How to Write a Paper? Plastic Surgeon as an Author

Abstract

In this chapter, the hidden tips are introduced which is helpful in writing scientific paper as well as thesis.

7.1 How to Write a Scientific Paper: Three Tips to Remember

In the field of plastic surgery, many new ideas and skills are developed by surgeons and researchers. “Publish or perish” is a phrase coined to describe the pressure in academia to publish work constantly to further or sustain one’s career [1]. To share knowledge or skill with others or promote one’s position in schools, they should write papers. However, it is not easy to gather and develop writing material.

I learned an invaluable lesson at the International Confederation of Plastic, Reconstructive, and Aesthetic Surgery meeting, which was held in Yokohama, Japan in 1995. At the opening ceremony, Dr. Joseph Murray, who performed the first successful human kidney transplant on identical twins and who shared the Nobel Prize in Physiology or Medicine, had the keynote lecture.

The elder retired plastic surgeon emphasized that scientists should remember three important words: curiosity, imagination, and persistence. Curiosity is an emotion related to natural inquisitive behavior, such as exploration, investigation, and learning. We can have curiosity in any basic research or about surgical procedures. Imagination is the ability to form mental images, sensations and concepts, in a moment when they are not perceived through sight, hearing, or the other senses. Lastly, persistence is the determination to do something even though it is difficult or other people oppose it.

Reading a book about swimming cannot guarantee the ability to swim. Likewise, there is no royal road to writing papers. However, it would be helpful to the surgeon to remember Dr. Murray’s three words: curiosity, imagination, and persistence.

7.2 The Importance of Brevity in Scientific Writing

I recently enjoyed rewatching the movie “A River Runs Through It,” directed by Robert Redford and starring Brad Pitt. It was based on a novel of the same name written by Norman Maclean in 1976. This semiautobiographical story tells how two sons (Norman and Paul) of a Presbyterian minister grow up and come of age in the Rocky Mountain area during a period of time approximately ranging from World War I to the early days of the Great Depression.

Early in the story, young Norman is shown writing and then rewriting a paper and having his minister father look it over for him.

(Norman is at his desk hard at work writing a paper, which he then turns in to his father for review. His father marks it up with a red pen and simply says, “Half as long.” Norman goes back to work, cuts the length of the paper in half, and turns it in for further review. His father marks it up once more and says, “Again, half as long.” Following a final round of edits, his father looks over the finished product and says, “Good, now throw it away.”) (Fig. 7.1).

Fig. 7.1

“Half as long.” The young son is shown writing and then rewriting a paper and having his minister father look it over for him

When writing a paper, it is challenging to summarize the manuscript without losing its content. The minister father is training his first son, who later becomes a professor, on brevity in writing. He also emphasizes the process of writing, rather than the finished output.

In preparing an original article or case report, we follow the order IMRAD (introduction, methods, results, and discussion) or ICD (introduction, case, and discussion), respectively. After finishing the text, we must summarize it as a structured or unstructured abstract of about 250 words. A structured abstract requires the purpose, methods, results, and conclusion. Sometimes it is not easy to include important results within the limited space of the abstract.

Therefore, training on “half as long” is needed for writing scientific papers. We should eliminate redundancy (i.e., unnecessary repetition). As an author for whom English is not my mother tongue, I have to write each sentence as concisely as possible.

Summarizing the results for an abstract is particularly difficult for me. At this stage, I make it “half as long” and “again half as long” and finally submit it.

7.3 Festina Lente in Writing Papers

Ohne Hast, aber ohne Rast,—Johann Wolfgang von Goethe and Friedrich Schiller (1796)

When searching the literature, I sometimes happen to see two or more papers that have very similar content, including the surgical methods. Interestingly, the papers were sometimes published in the same year by different authors from different institutions [2]. When writing my manuscript, I usually cite both of them; however, I sometimes have to cite only one due to limits on the number of references. In such cases, I choose the paper that was published in the earlier month of that year. Worldwide, many different authors may be focused on similar surgical methods for procedures that they perform every day. This raises the question of who will be acknowledged as the originator of the procedure. Needless to say, the author who publishes first should receive this recognition. Therefore, we must make haste (in Latin, festina) in writing a manuscript and submitting it to a journal.

In letters to the editor in some journals, we frequently find questions from a reader and answers from the authors. However, some questions do not have accompanying answers, because the authors could not defend their position to the reader who raised the question. Furthermore, when I review papers as an editorial board member, I frequently encounter manuscripts that were written in a hurry. Sometimes, the reference style is different from the journal instructions, and the font and size of the letters are different. The most important point, however, is how authors cite similar papers that have been previously published. Some authors do not point to previously published papers and state that their findings are novel or even develop new nomenclature for a structure they believe to have found by chance in an operation or cadaver dissection [3]. The point of commonality of these papers, I suspect, is that they were written in a hurry.

When I am preparing a manuscript that will be submitted to a scientific journal, I remember the epigram that Augustus, the Roman emperor, loved: festina lente (make haste slowly; more haste, less speed). He disapproved of urgency and rashness among his officers and so encouraged them with the Greek saying σπεύδε βραδέωζ (festina lente in Latin). The anchor-dolphin symbol in Erasmus’s book is from a Roman coin: these components symbolize the slowness of deliberation and the speed of performance, respectively (Fig. 7.2) [4].

Fig. 7.2

Dolphin-anchor symbol, on an 80 A.D. Roman coin

This motto was reused by Goethe and Schiller: “Ohne Hast, aber ohne Rast” (“without haste, but without rest”) (Zahme Xenien [with Schiller, 1796] Sect. 2, no. 6, l. 281) [5].

If writing and submitting are rushed too quickly, they are prone to mistakes, and the long-term results may not be as good as expected. In Buddhist terms, writing is best achieved in a state of flow in which one is fully engaged and there is no sense of time passing (freedom from all thought and ideas, 無念無想). When I sit down in my desk for writing, I always reiterate to myself, “festina lente.”

7.4 Writing Paper: Flash Inspiration or Arduous Effort?

They go from strength to strength; God of gods will appear in Zion.—Psalm 84:7

For me, the most difficult step of writing a new paper is in the first part of the introduction and the beginning of the discussion. Major revisions following reviewer’s comments are stressful. Rewriting a rejected paper following the comments of referees, which have abandoned me, is even more distressing.

During the rewriting of a rejected paper or when going through major revisions, I sometimes feel I’m in front of a wall without an exit.

In those moments, I recall the picture “Saint Matthew and the Angel” by Caravaggio in 1602 (Fig. 7.3) [6]. Saint Matthew is holding a pen, and an angel is moving his hand to write the Gospel. It would be very auspicious if an angel would come to me and grant me flash inspiration or guide my hand to write the blocked part of a draft! I wish I were a genius and had creative brilliance like Mozart.

Fig. 7.3

“Saint Matthew and the Angel” by Caravaggio (1602)

In the Oscar-winning film “Amadeus,” Mozart was an idiot savant divinely inspired. He could envision pieces whole in his imagination and needed only time to write them down [7]. This tale was from the letter published in 1815, in which Mozart is said to have written to Baron von X. However, it was later discovered that this letter was markedly different from Mozart’s actual descriptions, and it proved a forgery. The musical manuscripts of Mozart contained sketches or drafts of unrealized works, which were kept for possible completion by others, while curiously, those containing sketches or drafts of completed works could be discarded. This genius composer also needed arduous and intensive training and much practice and hard work in a lucid state [7].

In writing the first part of an introduction, I usually start with three sentences: something already known, what is still unknown and current controversies, and, finally, the question and purpose of my paper [8]. The easiest way to begin the discussion is to redescribe the purpose of the study and show that some previous studies support or at least do not contradict my results [9].

The referees with keen eyes usually point out deficiencies as part of the “answers.” Thereafter, during the rewriting of the rejected paper or for major revisions, I have to explain and defend the answer, which is the result I found through my methods. I have to explain conflicting results or unexpected findings.

What shall I do when I have an uncompleted draft? Instead of waiting for an angel’s hand, shall I find an angel’s hand myself?

I believe that the more belligerent the referees’ comments are, the more vulnerable points of my paper can be overcome through revisions. I ritually search previous literature with the keywords from the tenacious and sharp comments of referees who have reviewed my paper. The work of previous researchers will help to explain and defend my findings. By analyzing every detail of referees’ comments and have consideration on them, the draft receives a new breath. Thereafter, referee’s comments can be the hand of an angel and the literature discovered can be a whispering of God.

I hope to go “from strength to strength” by the comments of other researchers. If I revise section by section following “the hands” and “the whispering,” I do believe the paper will ultimately be completed.

7.5 In the Heart of the Sea: How to Get a Motif?

All visible objects, man, are but pasteboard masks […] If man will strike, strike through the mask! How can the prisoner reach outside except by thrusting through the wall? To me, the white whale is that wall, shoved near to me.—Herman Melville in Moby-Dick (1851)

The most difficult step in research is to improvise a motif. If the first line could not be written, there is my improvised ritual that will rectify the situation. I open the refrigerator in the kitchen, get out of the house, walk down the road, or sit peacefully on a bench in the park. However, there are times where the idea just simply would not come up in my mind.

With the purpose of finding a motif that is masked for me, I went to see the movie “In the Heart of the Sea,” where the plot regards the loss of a ship in Essex written by Nathaniel Philbrick.

The movie started with the scene where Herman Melville, a writer who later became the author of Moby-Dick, knocks on the house door of old Thomas Nickerson in the rain. Mrs. Nickerson persuaded her husband to exhort his painful experiences to Melville. The story was regarding a whaleship from Massachusetts (Essex), which sank following an attack from a sperm whale in the Pacific Ocean in 1820. Having lost their ship, the crew underwent severe starvation, where most of the crew died, with only eight survivors.

Melville wrote down what Nickerson remembered, told, and confessed, after paying a sum of money. Toward the end of the encounter, Nickerson asked Melville whether he will write everything that was told to him. There was a consensus that a novel “inspired by the fact” will be written. This of course became Moby-Dick. In this novel, the only survivor of whaling ship narrates the tale of his captain’s obsession to hunt the white whale, which gave him his crutch. Combining his experience as a whaleman and Melville’s account, Moby-Dick was generated.

The compelling plot ended and I returned to my desk. I remembered that I in fact have a similar experience of gaining a motif from the discussion with a plastic surgeon, whom I had met in a conference. He consulted me whether the location of the mandibular branch of the facial nerve according to the neck position could be known. His curiosity was originating from his surgical regimen, where he moves the patient’s neck from one side to the other. I answered him: “I cannot answer your question right now, but I will find it and let you know.” A paper was published the following year [10], and a manuscript was sent to him. Of course, at the end of the paper, I acknowledged and thanked him for discussing the idea he had in mind.

Plastic surgeons, especially those who specialize in a specific area, may have abundant surgical experiences. A lot of them also would have curiosities to break through the masked anatomical structures that cannot be explained from studying orthodox anatomical textbooks. Their curiosities and imaginations can be a real motif for the research, “inspired by surgery.” If persistence is added, I believe a paper could be published.

7.6 Selecting Trustworthy Papers

But while everyone was sleeping, his enemy came and sowed weeds among the wheat, and went away.—Matthew 13:25

First collect the weeds and tie them in bundles to be burned; then gather the wheat and bring it into my barn.—Matthew 13:30

It goes without saying that plastic surgeons need solid anatomical knowledge. Surgeons without anatomy are similar to the moles that dig mole hills in the dark [11]. Not every plastic surgeon has the opportunity to dissect cadavers. Of course, participating in a workshop with hands-on dissection cannot guarantee true learning. In any patient, most of us learn anatomy from published journal articles or book chapters. Given that the number of papers which describe the surgical anatomy of the face is growing, surgeons have to try to identify the papers that are most trustworthy and applicable.

And which anatomy papers are trustworthy and applicable? It is difficult to distinguish papers written just to meet publication requirements from the true gems; readers should open their eyes wide to distinguish the weeds from the wheat (Fig. 7.4). Papers that have not cited previous papers on similar topics (similar article not cited) [12] and insist on their originality should be filtered out in the review process; however, sometimes appear in publication. If a paper has provoked a letter to the editor and if the authors have not responded to this letter, it can be concluded that the authors were avoiding criticism and their paper should be disregarded.

Fig. 7.4

Enemy sowing weeds. Heinrich Füllmaurer (1505–1546)

Anatomical researchers’ paper should do research provoked by their own curiosity arising from their surgical experiences or discussions with their colleagues. The structures should be located using topography relative to anatomical landmarks. Anatomic landmark is a morphologic feature of the anatomy that is readily recognizable and may be used as a reference point for other body features [13]. Structures should be demonstrated in layer-by-layer dissections, along the surgical plane same as real operation field. Additionally, the depth of the structure should be displayed using histology or tomography [14]. Since facial appearance varies in people of different ethnic origins, transracial anatomy may also be needed.

Systematic reviews and meta-analyses of the facial anatomy are encouraged. Through systematic reviews, readers can see the whole picture and cannot be shifted to a biased perspective. A well-written systematic review should be helpful for selecting trustworthy and applicable papers, removing the weeds from the wheat.

Writing the Discussion

Some residents and junior staff members have asked me how to write the “discussion part” of a scientific paper. In reviewing the manuscripts of original articles and case reports submitted to journals including the Archives of Plastic Surgery, I don’t infrequently find or I frequently find that the authors have written summaries of references cited that are not directly related to the topic they are discussing. This paper is aimed at helping beginners easily start and end the discussion section of a journal article.

What do your findings mean? Why are they important? Discussion and conclusion sections exist to answer these questions [15]. Hess [16] summarized the tasks performed in the discussion as follows: state the study’s major findings, explain the meaning and importance of the findings, relate the findings to those of similar studies, consider alternative explanations of the findings, state the clinical relevance of the findings, acknowledge the study’s limitations, and make suggestions for further research. He also stated that elements to be avoided in the discussion are as follows: over presentation of the results, unwarranted speculation, inflation of the importance of the findings, tangential issues, and the “bully pulpit” [16].

Most authors agree that beginning the discussion is difficult. Huth [17] emphasized that the opening of the discussion should give the answer to the research question. In the first paragraph of the section, state concisely the central conclusion, or answer, to be drawn from the data presented in the results.

In my experience, the easiest way to begin the discussion is to redescribe the purpose of the study and show that some (about 40%) previous studies support or at least do not contradict my results. For example, “Results of this study ‘correspond well with’ those of an earlier study which….” Use phrases such as “be quite similar to; resemble; in agreement with; almost identical to; coincide with; be in accord with; show similarity to” instead of repeating “corresponds with” each time.

Then, I present a lesser number (about 25%) of previous studies that contradict my results. An example is “Our findings are in contrast to the results of Hwang et al.” Use the phrases “differ from; be distinct from; do not correspond with; disagree with; be contrary to; be inconsistent with; be in disagreement with” as well.

The rest of the references (35%) were already described in introduction and do not appear in the discussion again. Lastly, I indicate what is new (etwas neues in German) in my results and describe its significance. If you are sure of your findings, use “prove”; in case you are less confident, use “demonstrate, or document.” Usually “show or indicate” is stronger than “suggest, imply, suppose, or assume.” I usually do not repeat the same content or same contents that already appeared in the introduction.

The most important thing, I think, in writing the discussion is “write the discussion for the reader,” that is to say, be “reader friendly.”

7.7 Missing Pieces of Surgery, Puzzle, and Systematic Review

The plastic surgeon requires imagination for he must look into the puzzle of cleft. With this picture as transparency in his mind eye superimposed over the cleft patient, the surgeon is abetted in the sorting out and fitting together of the pieces of the puzzle.—Ralph Millard Jr, 1919–2011

In the systematic review/meta-analysis, the first step is finding papers and the accuracy for presenting data is essential. MEDLINE and EMBASE searches are usually used. If EMBASE is not available, a Scopus search can be used instead [18]. For the meta-analysis, it might be possible to combine the homogenous data from at least two papers. However, more than four papers are preferred to make a forest plot. In case I could not find sufficient full-text papers, I feel like I am trapped in a four-walled room without an exit. Shall I give up or continue searching? In such situations, I recall the front cover of Dr. Millard’s “Cleft craft: the evolution of its surgery (1976) [19]” and reiterate to myself: “Find the missing pieces. They should be somewhere.”

The front cover of the book is an unfinished jigsaw puzzle of a blond-haired boy with charming eyes. The central part of the face including his nose and mouth needed to be completed. In the preface of that book, Dr. Millard wrote “puzzle” and “piece” each four times and “normal” five times. He wrote this book to “find the missing pieces and fitting them carefully into the puzzle so that the final picture is complete, normal, and happy.”

Usual jigsaw puzzle players first find a hard flat surface area large enough to accommodate the total number of pieces laid out individually face up. While turning all pieces face up, they first select all the edge pieces and put them to one side and construct the “frame” of the puzzle by assembling the edge pieces. They usually arrange all pieces into color groups and complete the different color groups of the puzzle after sorting. When daunted by what seems like an insurmountably difficult section, they are convinced that there are no missing pieces in the box, and if they applied one piece at a time, they finally conquer the challenge.

When I am on a systematic review, I arrange my pieces of references and data in a large table and classify and make a precise flow sheet using preferred reporting items for systematic reviews and meta-analyses [20]. Very frequently, I feel daunted by what seems like an insurmountably difficult situation. Sometimes, I am concerned if there are missing pieces in my results.

The missing pieces can be found in “the mined papers” that cannot be searched in the database but could be “mined” from the references of the papers.

Unpublished papers from the thesis or dissertation can be used for completion of the puzzle. Thereafter, the grey literature (gray literature) should be searched. The grey literature is a type of information or research output produced by organizations outside commercial or academic publishing and distribution channels. Examples of grey literature include technical or research reports, doctoral dissertations, some conference papers, and some official publications [21].

As in cleft surgeries or in jigsaw puzzles, missing pieces of systematic review can be found through the extensive and precise literature search. Of course, the “persistence” is necessary in all the procedures.

7.8 The Right to Heresy: Letters to the Editor

Nothing whets the intelligence more than a passionate suspicion, nothing develops all the faculties of an immature mind more than a trail running away into the dark.—Stefan Zweig

When I receive a new issue of The Journal of Craniofacial Surgery (JCFS), I run my eyes over the titles. When I find an interesting paper, I read the abstract, then the methods.

When I disagree with the methods or results, I select the paper for my department’s weekly journal club. A resident in training usually presents it using PowerPoint, and I ask for all the participants’ opinions.

As the founding editor-in-chief declared in the first issue, JCFS is open to suggestions and comments from readers [22]. Letter to editor includes an interesting patient report or response to previous work published; however, too combative letters are not be welcomed.

If there are important questions for the authors, critiques, or disagreements with the article, I consider writing a letter to the editor.

When writing a letter to the editor with a difference in opinion regarding a published paper written by a famous author, I feel like a mosquito in front of an elephant. However, if there is something I really want to know from the authors and it would be of common interest for other readers, I start writing a letter to the editor.

After a letter has been submitted and, fortunately, accepted by the journal, I usually receive a sincere response from the authors. They are usually frank and kind and resolve most of my questions. However, sometimes, no answer follows, or the answer is even full of rage. I myself have had the experience of being asked to respond to a letter about a published paper of mine. I responded clause by clause to the question contained in the letter.

The recommendations of the International Committee of Medical Journal Editors (ICJME) state: “The authors of articles discussed in correspondence or an online forum have a responsibility to respond to substantial criticisms of their work using those same mechanisms and should be asked by editors to respond. Responsible debate, critique and disagreement are important features of science, and journal editors should encourage such discourse ideally within their own journals about the material they have published [23].”

The introduction of e-publications ahead of print can allow uninvited letters to the editor and the authors’ replies to appear in the same printed issue, given the interval between the electronic publication and its appearance in print. I hope that journal readers do not hesitate to write a letter to the editor when they have questions or a difference of opinion.

Like many other journals, JCFS has “published ahead-of-print,” that there will be interesting comments published online with responses from the authors. This will remove the obsolete publications and make it more dynamic with open time frame.

Finally, I must acknowledge the book The Right to Heresy written by Stefan Zweig (Fig. 7.5), who studied and summarized the story of three historical figures. First, John Calvin (1509–1564) was a reformer turned dreadful dictator. During his theocracy in Geneva, he expelled, and even killed, many people who opposed him. The second, Miguel Servetus (1511–1553), was a medical doctor who first described the function of pulmonary circulation and wrote a theological book to point out certain errors regarding the nature of the Trinity. Because Servetus argued for certain opinions that disagreed with Calvin’s Christian Religion, Calvin became angry and demonized him. Servetus was rushed to judgment as a heretic and burned. Servetus did not withdraw the doctrine and kept his convictions. The third figure, Sebastian Castellio (1515–1563), was a humanist scholar, who studied and translated the Bible. He demonstrated that Calvin definitely did wrong to Servetus and defended the freedom of thinking and writing.

Fig. 7.5

Title page of The Right to Heresy written by Stefan Zweig

In the scientific field, we all have the “the right to heresy,” even when it comes to disagreements with famous authors, just as Castellio argued against Calvin.

7.9 Finishing a Revision in Extreme Fatigue

Yes, I have had my vision.—Virginia Woolf (1882–1941)

It is painstaking work to respond to all of the reviewers’ comments to a submitted article. Sometimes, there are two reviewers, sometimes three, and in rare cases even four or five.

Most reviewers hope to improve the manuscript, and their comments are truly helpful for polishing the paper. Usually, I agree with their keen insights into the weak points of my submitted manuscript.

However, because each reviewer has his or her own viewpoint; sometimes their opinions contradict each other. In those cases, I cannot follow all of their suggestions. If they want me to make extensive revisions, I cannot start to revise the manuscript immediately, or I become extremely fatigued during the revision process.

Usually, the time limit for a revision is 3 months, and no longer than 6 months. I have had the experience of not being able to complete the revision and abandoning the manuscript. Years later, I found that the manuscript had been removed from the journal’s system, and I resubmitted the revised version to another journal.

When the deadline is approaching for completing a revision, I often become very nervous. In such moments, I will often open the refrigerator to get some food, even though I know that instant food is not good for me. If inspiration fails to strike even after I have a meal, I go out and walk along a trail near my home. If I have no idea of how to respond even once I return home, I watch a movie or read a novel. Under the heavy stress of two major revisions, to relax, I recently read and watched To the Lighthouse, written by Virginia Woolf (1882–1941) (Fig. 7.6).

Fig. 7.6

Front cover of the To the Lighthouse (1st ed., 1927) by Virginia Woolf (1882–1941)

In the first section (“The Window”), Mr. and Mrs. Ramsay, their eight children, and several guests are staying at the family’s summer home. Just across the bay is a lighthouse. James, the youngest child, wants to go to the lighthouse the next day, but his father crushes his hopes by saying that the weather will not be pleasant enough for the trip. One of the houseguests, an unmarried artist named Lily, begins to paint a portrait of Mrs. Ramsay. In the second section (“Time Passes”), Mrs. Ramsay unexpectedly dies one night and the house is abandoned for 10 years and falls into decay. In the third part (“The Lighthouse”), all of the living family and other guests (including Lily) return to the summer home. Mr. Ramsay decides that he and his sons will take the trip to the lighthouse. Lily decides to finally finish the painting that she started 10 years ago. As the boat reaches the island where the lighthouse is located, Lily paints the final stroke on her canvas and finally achieves her vision. The novel closes with the following paragraph: “Quickly, as if she were recalled by something over there, she turned to her canvas. There it was—her picture. Yes, with all its greens and blues, its lines running up and across, its attempt at something. It would be hung in the attics, she thought; it would be destroyed. But what did that matter? She asked herself, taking up her brush again. She looked at the steps; they were empty; she looked at her canvas; it was blurred. With a sudden intensity, as if she saw it clear for a second, she drew a line there, in the centre. It was done; it was finished. Yes, she thought, laying down her brush in extreme fatigue, I have had my vision.”

After reading the book, I returned to my manuscript. I had to answer all the reviewers’ comments. I reflected on how even if the paper were to be accepted after revisions, it would not be cited very often. But what does that matter? Only a few attentive and motivated readers are enough for me. I sat at the keyboard again and looked at the screen, which was blurry because I had stared at it for a long time. I focused my eyes on the key points of the revision and finally finished it in a state of extreme fatigue. Then, I was able to say, “I have had my vision.”

7.10 A Lifetime of Rejection

Again, I received an email, “Major revision required—No guarantee of acceptance” for the revised manuscript, which was submitted recently. Each rejection still seems to disappoint me deeply. To overcome this feeling, I took my family to the theatre to watch the movie “The Intern.” This was also a way to spend some time with my eldest son, who just completed his first year of medical intern in the UK and had to return to Korea for his 2-year military service.

In the movie, Ben Whittaker (Robert De Niro), a retired widower in his 70 s, applies for a senior internship position at an online fashion company, founded and run by 30-year-old Jules Ostin (Anne Hathaway). Initially, Jules was skeptical about bringing an old-timer like Ben into the mix. As she struggles juggling her business and a demanding home life of her husband and daughter, she finds Ben’s wisdom and support very helpful. He provides advice and becomes her trusted friend over time.

I believe that wisdom, experience, and judgement come with age. More often than not, we miss the opportunity to utilize the qualities with early retirement. The movie provoked reflections on how I could reinvigorate the new generation of doctors, including my son who may face numerous uncertainties and challenges in the forthcoming future.

After coming home, I watched Robert De Niro’s 2015 Commencement Speech, given at New York University TISCH School of the Arts [24]. He said: “You made it, and you’re f***ed. A new door is opening for you; a door to a lifetime of rejection. It is inevitable. Rejection might sting, but my feeling is that often, it has very little to do with you. ‘Next!’ should be shouted when you didn’t get that part.”

I was surprised at his confession that even he, the famous actor and director, experiences numerous rejections until now. I had assumed that famous actors never get rejected according to the Matthew effect, which was derived from the Bible (Matthew 13:12 “For whoever has, to him shall be given, and he shall have more abundance: but whoever has not, from him shall be taken away even what he has.”). In the case of academic publication, this effect means that manuscripts of famous researchers have a greater chance of being published even if they are inadequate, whereas unknown authors’ work may be required to meet a higher standard or even rejected simply because of lack of an established reputation [25].

Several days later, I had a chance to talk to 250 young medical scientists for 40 minutes in a workshop on medical writing. The topic was as follows: how to refine the introduction, abstract, and title. I asked the audience to raise their hand, whether they had experienced rejection of their work. More than half raised their hand. Then, I asked whether any had experienced rejection of their work more than100 times, to which no one raised their hand. With conviction, I told them that experiencing repeated rejections makes a researcher more mature because it produces endurance. Once one acquires resilience to criticism, he will not be negatively affected by rejection. One can simply submit his manuscript to the next journal.

I sit at my desk to do “major revision” once again. I embark with the belief that as I revise section by section, the job will ultimately be accomplished.

7.11 Ephemeral or Timeless? The Brontë Sisters

Life is so constructed, that the event does not, cannot, and will not match the expectation.—Charlotte Brontë

“First study; then approve; then love.”—Anne Brontë.

In my school days, I have read the Korean translated version of “Wuthering Heights,” written by Emily Brontë, and “Jane Eyre,” by Charlotte Brontë. Several years ago, I enjoyed the film of the latter, which reminded me of the touching impression I received 40 years ago.

Last week, I visited the National Portrait Gallery and watched a display “Celebrating Charlotte Brontë: 1816–1855.” This exhibition explored the Brontës’ life and literary career through the portraits and their handwritten manuscripts. All of their portraits look young. I could not find any middle-aged portraits. There was a colored portrait including the three sisters painted by their brother Branwell (Fig. 7.7). He painted himself among his sisters but later removed the image so as not to clutter the picture. At the exhibit hall, I first noticed that they had all died before 40: Charlotte (1816–1855), Emily (1818–1848), and Anne (1820–1849).

Fig. 7.7

Portrait of Brontë sisters (Charlotte, Emily, and Anne from left clockwise) by their brother Branwell (c. 1834). Reproduced with the kind permission from National Portrait Gallery (NPG 1715)

Although Charlotte was ephemeral, her literary work is enduring, and thereafter, her 200th anniversary of birth is being celebrated. Although the Brontë sisters did not have any offspring, their literary DNA is still replicated because they inspire many readers.

Like the great writers, the Brontë sisters, surgeons must perish also. Then, how could we descend our academic DNAs as a surgeon and researcher? I believe our knowledge can get immortality through scientific papers.

If so, how can we write an everlasting paper? The ageless paper is an article that is loved and remembered by their readers for a long time. To be remembered and loved by the surgeons, it must be useful to surgeons. A useful paper is a paper that can help the surgeons take care of the patients in the “real field” (operating room, ward, or clinic). That is what the surgical literature is for: to help the patients.

The sequence of research (first, study; then, approve; then, write) is similar to that of love (first, study; then, approve; then, love). We should have curiosity and search for the previous work. If we cannot find the answer from the papers of other researchers, we can start. The papers have to approve something new (etwas Neues). A “Me-too paper” must be ephemeral. Of course, research is so constructed that the result does not, cannot, and will not match the expectations.

A logically written paper is easy to follow. A flight of ideas is not permitted in discussion. If we write “reader-friendly” papers, the readers feel comfortable in reading them, and we will have a better chance to be cited. Lastly, we should try hard to polish off the papers. Once it is published, we cannot revise it anymore.

The works of the Brontë sisters are being loved by readers for hundreds of years, because they create impressions to the readers. If our papers are helpful to the surgeons in the “real field,” our papers will be remembered and cited for generations to come.