The Patience-Producing Publishing Process

 

by Carlan

Our team has been blessed with the opportunity to share some of our reflections, observations, and developments with others. Some of us have recorded music (Michelle still gets royalty checks from time to time). Some of us have published whole books (Eric’s book). Many of us have participated in the process of scientific-medical research and journal publication. All of us have posted on this blog and everyone in the whole world has shared something on social media.*

As a physician I have been fielding lots of questions from friends about different preventative measures, vaccines, medications, and treatments for COVID-19 over the past year, a year in which I have been getting more personal experience with the process of publishing research studies. I wanted to share some observations from my own heart as well as elucidate a bit more of why the process is so slow. I hope that the reader will thus understand why controversies over specific treatments or the impacts of preventative measures continue.

Publishing in a peer-reviewed journal starts with a question. It could be a very general question like, “how do I treat malaria if we run out of our usual medication?” or a very specific question like, “is it safe to perform a lumbar puncture on an AIDS patient with a CD4 count <200 in the setting of behavioral changes?” Then you look for evidence published by others that can answer your question. In the case of the first question, the Burundian Ministry of Health has a whole treatment protocol dedicated to malaria and it includes first- and second-line treatment regimens. In the case of the second question, there are related guidelines from many institutional and professional bodies which don’t specifically address the behavior changes as well as some peripheral data from journals about the eventual diagnosis in such patients with those behavior changes.

Occasionally, you pose a question that is not yet directly addressed in the published evidence AND is amenable to you studying it. This happened with one of my students in 2018. We wanted to know if the surface area of a Burundian’s hand was really about 1% of their total body surface area. You see, we use the surface of the patient’s hand to estimate how extensive a burn is, especially when it is large and irregular in coverage (like a splash burn from a pot of boiling beans). There were some studies in other populations that showed it was variable, but almost no one had ever looked at Africans.

So in 2018 and 2019 we traced the hands of hundreds of patients and collected data about their age, gender, height, and weight that would allow us to estimate their total body surface area (TBSA). We plugged in the formulae and compared the measured surface of their hands with 1% of their TBSA. Lo and behold, it was significantly different. Now I felt an ethical obligation to share this finding with the broader community. You see, overestimating the extent of a burn might lead the clinician to give too much fluid in resuscitation. Especially in kids and especially in settings where malnutrition is a consideration, overly aggressive rehydration can lead to swelling of the brain and fluid on the lungs…neither of which is benign.

So my colleague and I (he had graduated med school in the meantime) wrote up our results as a paper. We triple-checked all the figures. I spent hours reading formatting guides for various journals. We looked at similar types of articles to get a sense for how verbose or succinct we needed to be. I had Randy Bond look over the draft of the paper and made corrections based on his feedback.

 

 

 

These med students solve other challenges to writing in Kibuye.

When everyone had signed off, I went through the somewhat convoluted process of breaking the paper into its constituent parts and submitting them separately so that the online submission tool could build them back together as a PDF. Then I waited for a bit over a month. Two out of three reviewers had asked for “major” corrections, so I redid all the figures, added another table of data, and resubmitted. Then I waited for a bit over a month. The rebuilt PDF was formatted incorrectly. So I broke it back into its constituent parts and resubmitted everything. Then I waited.

That is where I am today, waiting for a decision from the journal editors as to whether or not my revisions pass muster and to know if they have a spot to publish our findings. What started as a question and some data in 2018 is still unpublished in early 2021. I need also to say that ours was not a complex study. The data set was relatively small (~350 patients). The math was pretty straightforward (multiplication, averages, Student’s t-test). In all, it took about 3 pages to report everything.

We might get accepted by this journal. We might have to start the process over at a different journal. (You are not allowed to submit to multiple journals simultaneously, so rejection results in lengthy delays.) Yet I find in this process that God is teaching me some valuable lessons…lessons that I should have learned by now but that show His incredibly patient love towards me. 

First, to be hurried is to be harried. A friend of mine told me recently that he doesn’t read newspaper websites anymore because they are “too slow.” He gets his news exclusively from Twitter. I understand that instinct, to want to be on the cutting edge, to hear in “real time” what is happening in the world. But at some fundamental level, God did not design me (or you, I would contend) to be au courant of everything all the time. Eternal omniscience is distinctive to God. When I submit to that, I feel more relaxed and at peace.

One of my favorite musicians/authors.

Second, God wants us to be subject to process. Think of it, God invented time. He Himself was not subject to process. There is no necessary “order of operations” or “steps 1, 2, and 3” for God. As He is He thinks and He does. The theological term for this is God’s “simplicity” and I can’t stop thinking about it. There is no space or delay between God’s character, Person, will, and action. This makes it all the more remarkable that Jesus came down as a baby and grew in wisdom, in stature, and in favor with God and men (Luke 2:52). Furthermore, God established some processes. A sabbath takes 24 hrs because it is a day. You can’t hustle a sabbath. A gestation takes 9 months. You don’t want to accelerate a pregnancy. From digestion to development, from germination to glorification, life requires process.

So as I hit “refresh” once again to see if that paper has been accepted for publication, I call to mind God’s gift of process. As I sit typing in California instead of treating and training in Kibuye, I remember that God has chosen a slower pace for my sanctification than I thought best. And as you navigate your social media feeds and the rancorous debates about the science of vaccines, masks, school reopenings, and repurposed pharmaceuticals, I hope you are able to appreciate a little more why good answers in a complex world come slowly.

The greatest encouragement to publish our data.

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*I realize that there are some folks alive who have not actually posted on social media…it just feels like all eight billion people are using some form of it these days.