As a senior fellow, one is blessed to have a light call schedule compared with that of our younger peers. Having paid our dues during residency and fellowship, we get the privilege of picking our call schedules and are required to cover just 4 weekends for the whole year.

With 3 call weekends left on my schedule, it was smooth sailing. I was scheduled for the weekend of September 8, 2017, which looked to be a warm but unremarkable Miami weekend. I would be rounding on the patients, taking in new consults, and covering for colleagues who were taking the weekend of. There was some talk and background noise that Hurricane Irma, brewing in the Atlantic Ocean, might make its way to Miami in the coming days. After all, it was hurricane season, and that’s a weekly story, nothing to worry about—or so I thought.

I have had my share of calamities during my medical training. I spent a month at a military hospital during wartime in Lebanon, was stuck at Memorial Sloan Kettering Cancer Center in New York City throughout Hurricane Sandy, and was the weekend on-call fellow during the blizzard of 2015, also in New York City. I figured I had enough “when I was your age” stories to tell younger physicians 20 years from now.

Irma had other plans. As the week progressed and the e-mail frequency increased, I soon found out that the hurricane would be making landfall during my call weekend. The emergency plan was basically for the house staff and attending physicians to pack and head to the hospital on Saturday morning, with no expectations of leaving before getting the green light from the hospital leadership. Every patient who didn’t need to be hospitalized over the weekend had to be discharged as soon as possible. All noncurative chemotherapy was put on hold until further notice. This was obviously not the first rodeo for our hospital.

After my fair share of lamenting my fate (a little dramatic here), I was on my way for my 3-day lockdown. When I arrived at the hospital, I found it barricaded as though ready for the apocalypse. No door or window was left uncovered. Only a few entrances were open; they would be locked down at noon that day.

Despite the warnings, it was sunny and beautiful outside— the calm before the storm. I walked in, expecting chaos, but it was business as usual for the nursing staff and hospital operations. Everyone was in a good mood and ready to go. I found a place to sleep and created my own area, which I split with my attending physician. I had enough snacks for 3 days. They were gone in 3 hours&mdash;stress eating, I guess. Soon after, the hospital was on lockdown. No one could get in or out, wind speeds started picking up, and the only way to know what was happening outside was by watching the TV screens in the hallways and patient rooms. It began.

Cabin fever hit hard. I was isolated from the outside world, with no natural light and no cell phone reception. Going for a walk meant pacing the hallways and visiting patients on the other side of the hospital. No one—neither us nor the patients&mdash; could really sleep or eat well. We were more concerned with the goings on outside, and then for ourselves inside. Patients asked me more about what I thought would happen to their loved ones than about what was happening with their treatment and disease. That’s not uncommon with people who have cancer; despite having to fight the hardest fight of their life, they always feel that they have to take care of those around them. I never get used to their show of strength, and even though I cannot know where or how they get it, I admire it and accept it.

I spent more time than usual with patients, because time was the only thing I had plenty of at that point. We briefly discussed their treatment and complaints for the day, and then they always moved on to telling me stories about their last hurricane and how bravely they prepared for it and got through it—how they rebuilt what was lost better than ever. We would end the conversation by comparing their cancer with the hurricane and how they would get through that, too.

In my downtime, I tried without success to study. I just had to follow the path of that big spiral in the sky. On TV, online, on my phone…I never knew there were so many weather apps out there!

After 3 days and 2 sleepless nights with no sunlight to go by, no window to peak through, my body and mind started losing track of time. It’s hard to explain, but I soon became disoriented: 3 PM felt like 3 AM and vice versa—not a good feeling.

And then, at the nurses’ station, we received an email saying that it was safe to go outside—the worst of the storm had passed. We were advised that some roads would not be accessible because of broken trees and downed power lines, but I didn’t read that part. All I wanted was to get out. As I walked through the exit, I could see the first signs of the aftermath&mdash; massive trees ripped by their roots lying in the middle of the street, which would require lots of manpower and machinery to budge. Nature’s wrath is scary.

After I walked around a bit, watching as people started to clean and fix what was broken or lost, I went back to check on patients before my relief coverage took over. One of my patients with leukemia asked me when I was going home. “In an hour or 2, I hope,” I replied. She said she was happy that I finally would get some rest in my own bed. “You deserve it. And go shave—you look better without a beard!” she said.

My drive home was a slow one, although the streets of Miami were eerily calm. Not too many people were outside or even around, because most of the city had been evacuated. Some streets were either flooded or so strewn with debris that I had to change routes. Electricity was out in some areas and phone reception was spotty at best, but all in all, I thought, we dodged a bullet. All I cared about was a warm shower and few good hours of sleep. I made it home.

The next morning, I woke up to a phone call from the hospital— I had overslept. I dressed hastily and headed back to work. Just another day on the job. No glory or fame. Life of a doctor, I guess… As doctors, we are committed to certain things that most people do not even consider. We work at night, we work during holidays, we work on weekends, we work after hours, we work before hours, we work when everyone else evacuates to safety. We also leave behind our families, our loved ones, and our children to fulfll our duty to strangers, hoping that those we love will take care of themselves. It’s unfair, one might say, and it raises a lot of questions about the work that we do&mdash;questions such as “Why shouldn’t I be able to evacuate with my family?” and “Why should I be separated from my loved ones when it matters the most, to go take care of others?” It’s exhausting and makes you age quicker, plagued by guilt trips every time you think about it.

At the end of the day, that’s what makes our lives as doctors unique and, dare I say, brave. We fght for our patients and for their well-being every single day, rain or shine, hurricane or war. We do it not because we are forced to; we do it without questioning. We never ask if we should do it, for that’s a fait accompli; we ask what the best way to do it is.

I had so many questions leaving home the day of the hurricane, not knowing what I would return to, but I never questioned whether or not I should be at the hospital. It was my duty. I could say that doctors have a military-level commitment to their duty toward their patients. That makes us proud! At the end of the day, I made a diference for the fathers, mothers, brothers, sisters, cousins...everyone I took care of during the hurricane. Who knows, maybe I had a role in saving a life or two.

I hope that I don’t keep attracting disaster situations on my weekend call days. I am happy to pass the torch, but if I end up in another hurricane, I can say that I’ve seen enough to be ready!

Articles

Simon Abi Aad, MD, discusses caring for patients during Hurricane Irma.

Our Patients' Care Comes First, Even During Natural Disasters

Early on in my training, an email addressed to 16 physicians made its way to my in-box. Within the body of the message was the following statement: “Each of you are listed as coauthors because of your contribution of cases.”

What started of as a research idea under the supervision of 1 mentor and progressed to hours upon hours of data collection, periodic meetings, and synthesis of results was about to be presented as a collaborative efort that included 16 uninvolved individuals! I paused as I read the email and wondered if I could have asked for their help collecting data. That would have hastened the process quite a bit and legitimized the email. Nevertheless, the abstract was submitted with all additional 16 names. “This must have been a mistake!” I thought. “After all, how often do physicians accept credit for work they were not involved in?”

It was always my understanding that those listed as authors made a substantial, direct, and intellectual contribution to the work. In the case of medical authorship, that meant contributing to the conception, design, acquisition of data, and actual writing of the article. This was plausible when 2 or 3 individuals authored scientifc papers, as was the case from the late 1600s until the 1920s.

 However, in today’s world, in which a paper written by 1 author raises red fags and multiple authors are the norm, how plausible is it that 20 authors substantially contributed to an article?

To ensure some form of regulation, in 1979, the International Committee of Medical Journal Editors (ICMJE) established the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. These guidelines

 have been updated periodically and in their most recent format state that authorship credit should be based on (1) substantial contributions toward the work in areas of conception or design, acquisition, analysis, or interpretation of data; (2) drafting the article or revising it critically for intellectual content; (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.

 All 4 requirements must be met. These guidelines are adapted by hundreds of journals and form the ethical backbone of medical authorship.

In the shadow of fierce competition for government funding and institutional requirements for research, opportunistic behavior is rising and leaving in its wake what is called authorship abuse. This manifests in many ways, including coercive authorship, in which an author is listed simply because of senior status over junior investigators; honorary authorship, in which one is awarded authorship out of respect or friendship—also known as gift authorship; mutual support authorship, in which 2 or more investigators place their names on each other’s papers to increase their perceived productivity within the feld; and ghost authorship, in which the true author’s name is omitted from the paper for various deceitful or unjust reasons.

Authorship of scientifc papers is a mainstay of academic medicine. It does not take long for one to realize that the attraction toward the academic environment has its origins rooted in publishing. Unfortunately, the more time I spend in the academic setting, the more apparent it becomes that in order to publish, I would have to partake in academic misconduct. Perhaps I was naïve enough to have believed that the ethical principles of medical authorship are always upheld or that I can avoid the problem if I so choose. The problem is quite prevalent, as investigators of 1 study estimated that 141 out of 577 (39%) Cochrane reviews have evidence of dishonorable authorship.

The ethical principles surrounding medical authorship are clearly not being upheld in various realms of the scientifc community and appear to be the most tolerated form of unethical scientific conduct. So, what is the solution?

First, researchers need to realize that the net efect of authorship abuse is profoundly negative. Not only does it place authors who were not intimately involved in the work in a position of responsibility to defend it should the need arise, but, perhaps more importantly, it also discourages junior investigators from further pursuing research when their work is essentially hijacked by the addition of multiple noncontributors masquerading as collaborators.

Second, journals need to list the specifc contributions of each author and hold all authors accountable for the integrity of their product. This requires logical thinking when examining the number of authors per article. For example, it is unlikely that 10 to 15 authors are substantial contributors toward the conception, design, and drafting of a case series, retrospective study, or review article. If such a response is reported on the ICMJE form, it should be carefully examined and questioned before it is accepted as final.

Third, limit the number of authors for specific papers. This is more easily accomplished with review articles, editorials, and special communications but may be more difcult when applied to original research. An estimate of the number of authors should be applied based on study setting, patient size, and the expected amount of work required. For example, a single-center retrospective chart review of 100 patients is rarely the result of a collaborative effort by 20 authors. On the other hand, multi-institutional prospective clinical trials with thousands of patients are expected to have a larger number of authors.

Fortunately, most impactful journals do follow these guidelines and are keen on maintaining ethical conduct in medical journalism. However, for students, residents, and fellows to attain the highest standards of publication ethics, it is imperative that senior investigators and institutions not only support this endeavor but also consider establishing research policies that minimize authorship abuse. This ultimately will improve research integrity, quality, and productivity if all coauthors participated seriously in the work leading to publication. The attitude that “everyone does it” simply should not be tolerated.

After all, the goal of what we do revolves around the patient and not ourselves. We owe it to our profession to ensure that the ethical principles of medical authorship are honored and that there is just distribution of credit and acceptance of responsibility.

Greene M. The demise of the lone author. 

. 2007;450(7173):1165. doi: 10.1038/4501165a.

Onwude JL, Staines A, Lilford RJ. Multiple author trend worst in medicine. 

International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. 

1997;336(4):309-315. doi: 10.1056/NEJM199701233360422.

Recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals. ICMJE website. icmje.org/icmje-recommendations.pdf. Updated December 2017. Accessed March 8, 2018.

Strange K. Authorship: why not just toss a coin? 

2008;295(3):C567-575. doi: 10.1152/ajpcell.00208.2008.

Flanagin A, Carey LA, Fontanarosa PB, et al. Prevalence of articles with honorary authors and ghost authors in peer-reviewed medical journals. 

Eysenbach G. Medical students see that academic misconduct is common. 

Talal Hilal, MD, on the ethical principles of medical authorship and a just distribution of credit.

March 2018 | Oncology Fellows

Our Patients' Care Comes First, Even During Natural Disasters

Addressing a Crisis of Authorship Abuse