The purpose of ‘Discussion’ is to interpret the
meaning of results, justify their significance and suggest avenues for
further research. This section explains how the research questions or
hypotheses presented in the Introduction [1] have been addressed by the
results [2], and their impact on the understanding of the research
problem. Formulating the discussion requires analytic thinking for
synthesis and interpretation of findings and defining key messages that
emphasize the implications of research [3]. Drafting an articulate
discussion requires scholarly confidence and an ability to think and
write creatively. For the majority of authors, this section of the
research paper is the most challenging!
This article endeavors to simplify this seemingly
tough task by outlining its key components (Box 1). The
discussion is crafted around the following questions: What do the
results mean? How true and relevant are the findings? Why are they
important or unique? How does this study expand current knowledge? Do
they have any clinical implications? Is there a "take home message"?
Box 1
Key Components of Discussion |
• Opening paragraph: Summarize what was
done and what was found, e.g., "In order to determine the
genetic factors implicated in autism, we used next-generation
sequencing to examine 44 genes in 108 patients and 100 controls. We
found variations involving multiple genes ……"
• Limitations and strengths: Identify and
acknowledge the limitations, than to have them pointed out by the
reviewers. Discuss concerns of internal and external validity and
generalizability of the results. Mention positive attributes
(randomized trial, homogeneous population, large cohort, novelty)
without ‘claiming the first’ and sounding pompous.
• Subsequent paragraphs: Explain the key
findings, one by one. For each, summarize what was found and explain
how it confirms or refutes what is known on the topic. If there are
methodological differences or limitations in the present study,
discuss how they impact the results.
• In the next 1-2 paragraphs, focus on the
primary outcome. For example, if you found a novel mutation
associated with autism, describe the mutation, its population
frequency, and properties and function of the translated protein.
Discuss what is known about the gene and protein in relation to
brain development, and association with other diseases. Scholarly
references enhance the discussion.
• Concluding paragraph: Conclude with a
sentence each on the main finding(s) of the study and its clinical
relevance. Make focused suggestion for research that would further
improve the understanding of the disease or result in better
therapies.
|
Writing Discussion Section
Interpret and Highlight Importance of Results
The analogy of an inverted funnel is used to describe
the discussion; the flow of information goes from narrow (focused and
precise) to broad [4]. Therefore, the opening paragraph should be a
clear and succinct answer to the research question that was posed at the
end of Introduction [1,5]. Several illustrations highlight the
importance of a direct and explicit opening.
• In a recent paper in the NEJM, Hoberman, et
al. [6] begin the discussion as follows: "Antimicrobial
prophylaxis in children with vesicoureteral reflux diagnosed after a
first or second urinary tract infection was associated with a
halving of the risk of febrile or symptomatic recurrences.
Differences between the prophylaxis and placebo groups were apparent
early-on, and increased over a two-year period. Children with
bladder and bowel dysfunction at baseline and children whose index
infection was febrile derived particular benefit from prophylaxis,
with reductions in recurrences of approximately 80% and 60%,
respectively" [6].
• In a randomized controlled study in patients
with steroid resistant nephrotic syndrome, Gulati, et al. [7]
state: "Results of this trial show that treatment with tacrolimus
and alternate-day prednisone was effective and safe in inducing and
sustaining remission in patients with newly diagnosed,
steroid-resistant nephrotic syndrome" [7].
• A recently published randomized study in the
NEJM [8] begins the discussion as follows: "The results of
our trial showed that withholding parenteral nutrition for 1 week in
the pediatric ICU was clinically superior to providing early
parenteral nutrition; late parenteral nutrition resulted in fewer
new infections, a shorter duration of dependency on intensive care,
and a shorter hospital stay. The clinical superiority of late
parenteral nutrition was shown irrespective of diagnosis, severity
of illness, risk of malnutrition, or age of the child" [8].
Two additional points need emphasis. While the most
relevant findings are explained, how the results support the answer to
the research question should be defined at the beginning of the
discussion. Repetition of background information or results is
unnecessary and tedious. It also increases the length of the manuscript
and reduces reader interest. Secondly, the significance of the study
results may not immediately be as apparent to the readers, as it is to
the author who has devoted a significant amount of time to review the
literature, design and conduct the study, and analyze the data [5]. The
discussion should attempt to ensure that the readers grasp the
importance and uniqueness of the study the very first time they read the
manuscript. The central message and relevant findings should be
expressed convincingly enough not to be overlooked, even with a quick
reading of the discussion.
Acknowledge Limitations and Strengths
Authors can engage their readers effectively with a
balanced presentation that emphasizes the strengths but acknowledges the
limitations. One should consider all possible alternative reasons for
the study results, without being prejudiced to consider only those
explanations which support the proposed hypothesis. Secondly, while it
is relevant to address limitations on study design, methods or patient
number, their implication on validity of the results should be stated
[3,10]. Common concerns related to internal validity are issues related
to study design, measurement and statistical power. Threats to external
validity include sample bias and patient/sample characteristics that
limit generalizability of findings. The author(s) may present
counter-arguments to mitigate the limitations, or mention strengths to
end on a positive note [11].
As an example, while accepting limitations, Gulati,
et al. [7] state: "This study …. was not stratified on renal
histology, although there was equal distribution of histopathologies in
both arms. While the NIH trial was limited to patients with FSGS, we
also included patients with minimal change disease. Although not powered
for subgroup analysis, we found that therapy …. was effective in
patients with minimal change disease and FSGS. The strengths of this
adequately sized trial were that randomization, data collection, and
analysis were performed centrally. The baseline characteristics were
well balanced, and a widely accepted definition of steroid resistance
was used. Safety monitoring was ensured and nonresponders were managed
appropriately. The results of this study on children with initial and
late resistance and major biopsy diagnoses are therefore generalizable"
[7].
Challenge and Expand Scientific Knowledge: Relate to
the Literature
Subsequently, to broaden the scope of discussion
according to the inverted cone analogy, the research should be compared
and contrasted with other studies to add to existing knowledge [4].
Questions left unanswered by previous studies may have driven the
current research; all such work which support and strengthen the
authors’ findings should be comprehensively cited. However, a cluttered
description of all similar studies should be avoided. Earlier research
is best covered in a well-articulated manner, aiming to reflect a clear
set of ideas that enable logical conclusions. One technique is to
construct separate paragraphs for each salient finding, covering
relevant literature and concluding with a specific summary point [9].
While the key findings are discussed in this manner, care is taken to
avoid discussing each and every finding [3].
Appropriate and scholarly referencing is important to
validate the present research and credit the work of others [10]. While
results should be discussed in the context of similar findings from
prior reports, it is important not to overlook findings that are
contrary to published literature [5]. Conflicting results should be
mentioned with transparency, and an attempt to determine the cause(s) of
contrary data, which might include differences in design, methods and
patient population. If a reason for the difference is not found, this
should be acknowledged clearly.
Clinical Implications and Suggestion for Further
Research
The fundamental goal of all medical research is to
improve patient-care. Therefore, when applicable, practical and clinical
implications of the study should be included. Recommendations for
practice change may be offered [5]. In the study cited earlier [6], the
authors write: "We suggest that in early CKD clinicians should
understand the limitations of the creatinine-based equation, and
preferably use cystatin-C based equations" [6].
Next, the author should attempt to provide a specific
agenda of research that would further our understanding on the subject
[3]. While making such suggestions, it should be remembered that the
hypothesis that was tested, the outcome measures, and the statistical
analyses have nothing to do with the concept of requiring further
testing [10].
The "Take Home Message"
The discussion should conclude with a strong, concise
statement(s) that summarize the study. The content and tone of the
concluding sentences should be congruent with the rest of the
manuscript. The final perspective is presented, without overstating or
introducing any new information. The conclusion may also provide
suggestions for practice change, if relevant. In examples given above,
the concluding sentences were:
• "Therapy with tacrolimus and low-dose
prednisone should be preferred to cyclophosphamide as the
initial therapy for patients with steroid-resistant nephrotic
syndrome, as it is effective and safe in inducing and
maintaining remission of proteinuria" [7].
• "In conclusion, in critically ill children,
withholding parenteral nutrition for 1-week while administering
micronutrients intravenously was clinically superior to providing
early parenteral nutrition to supplement insufficient enteral
nutrition" [8].
Elements to Avoid When Writing the Discussion
Scientific writing needs to be objective, modest and
pragmatic. The results must be supported by data, and it is important to
not go overboard while interpreting the results [5]. While the overall
purpose of discussion is to justify the contribution made by this study
to scientific literature, the writing should not appear exaggerated or
pompous [5]. Large claims should be avoided; statements such as "first
time", "all the time", "wholly explains" might inflate the actual worth
of the results, and do not go well with the reviewers or readers (Table
I). The writing should be respectful and should not attack or
criticize past or contemporary researchers [5].
TABLE I Things to Avoid in Discussion
Avoid |
Comment |
Rewriting the results |
Do not restate your results; discussion should focus on
interpretation. Use bridge sentences that relate the result to
interpretation. |
Introducing new results |
Do not present new findings in discussion. |
Discussing every finding |
Emphasize the key findings in a lively, crisp manner that holds
attention; avoid tangential issues that distract readers. |
Lengthy text |
Length should be 20-25% of the overall text; avoid subtitles;
references should be contemporary and focused. |
Academic arrogance |
Avoid claiming priority and alluding to work that is not yet
completed. |
Criticizing other workers |
Findings that are contrary need to be handled professionally. |
Over interpretation |
Do not inflate importance or read more into the findings than
supported by the data. |
Unnecessary speculation |
Emphasize the part that is a speculation, and not supported by
data. Highlight need for further research. |
The discussion must focus on key messages that should
be defined beforehand; tangential issues tend to dilute the major
conclusion [5]. It is often tempting to report results of unplanned
analysis, deviating from the original hypothesis, when the primary
results are not as expected [10]. However, no new information should be
introduced in the discussion and results as obtained from the original
hypothesis must be reported as such. While discussion of data derived
from post-hoc analyses is acceptable and might serve as the trigger for
future research, it is useful to describe such issues with clarity for
the readers.
Coherent Communication of Key Messages
An efficient and stimulating discussion is one that
is written with the readership in mind. Most readers of medical
journals, have limited time for reading, therefore read rapidly and may
miss or misinterpret ideas at points that slow their reading [12]. This
also implies that readers should be easily able to follow the author[s]
train of thought, without having to decode or reconstruct the manuscript
[12]. Clarity of expression is crucial, and imprecise words are better
avoided. Authors should resist using complicated and less familiar
words, avoid wordiness and delete unnecessary adverbs or adjectives.
Phrases like "it is interesting to note that", "it is often the case
that", "has the capability to", "is of the opinion that" and "is unable
to" can be replaced by: interestingly, often, can, believes and cannot.
Brevity allows readers to capture more information in
a given time [13]. Vital ideas should be expressed by short and
well-constructed sentences that have more impact. Each paragraph should
convey a single major point which is clearly brought forward in the
first sentence, and the idea is then developed through the paragraph
[12]. Continuity must be ensured between paragraphs; sentences should be
ordered logically to ensure a smooth flow of ideas. Sub-sectioning
interrupts this flow; therefore the discussion is best written
unstructured, with transitions for moving between ideas [10]. Extensive
paragraphing that interrupts flow and hinders communication of the main
messages should be avoided. Clarity and conciseness often go
hand-in-hand: writing that focuses directly on a point and maximizes
meaning with minimum wordiness tends to be both clear and concise.
Perfecting the Discussion
The discussion invariably requires careful editing,
reconstruction and several rounds of writing attempts until real
messages emerge. Two strategies which help to overcome writing flaws are
described. A colleague, not involved in the manuscript, can be requested
to read and suggest areas that need clarity [11]. Another strategy is to
distance oneself from the first draft after writing it, regain some
objectivity, re-read the relevant literature and then review the
manuscript again. On returning to the manuscript, authors are bound to
discover flaws missed in the first draft [13]. Additionally, authors
should also consult the website of the concerned journal for additional
suggestions on writing the discussion e.g., use of sub-headings
or key messages in a text-box [14].
Practice makes perfect, and scientific writing is no
exception. A concise, convincing and meticulous discussion with
scholarly referencing is the key to a lasting impression.
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