researcher myself, the analysis may be incomplete or sub-optimal, we may have missed studies in our literature review and we may have missed significant limitations that may prevent publishing. Offer to relinquish last authorship if he can show you how to improve analysis and discussion (it’s still early in my career anyway, manuscripts are manuscripts at this point). Then, subject to success, ask additionally for him to take a more active role in Andrei’s career, primping his ‘significant’ role in the development of a future researcher. I would also ask for support for my own projects as I had successfully guided Andrei through this process and offer, in kind, to participate in a similar role with future residents who wish to do research.

    Now, even if I remove my rose colored glasses and Lee is just unethical, this is still likely how I would handle the situation. There is clearly no easy answer for how to handle dishonorable behavior from those who directly impact your career. The best I can say is play ignorant, act as though you assume their behavior is ethical and then make them reject your more positive version. They are likely smart enough to make the connection, but you’ve given them outs either way. Either they make a substantial contribution and all are better for it or they realize they stepped too far and realize on second view, the manuscript stands on it’s own. If Lee continues to act unethically or uses a power dynamic to force the issue, I’m out. Dignity and veracity are core to any successful career, this situation carries neither.

  • Anne Messman

    Very interesting (and uncomfortable) situation! I think question of whether senior authorship is appropriate has been adequately addressed in the comments below, and I agree that “no” is the correct answer. I do not feel the Dr. Keurin should “confront” Dr. Lee, but I think that an honest and open discussion is appropriate. ICMJE has very clear authorship recommendations that Dr. Lee can’t really argue with, and I think these recommendations should be presented to him with an ensuing conversation. I also agree with Kory London’s comments below that he would not stay at a facility that condoned this sort of behavior. If Dr. Lee disagreed with the ICMJE recommendations and continued to insist on senior authorship, I would take my concerns to the department chair and if my concerns were not met with a satisfactory resolution, I would absolutely re-examine my decision to stay at an institution like that. I know “bullying” is a very hot term right now, and I would consider this a sort of academic “bullying” if Dr. Lee became a senior author on this project.