Copyright ( 1999 John Wiley & Sons, Ltd.

STATISTICS IN MEDICINE

Statist. Med. 18, 2809}2814 (1999)

BOOK REVIEWSEditor: Niels Keiding

1. ¹homas A. ¸ang and Michelle Secic, How to Report Statistics in Medicine: Annotated Guidelines forAuthors, Editors and Reviewers.

2. Daniel=. Byrne, Publishing Your Medical Research Paper: What They Don't Teach in Medical School.

3. Peter M. ¸ee, Bayesian Statistics: An Introduction (second edition).

4. S. French and J. Q. Smith (eds), The Practice of Bayesian Analysis.

1. HOW TO REPORT STATISTICS IN MEDICINE: ANNO-

TATED GUIDELINES FOR AUTHORS, EDITORS AND

REVIEWERS. Thomas A. Lang and Michelle Secic,American College of Physicians, Philadelphia PA,1997. No. of pages: 367. Price: $39.95. ISBN0-943126-44-4

2. PUBLISHING YOUR MEDICAL RESEARCH PAPER:

WHAT THEY DON'T TEACH IN MEDICAL SCHOOL.Daniel W. Byrne, Williams & Wilkins, Philadel-phia, PA, 1998. No. of pages: 298. Price: $23.95.ISBN 0-683-30074-1

This brace of books share much in common. Bothseek to improve clinical researchers' chances ofpublication in the medical literature by providingnumerous in-depth tips on the proper reporting ofresearch papers. Both achieve and surpass thisaim, in di!erent ways, and provide a rich source ofinformation that should be well received, especiallyby clinicians who have been wary of statistics. Asexpected from authors with experience at the pub-lishing end of research, both are clearly written,making them highly recommendable to medicalcolleagues. Neither book, however, substitutes fora comprehensive and comprehensible textbookon medical statistics, but in fairness to theauthors, such is not their intention. Indeed, Byrne'sbook proclaims on the back cover that his is &writ-ten for the clinician, not the statistician', thoughinterestingly, this contradicts the sentence immedi-ately beforehand describing the volume as a mustfor, among others, the biostatistician. So, which isright?

First, How to Report Statistics in Medicine startssoundly with a brief section highlighting the di!er-

ences between clinical and statistical signi"cance.As the book's sub-title suggests, it too is not int-ended primarily for statisticians but for those in-volved in contributing to the medical literature asauthors, editors and reviewers. Next come fourparts, the main one being &1. Annotated guidelinesfor reporting statistical information'. This com-prises 15 chapters, each with a sub-title beginning&Reporting2' to underscore the book's emphasis.Topics covered are: research designs; descriptivestatistics; con"dence intervals; p-values; multipletesting; correlation; regression; ANOVA; survivaldata; diagnostic tests; meta-analyses; economicevaluations; decision analyses, and Bayesian ana-lyses. The "nal miscellaneous chapter is describedas providing &conventions for reporting outcomesin clinically applicable terms' (p. 237) and makesthe case for writing up the interpretative sections ofa medical paper from the reader's viewpoint ratherthan just the researcher's.

Lang and Secic, medical writer and biostatis-tician, respectively, adopt the format of guidelinesusually simply put (for example, 7)26 Specifywhether the model was validated) or occasionallynot so simply (for example, 7)25 Summarize thelogistic regression equation in a table. Include thenumber of observations in the analysis, the coe.c-ient of the explanatory variable, and the associatedstandard error, the odds ratio, the (95%) con,denceinterval of the odds ratio, and the P value). Chapter 1has over 60 guidelines, chapter 3 just four, creatinganother source of heterogeneity. Overall, any senseof the relative importance of guidelines is absent.Some guidelines, though, are expanded uponby the use of &sub-guidelines', allowing theauthors to go into considerable detail. This is so

much so that the book will serve better as a refer-ence rather than one digested by reading fromcover to cover.

For a book that is generally well presented,I found a couple of minor irritants. Part 1 has a keyto four self-explanatory symbols (indicatingsub-guideline, method of checking, potentialproblem and related information, respectively) un-necessarily printed at the foot of every page.Secondly, pages use up to six di!erent combina-tions of font styles and sizes, a recipe for visualoverload. A more serious omission concerns howto report statistics graphically or in tabularform. Today's over-use in the medical literature ofinappropriate three-dimensional images (forexample, rotated pie charts with part-removed sli-ces) surely calls for an entire chapter, or at leasta major part of the one devoted to descriptivestatistics. As it is, however, the present edition failsto list pie chart, histogram, bar chart or scatter plotin its index.

Part 2, &Guide to statistical terms and tests' isexcellent for de"ning terminology succinctly, con-taining concise de"nitions that will appeal to clini-cians wanting a quick reference or rudimentaryunderstanding } a poor man's Encyclopedia of Bio-statistics. Part 2 begins, as do all chapters, with anapt quotation: &Statistics with plain English asa propellant are formidable missiles (Pearl, 1941)'.This incidentally could be the motto for bothbooks reviewed. While it is possible to suggestadding a few more entries to the 350 or so, givenacross 50 pages, this is essentially a complete list-ing of terms any clinician is ever likely to want toknow. An interesting, alliterative conjunction oc-curs in successive entries on p. 256: Duncan's,Dunn's and Dunnett's procedures, each beingcross-referenced with &See multiple (pairwise)comparison procedures' } quite an alphabeticalcoincidence. The authors try to introduce someself-deprecating humour, for example, the lastentry reads &zzz Sound made by most peopleafter only a short period of reading any book onstatistics'.

Among errors noticed, under interval data (p.263) readers are told rightly not to consider 403Cas twice as hot as 203C, Celsius not being on a ratioscale. Why then, I wonder, is an example given onp. 41 saying &A 103 increase in body temperaturefrom 303C to 403C is a 33% increase'? (It wouldonly be 21 per cent in Fahrenheit, equally illegit-imate.) The example is doubly perverse, as I doubtsomeone starting with a body temperature thatlow would be alive to experience such an increaseanyway!

The remaining, shorter parts are: &3. An unan-notated, referenced list of the guidelines', itselfa handy condensed reference, and &4. Appendices',including a near stop-press comparison of theguidelines described and the recent CONSORTstatement on improving the quality of reporting ofrandomized controlled trials.

On the whole, Publishing your Medical ResearchPaper is the more readable of the two and, unre-lated to the zzz de"nition above, has proportion-ately less statistical content. Both books arelengthy and detailed: Lang and Secic enunciate 287guidelines, Byrne discusses no fewer than 245 prin-ciples, all of which are expanded upon. Theseprinciples range from the pithy &171. Speculateintelligently', &177. Be modest' or &9. Edit ruthlessly'to the enigmatic &88. Begin with thunder' or, notvery helpfully for the intended target audience,&116. Make the statistics easy to understand'. Atleast he took his own advice on reaching the lastone for it reads &245. Know when to stop'!

Byrne, in strikingly similar style to Lang andSecic, uses four pictogram symbols throughout toillustrate key points. These #ag actual peer re-viewer criticism about a manuscript, commentfrom survey respondents, vital points and sourcesof further information, respectively. These, espe-cially the "rst and third, are particular stengths ofthe book, even if icons were also annoyingly over-used, for example, seven times on a single pagewhere once would have su$ced. The book includesover 60 tables and more than 40 "gures and hasa structure woven around the acronym POWER;not statistical power, but sections on Planning,Observing, Writing, Editing and Revising. Eachsection has from three to eleven short chapters, 34in total, with just over half devoted to statisticaltopics within the "rst two sections. The latter three,as their names suggest, focus more directly onpreparing the manuscript and responding to com-ments from editors and reviewers.

Another thread throughout the text is the re-porting of results from an original survey thatsolicited opinions from nearly 30 &experts', includ-ing medical journal editors and peer reviewers.Wisely, the author resisted any temptation to writea chapter summarizing his study as if it were to besubmitted to a journal. Perhaps he is aware ofa Biblical principle concerned with removinga plank from one's own eyes before removingspecks of dust from the eyes of others!

An introductory chapter lists ten fundamentalprinciples, reminiscent of the Ten Commandments,to which readers are urged to return periodically.This, along with the vital point icon (concentric

2810 BOOK REVIEWS

Copyright ( 1999 John Wiley & Sons, Ltd. Statist. Med. 18, 2809}2814 (1999)

circles, presumably to indicate a target?) means thesecond book highlights the important topics verywell. The sections begin with several key questions,although it is not always clear that they are ad-equately answered. For instance, the section onplanning starts: &What is the research problem?What is the plan to study this problem? How canthis study bene"t patient care?' Among topicscovered are research methodology; study design;minimizing bias; data collection forms; eligibility;randomization; outcome measures; sample size; pre-paring for statistical analysis; and preparing towrite a publishable paper. The last con"rms theauthor's intent to have researchers consider theend result in terms of a publication from the outset.

The observing section goes from collecting datato multivariate analysis in seven chapters, so ispresented more compactly than comparable ma-terial in the "rst book. A summary table of when touse which hypothesis test will prove helpful toclinicians. They should be aware though that thebook does not teach concepts but merely discussesprinciples, such as &74 Learn when to use multivari-ate analysis', &76. Become familiar with logisticregression analysis' or &80. Learn Cox propor-tional-hazards regression'. Sage advice indeed, solong as potential readers understand it is not self-contained in this, or for that matter the other, text.

If that remains a weakness of the book, its truestrength lies in the &W, E and R' sections whichprovide a fresh perspective on how to write, as wellas words of wisdom about gaining coveted accept-ance letters from medical journal editors. As manyas three principles, two tables and an entire chap-ter, albeit short, are devoted to writing a paper'stitle, with another chapter on the abstract. Sub-sequent chapters cover introduction, methods, re-sults and discussion, respectively. (These four alonewill be particularly useful to, among others, noviceand experienced statistical referees for medicaljournals.) The four areas appear as subheadings inmany of the chapters constituting Part 1 of How toReport Statistics in Medicine. In this regard, there-fore, the style of Publishing >our Medical ResearchPaper is less repetitive, but less speci"c.

The rest of the book includes numerous tablescontrasting problematic and preferred usages ofphrases, words or numbers. Among dozens of writ-ing tips, some were amusing, some pedantic andsome helpful. How many know that holding &Alt'down while entering 230 on the numeric keypadyields &k'? (It is better, for example, to eliminate &it'at the start of, and &there' anywhere within senten-

ces, and to avoid colloquialisms, so there you haveit.) The POWER acronym seems to be the onlyexcuse for not amalgamating the last two sections.Lastly, the author provides some worthwhile ap-pendixes. In the medical world, so we learn, &ap-pendices' is not the preferred plural, meaning the"rst book got that wrong! Byrne includes copies ofUniform Requirements for Manuscripts Submit-ted to Biomedical Journals and the World MedicalAssociation's Declaration of Helsinki plus an ex-tensive listing of URL's that may prove useful tonet-sur"ng medical researchers. Like Lang andSecic, he "nishes light-heartedly, citing a poem&Ode to multiauthorship' previously published in¹he ¸ancet. By contrast, his book did not refer tothe CONSORT statement, although principle 150pre-dates it by recommending the use of #owcharts in reporting clinical trials.

A weakness is the extent of overlap among theprinciples. Ironically, Byrne could heed his ownadvice on editing, for a recurring theme is toshorten and simplify wherever possible. Arguably,redundant repetitions do at least serve to reinforcethe message. The book contains a few faults. Anomission, I thought, was a chapter speci"cally ad-dressing statistical review, or even just a principlesuch as &Don't try to blu! with statistics'. Someformulae have typesetting errors (for example,missing lines of division in odds ratios and relativerisks on p. 125). I would contest the author's claimthat cohort studies &are e!ective for proving causa-tion' (p. 17) which does not go well with the pre-viously cited principle &be modest' when it comesto writing up such studies.

In conclusion, I recommend both books. Earlier,I asked which statement was right concerningwhether they were for statisticians or non-statisti-cians. The answer, I believe, is that both groupswould bene"t. Whereas clinicians would most like-ly learn more, biostatisticians would become moree!ective as co-authors and referees for papers sub-mitted to medical journals. If the principles andguidelines described were adhered to, editorswould rejoice and the quality of medical researchwould be improved signi"cantly } and that is bothstatistically and clinically. Time now to apply that2455) principle2

CHRIS PALMER

Centre for Applied Medical StatisticsDepartment of Community Medicine

University of Cambridge, Institute of Public HealthRobinson Way, Cambridge CB2 2SR, U.K.

BOOK REVIEWS 2811

Copyright ( 1999 John Wiley & Sons, Ltd. Statist. Med. 18, 2809}2814 (1999)