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    FREELANCE SPOTLIGHT << Caitlin Rothermel

    Caitlin Rothermel An interview with Caitlin Rothermel
    Published 5 October 2010

    Neil Armand speaks to Caitlin Rothermel, a freelance medical writer based in Seattle who runs her own company MedLitera.

    Q: Medical writing was a change of career for you I believe?

    A: Right. Previously I was a professional grant writer, so it wasn’t so dramatic a change. I knew I wanted to write for a living from when I was about seventeen. My undergraduate and graduate schools were both focused on writing, and because of the way the academic structure is set up I ended up with two degrees in English literature.

    Initially I thought I was going to be a fiction writer, but I discovered I can’t invent plots very well. If you give me a plot, however, I can write it!

    Q: How did you get into the grant writing business?

    A: When I was in college I was an activist, and I had a job at the YWCA in New York, where I started grant writing as a way of being proactive. I was also doing activism in family planning health care. That meant that by the time I was done with school I had a good set of credentials to get a real job.

    Q: And later you moved into medical writing. Is your university background helpful for that kind of writing?

    A: Looking back I would say that what I learned at university has proved critical — because I was trained to take a hard look at my own writing and to edit it rigorously. I spent an awful lot of time in workshops having to listen to what I had written being torn apart. Another consequence of that was that I developed a thick skin!

    Q: Are there many freelance medical writers who do not have a science background?

    A: I would say there is a good split between those who come from more of an English Literature writing background and those who are science based.

    Q: Presumably there are real challenges for an arts graduate to move into medical writing?

    A: Certainly there are hurdles. But there are hurdles if you come from a science background, too. For instance, you might not have been trained to write extremely well, or to edit your own work rigorously.

    English Literature people, on the other hand, have a lot of science to learn; it becomes a matter of how much aptitude you have. Right now I am trying to finish my Masters in Public Health. I have done all the course work, but I have been so busy writing and raising my kids that I haven’t finished my thesis yet.

    Q: The organisation you work for — MedLitera. Is it a company or a group of freelance writers?

    A: It is my company, and I have a group of freelance writers who contract with me when I get overflow. They are not my employees, and the majority have other freelance careers that they are pursuing.

    Q: You subcontract work to them then?

    A: Right. After I had my first child I realised that there are a lot of very skilled people — both women with kids and younger people — who don’t want to be in a 9 to 5 environment.

    COMMISSIONING

    Q: Who commissions you to write medical papers?

    A: It varies. I would say that the majority of my clients are either medical education companies, or medical research companies. IMS is a client for instance. I also have a few pharmaceutical clients that I work directly for, as well as non-profit groups like the American Association of Clinical Endocrinologists.

    But medical writing varies: Other medical writers might work mainly for non-profits or hospitals, for instance.

    Q: Do you ever get commissioned directly by researchers?

    A: Yes, I have a few academic authors I work with. I often lower my rates substantially in that circumstance.

    Q: Can you give me an example of a typical day for you?

    A: Take today, for instance. After I get off the phone, I am going to make some lunches and get the kids to school, and in an hour and a half or so I will be back at my desk.

    Then I am going to spend most of today working on a paper that is almost written but which has a thousand and one small things to be checked. The authors have asked me to cover certain things in the discussion and I have to perform a literature search to see if I can accomplish that.

    Today I am also going to be reviewing some draft notes for a slide kit I am going to start work on next week.

    Q: What is a slide kit?

    A: Whether we like it or not, more and more professional education is being conducted via slide presentations; I help to develop these.

    Q: Once school ends, you are back on childcare duties I guess?

    A: And after they go to bed I sometimes do a little more work, or I wake up early and so some work — as I did today.

    Q: Medical writing is quite broad in scope. You mentioned slide kits, but medical writers also work on clinical papers, mini reviews, case reports, editorials, letters, comments, posters etc. etc. What do you mainly write?

    A: Mainly original research and new articles. I have also worked on editorials, not for publication in a medical journal but for newsletters I am involved with.

    Q: When a medical writer has produced a research paper he or she is sometimes listed as having provided “editorial support”. What does editorial support mean in this context?

    A: It’s a rather vague term isn’t it? It may mean that I have drafted an article and, apart from changes made by the authors, the published paper is basically what I wrote. Or it could mean that I re-read the final document and did a careful line editing. It can mean many things. And sometimes you will see three or four people credited with having provided editorial assistance.

    WRITING

    Q: So talk me through the process of how a typical paper might get written: Who do you liaise with? How many steps are there in producing the paper? And what happens in each stage?

    A: It depends on how it is run. I might speak with the authors first, or I might review the background literature first. But generally I start by getting some input. Usually there is a study report or something I can look at. Ideally, I will get on the phone with the authors once I am familiar enough with the literature to be able to say: “Do you want to do this? Would it work this way?” Or I might say, “Well, there is also this part of the trial. What do you think of that?” And so on.

    I find that some scientists have a very clear idea of what they want to discuss. With others it will be more a case of pulling it out of them. But I think I am pretty good at asking the right questions.

    After that, I will put together the bare bones of an outline with rough suggestions of things that might be covered. And, lacking specific input, I will generally leave the introduction open, because that is for the authors to write. I am not the expert so far as the actual research is concerned.

    Q: What happens then?

    A: The way it generally works is that I would write the first draft and send it in for review. The way I prefer to work is with a middle person — a medical education company, for example — where someone will check it for accuracy and editorial content, and see if there are any mistakes. However, most of the feedback will come from the authors.

    Q: Who puts the final draft together?

    A: That also varies. It used to be much more of a black box type of thing. I would do the first draft and send it back and they would say, “Thank you, we’ll take it from here.” But nowadays I am increasingly being asked to follow papers all the way through peer review.

    Q: Who submits the paper for peer review?

    A: Usually the medical education company, who works with the lead author.

    THE AIM

    Q: How would you define the purpose of what you do? What is the aim?

    A: The assumption I work on when drafting a paper is that there is something meaningful that needs to be communicated. My view is that there is now so much scientific information out there – and the quantity is growing all the time – that that information needs to be organised and made digestible.

    So when I help with medical papers, I see my job as being to help researchers dialogue with one other. And when doing patient-focused writing, my aim is to put together a stimulating dialogue and a thought process that will help individuals to think things through.

    Essentially, my task is to facilitate dialogue. There is a real dearth of people who are able to convey medical matters clearly, and I consider myself very lucky to be someone who gets to do that, even if it is in a very limited form.

    Q: So your audience is sometimes researchers, sometimes patients, and presumably also sometimes doctors?

    A: And I often write for other clinicians like pharmacists and nurses, too. In all cases, I see my purpose as being that of translating things, explaining them, and making the issues clear. My job is to cut through the garbage, and explain where there are caveats to consider before anyone goes headlong into a medical decision. Typically, here is no “black and white” in medical decisions; it is always a matter of weighing benefits against risks.

    Q: I think you also write “dossiers”. What are these, and who do you write them for?

    A: It is becoming increasingly important for drug and product manufacturers to make a cost effectiveness case for their products to commercial payers — Medicaid and Medicare etc.

    One way this is done is using the AMCP dossier [Academy of Managed Care Pharmacy] format. And yes I have written some of those types of dossiers.

    Q: When you are writing medical papers, do you always know when they are published, and in what journal?

    A: Not always. Where I have been able to track the published versions down I list the details in my resume.

    Q: So you do not know what the final version of some of the papers you worked on looks like?

    A: That’s true. There are one or two articles I lost track of. In a couple of cases, when I did I find the published version, and looked at it, I thought: “Well that is not really the article I wrote. They probably decided to go in a different direction with the data.”

    Q: Presumably it will be much easier to track papers down where you have been acknowledged as having provided editorial assistance?

    A: Correct. But it is only in the last two or three years that medical writers have begun to be acknowledged on a more consistent basis.

    GHOST WRITING

    Q: And that is only because industry organisations like ISMPP, AMWA and EMWA have introduced guidelines recommending that medical writers are acknowledged. Is acknowledgment a good idea?

    A: It is a great idea to acknowledge people. However, once you open that can of worms, you face the problem of establishing how a medical writer’s contribution is described. And how do you acknowledge all the other people who need to be acknowledged?

    Another problem is that some authors don’t like to accept that professional writers have helped them. They feel they should be able to do it all themselves. But the fact is that it is happening; it’s a reality — so I say let’s be transparent about it. It is only reasonable that we are.

    Q: What we are talking about here is the issue of ghost writing — where a commissioned medical writer drafts a paper, the scientists are named as authors, but the person who act

    ually wrote the paper is not named. A: Correct.

    Q: Since you have not been able to track down all the papers you wrote I guess you could not say whether or not you have ever ghost written an article?

    A: That is true. If I were to trace back to earlier in my career there are probably instances where I have participated unintentionally in ghost writing.

    Q: Medical education companies and publication planners have in the past few years had a lot of bad press over ghost writing haven’t they?

    A: Yes, but these articles that are coming out, criticising the practice describe things that probably took place 10 years ago! These are not recent events. I think that medical education companies have been seen as easy targets.

    Q: You perhaps saw the recent article in PLoS Medicine about Wyeth and DesignWrite and the articles that were produced about hormone replacement therapy (HRT)?

    A: I did.

    Q: As you said, the article describes events that took place in the late 90s. And your point is that articles like the PLoS one decrying ghost writing cite historical events in order to make their case. And things have changed?

    A: Yes. And the HRT story is interesting history. I was just getting involved in medical writing when that happened, but I do remember the debate. There were people — including certain epidemiologists — saying that the data for the claims being made was weird. But for the most part there was a frenzy of optimism, with everyone on a high over the possibilities of hormonal replacement. And the women who were taking them were thrilled.

    In retrospect it’s clear that a lot of people were ridiculously optimistic about the potential, including some physicians. As a result, writers were asked to say: Maybe it will do this; and maybe it will do that — and to write a story touting the potential benefits.

    We now know that people were doing things they should not have done, but to criticise the writers and medical communications agencies alone is to miss the point. They were not really doing anything that the rest of the crowd were not engaged in: overly optimistic early analysis.

    ETHICAL ISSUES

    Q: Another criticism the PLoS article makes is that in their attempts to promote their products, pharmaceutical companies sometimes ask medical writers to “insert marketing messages into articles published in medical journals”. Have you ever been asked to put marketing messages into a paper?

    A: Yes, I have been asked to put in marketing messages. Not very often, but I have. It is a very weird situation.

    Q: Can you say something about it?

    A: It may be that I have gotten on the phone to engage in what I had thought would be an objective discussion about a new article, and I discover that two or three of the people on the call are marketing folks who want to massage the article.

    Q: What is your response?

    A: The first time it happened was years ago; I didn’t know enough and I went with it — although in the end the paper never got published. Now I know to stop the process right there.

    The fact is that when you have marketing folk, medical education people, and authors all together in a room trying to decide on the content of a paper, you usually don’t wind up with an objective or coherent manuscript.

    Fortunately I have gotten to the point in my career where I can reject jobs if I think that what I am being asked to do fits that description — if I think I am being asked to “shill” for something.

    Q: Can you give me an example of when you have been asked to “shill”?

    A: Recently, for example, I was asked to do some work on a new product that has some limited efficacy data in a very small population. I was asked to draft something that would imply it had potential benefits for a much greater population. So I said no thanks.

    Q: You are saying that they wanted you to write a paper in which the conclusions you were being asked to reach were not supported by the data available?

    A: Exactly. Moreover, they had no author on hand to explain to me why this approach made sense.

    Q: From what you say there are clearly still ethical issues associated with medical writing. While you have learned to refuse to participate, I guess other writers might go along with it?

    A: It is more a case that other people might not know enough to say no. The fact is that there is a very fine line between hope and reality. People might say this drug works extremely well in people with one type of glaucoma, and it works pretty well for everyone. The problem comes when people end up writing articles saying maybe this is the drug of the future.

    But you have to be in the industry for a while — whether as a writer or a practising scientist — before you begin to realise how pervasive this desire to push optimism is, and to sometimes do so when it is not appropriate. So I don’t criticise people for doing it. It takes a while to learn to trust your gut.

    PUSH BACK

    Q: I guess one problem here is that we are talking about an industry that is very hard to police from outside. In the case of ghost writing, for example, no one outside the small group of people who produced the paper would know whether a medical writer had been used if there is no acknowledgement in the paper. Likewise, it would not be possible to know if any marketing messages not supported by the data had been inserted.

    A: Well people do regularly say that no one knows when it is happening. But most places I work with today, and most physicians I work with today, are really aware of all of these things.

    What we have learned is that there is a need for a concerted effort on all of our parts — the scientists, the medical education companies and the writers — to manage what we do. And it comes down to transparency: If you ensure that there is transparency, and there is always an audit trail, then everyone will know exactly what has happened to an article.

    Then if anyone ever asks, “How did this article get developed and what input was provided?”, we can show them the audit trail. And in the electronic age, nothing is simpler than tracking the production of an article.

    Q: What I am taking away from our conversation is the following: You work in an industry that consists of freelance writers, scientists, and medical education companies. This industry has made some mistakes in the past, but it has learned its lesson and improved its working practices. It now recognises that there are important ethical issues attached to what it does, and so transparency is essential? Indeed, it is in the interests of the industry itself to embrace transparency so that it can avoid future allegations of misdoing?

    A: Exactly. And the quality of what we are producing will get better, so anyone in the industry that might be tempted to undertake unnecessary or unwise marketing, or insert certain messages unjustifiably, will be pushed back. Above all they will be prodded back by the authors, who are now required to be very heavily involved, and who are being given more of a voice in the process.

    Q: So medical writers will no longer be ghosts, but important agents able to ensure ethical behaviour. Finally then, what advice would you give to someone who came to you and said they wanted to get into medical writing?

    A: I would tell they need to figure out what kind of environment they want to be in — pharma, medical education etc., and to get a few years of full-time experience in that environment.

    But if someone wanted to start freelance writing right away I wouldn’t have much in the way of useful advice to give them — because I don’t think you can start freelance medical writing without connections.

    Q: What are the main skills you need for medical writing?

    A: Above all you have to be extremely organised and meticulous, and really concerned with expressing data accurately. I like to say that, if you do not have an anal personality type, you need to be able to fake it, to put that hat on while you are a medical writer!

    Q: Because accuracy is essential in medical writing.

    A: Absolutely.

    CAITLIN’S HOT LINKS:

  • AMA Manual of Style Online
  • American Medical Writers Association
  • CONSORT Statement
  • FDA-approved drug products
  • Fierce Pharma
  • HealthEconomics.com
  • MedLitera: The Medical Writers’ Group (my website)
  • Wall Street Journal Health Blog

    © Neil Armand. This work is made available under the Creative Commons Attribution-NonCommercial-NoDerivs 2.0 Generic licence.

    Feedback: Do you have any comments about this article? Contact the Publisher, Peter Llewellyn.


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