Review Article 

Scientific Misconduct (Fraud) in Medical Writing

Andreas F. Mavrogenis, MD; Georgios N. Panagopoulos, MD; Panayiotis D. Megaloikonomos, MD; Vassilis N. Panagopoulos, MD; Cyril Mauffrey, MD; Andrew Quaile, MD; Marius M. Scarlat, MD


Scientific misconduct (fraud) in medical writing is an important and not infrequent problem for the scientific community. Although noteworthy examples of fraud surface occasionally in the media, detection of fraud in medical publishing is generally not as straightforward as one might think. National bodies on ethics in science, strict selection criteria, a robust peer-review process, careful statistical validation, and anti-plagiarism and image-fraud detection software contribute to the production of high-quality manuscripts. This article reviews the various types of fraud in medical writing, discusses the related literature, and describes tools journals implement to unmask fraud. [Orthopedics. 2018; 41(2):e176–e183].


Scientific misconduct (fraud) in medical writing is an important and not infrequent problem for the scientific community. Although noteworthy examples of fraud surface occasionally in the media, detection of fraud in medical publishing is generally not as straightforward as one might think. National bodies on ethics in science, strict selection criteria, a robust peer-review process, careful statistical validation, and anti-plagiarism and image-fraud detection software contribute to the production of high-quality manuscripts. This article reviews the various types of fraud in medical writing, discusses the related literature, and describes tools journals implement to unmask fraud. [Orthopedics. 2018; 41(2):e176–e183].

Medical writing is necessary for science,1 as science “does not exist until it is published”2 and progresses via the publication of novel ideas and experiments. Scientific papers are written to share ideas, report research, express opinions and generate discussion, assert ownership of a topic, or enhance personal reputation. Medical writing has its own unique considerations: it should be easy to understand, should not confuse the reader, and should be formal (ie, adhere to rules). More important, medical writing should be ethical and should conform to the rules of scientific conduct.

Medicine essentially remains a career-driven discipline. Institutional support and research funding largely depend on prestige and prolificity. Therefore, pressure to publish becomes greater, with more emphasis on quantity than quality. Despite the existence of austere ethical standards, scientific misconduct (fraud) has increased significantly and become more widespread.3–8 Fraud may misdirect research and have serious consequences for authors, journals, and public health.



There are many definitions of fraud in medical writing.4–8 The Royal College of Physicians of Edinburgh defines research fraud as “the behavior by a researcher, intentional or not, that falls short of good ethical and scientific standard.”5 The United Kingdom's Committee on Publication Ethics describes fraud as the “intention to cause others to regard as true that which is not true.”6 The US Office of Research Integrity defines fraud using the fabrication, falsification, and plagiarism model as follows: “Research misconduct means fabrication, falsification, or plagiarism in proposing, performing, or reviewing research, or in reporting research results.”7 According to Protti,8 fraud may also have a legal point of view: “Scientific fraud is a deliberate misrepresentation by someone who knows the truth.” Fraud may be related to writing (editors and authors) and publishing (editors and publishers). Fraud in publishing is not the subject of this article.


When an article is submitted to a journal, the review process begins. The article is assigned to a deputy or associate editor or perhaps to a section editor. The editor quickly reviews the article to determine whether it merits peer review, falls within the journal's scope, and conforms to the rules of scientific conduct. If these requirements are met, the editor assigns the article to reviewers. If the topic is unimportant, the information is outdated, the scientific methods are faulty, the article is poorly structured and written, or bias or other ethical concerns exist, then the article is rejected without being assigned to reviewers.9

Editors are engaging in fraud if they (1) explicitly request that authors include citations to their journal in a submitted article's reference list, (2) consider citations to their journal when deciding whether to accept an article, (3) insist that authors reduce citations to competing journals, (4) use their journal to promote their own work, (5) publish effortlessly, or (6) publish too many introductory articles in their journal. Editors are not engaging in fraud and are being accountable to their journal and authors if they (1) bring to the attention of authors articles related to their work and suggest references, (2) provide structural comments and suggest up-to-date citations, and (3) write state-of-the-art articles on important topics based on their experience and scientific skills with the aim of raising awareness of and interest in their journal.


The first scientific journal appeared in 1665, and the citation of manuscripts began in 1752.1 Thousands of scientific journals now exist, and ranking them is difficult.

In 1955, Garfield10 described impact factor (IF) for peer-reviewed scientific journals. Impact factor equals the ratio of the number of citations in the current year to articles published in a journal in the 2 preceding years divided by the number of citable items published in the same 2 years.10 Source items (original research papers, technical notes, reviews, and papers presented as proceedings) compose the denominator of the IF equation.11,12 Nonsource items (letters, news stories, abstracts, book reviews, and editorials) are not included in the denominator of the IF equation but may be included in the numerator as a pool for citations.13–16 Editors and journals can take advantage of the simple calculation method of IF.15–19 An editorial manipulation is to increase non-source items with citations (the numerator), and to limit the total number of articles and/or the number of original papers and increase the number of reviews and/or technical articles that are more likely to be cited (the denominator). The arbitrary selection of a 2-year reference period has been the subject of much debate.20 The practice by some journals of pre-releasing details of accepted articles may allow citation before those articles go to press, increasing the immediacy of impact.18,21

There is a poor correlation between the IF of a journal in which an article is published and the number of future citations to that article.22–24 Self-citation (ie, referring to articles from the same journal), citation density (ie, the number of references listed in a journal), quality of citations of a journal (ie, mainly English-language publications), types of articles published (eg, topical papers or review articles), ease of access to journals, and publication immediacy are major limitations of IF.21–30 Regarding IF, a citation from a large, important journal is not more valuable than a citation from a smaller journal.31,32 Journals not listed in the Science Citation Index (SCI) database are often referred to as having no IF. Finally, IF is often misused to evaluate scientists, influencing decisions regarding awards, grants, scholarships, and fellowships.21,33,34 Such evaluation is best performed by experts in the subject matter.

Alternative metrics for ranking journals, based on publications or Internet use, have been introduced by bibliometricians. The SCImago Journal Rank indicator represents prestige awarded per article in the analyzed year.25 It is calculated for a 3 calendar-year period. A complicated formula computes the prestige gained by a journal through the transfer of prestige from all of its citations during the past 3 years to all articles of a specific journal published in the past 3 years. This is divided by the total number of articles of the specific journal during the 3-year period. The amount of prestige of each journal transferred to another journal in the network is computed by considering the percentage of citations of the former journal directed to articles of the latter journal.25,35 A major advantage of the SCImago Journal Rank indicator is that it allows for the estimation of a journal's prestige without the influence of self-citations, as prestige can be transferred to a journal by other journals but not by itself.25,35 Other advantages include the greater number of journals and languages included in its database and the unrestricted (open) access.25,36 A major shortcoming of the SCImago Journal Rank indicator is the sophisticated methodology used in the calculation of this index. Further, it divides the prestige gained by a journal through the citations of its articles by the total number of articles included rather than by the number of citable articles.25

The Eigenfactor score is based on direct citation counts.26,27,31 It is a ratio of the number of citations to the total number of articles. Unlike IF, the Eigenfactor score counts citations to journals in both the sciences and the social sciences, eliminates self-citations by discounting every reference from one article in a journal to another article from the same journal, and weighs each reference according to a stochastic measure of the amount of time researchers spend reading the journal.37 The frequency with which a researcher visits each journal gives a measure of the journal's prestige within its network of academic citations. This frequency, expressed as a percentage, is essentially the Eigenfactor score of the journal.26,27,31 The Article Influence score also reflects a journal's prestige. It is a journal's Eigenfactor score divided by the fraction of articles published by the journal.26,27,31,37

Recently, altmetrics (alternative metrics) have been introduced as science evaluation metrics for the evaluation of publications and researchers.38 Altmetrics are based on citation counts from scientific and social media. They also cover other aspects of the impact of scholarly work (eg, how many databases refer to it; number of article views, downloads, and mentions in social media and news media). One proposed classification of altmetrics includes the categories “viewed,” “discussed,” “saved,” “cited,” and “recommended.”39 Altmetrics, although in their infancy, might be worth trying. However, many believe that all scientific metrics are eventually abused.40 According to Goodhart's law, when a feature of the economy is picked as an indicator of the economy, it inexorably ceases to function as such, as people soon start to game it.40


Citations are very important. A reference list should not be an afterthought or an appendage. It is an integral part of an article. However, “the whole process of citing references is very idiosyncratic and a reflection of author biases.”41 Authors often give referencing light consideration: (1) less than 20% of cited papers are actually read by authors; (2) 3% to 60% (mean, >20%) of citations contain errors; (3) citations are often chosen for convenience rather than for appropriateness; (4) easily available papers (eg, open access papers and papers written in English) are most often cited; and (5) more than 25% of citations are standard references (eg, classic papers). To avoid fraud in this realm, authors should consider the quality of papers, rather than social or strategic factors, when choosing citations.41


Fraud in medical writing itself occurs in the forms of fabrication, falsification, plagiarism, authorship issues, image manipulation, and redundant publications.


Fabrication involves the reporting of results that are completely made up. It is the most common type of fraud in writing, and it is most frequently observed in medical/pharmacological research. Fabrication is sometimes referred to as “forging” or “drylabbing,”42 meaning the invention of some or all of the research data being reported and the presentation of experiments that were never performed.43 A minor form of fabrication involves using fake or unrelated references to give a sense of widespread acceptance to an argument. The Pearce affair, which involved researchers publishing a paper in which they claimed to have successfully re-implanted an ectopic pregnancy, may be one of the most striking examples of fabrication in medical writing.44 This was proven to be a complete figment of the imagination after a whistleblower came forward.


Falsification involves manipulating and willfully distorting research materials, methods, or equipment and/or altering or omitting data or results such that the actual research is not accurately reported. “Cooking” or “suppression” is a form of falsification involving selectively retaining and analyzing only the results that strengthen a research hypothesis, while concurrently ignoring data that might weaken or disprove the favored outcome.43 Another form is “trimming,” which refers to smoothing any data irregularity that would make the research results less convincing or less pertinent for publication.43 Examples of falsification are well-known.45–52 The Wakefield affair, known as the measles, mumps, and rubella vaccine controversy, is a striking example of combined fabrication and falsification.50–52 As a result of that paper and the publications that followed, many children worldwide did not receive the preventive measles, mumps, and rubella vaccination because of parental concern over a link with autism.53


The term plagiarism derives from the Latin “plagium,” meaning kidnapping.54 In writing, this refers to the practice of copying, or kidnapping, text. Plagiarism refers to the appropriation of the ideas, methods, results, or words of others without giving credit (ie, the use or reporting of another researcher's work or words should be adequately referenced). The US Office of Research Integrity defines plagiarism as “both the theft or misappropriation of intellectual property and the substantial unattributed textual copying of another's work.”55 The World Association of Medical Editors defines plagiarism as “copying 6 consecutive words in a continuous set of 30 used characters.”54,56 That is, if 6 or more consecutive words are used, they should be placed in quotation marks.

Common types of plagiarism are listed in Table 1.57–59 One example of plagiarism involved the case of a medical researcher who, before his lack of knowledge was exposed, managed to publish more than 60 papers in 3 years and to join 11 scientific societies by copying entire published articles.60–63

Common Types of Plagiarism

Table 1:

Common Types of Plagiarism


Consensus regarding the precise definition of authorship is paramount to avoiding the ambiguity that frequently surrounds contributions and to ensuring scientific integrity.64,65 Authorship issues related to fraud are listed in Table 2.66–76 The Darsee affair is a striking example of this form of fraud. A total of 55 articles, which were ultimately retracted, written by Darsee included his famous mentor, who had little knowledge of their content, as an author.66–69

Common Authorship Issues

Table 2:

Common Authorship Issues

An author must have made “substantive intellectual contributions” to a manuscript.64 Most journals currently adhere to the guidelines for defining authorship of the International Committee of Medical Journal Editors.64 The International Committee of Medical Journal Editors recommends that each author of a paper meet 4 explicit criteria (Table 3). In addition, the International Committee of Medical Journal Editors states that an author should be able to identify which coauthors are responsible for other specific parts of the work and should have confidence in the integrity of the contributions of the coauthors.65 All individuals designated as authors should meet all 4 criteria for authorship; conversely, all who meet the 4 criteria should be identified as authors. Those who meet fewer than all 4 criteria should be acknowledged. Activities such as acquiring funding, supervising a research group or providing general administrative support, and providing assistance with writing, editing, and proofreading do not necessarily qualify an individual for authorship.64

The International Committee of Medical Journal Editors Criteria64 for the Role of Author and Contributor

Table 3:

The International Committee of Medical Journal Editors Criteria64 for the Role of Author and Contributor

In most cases, the order of authors indicates, to some extent, the magnitude of contribution. The first author adds the most value. The last author has the most senior, predominantly supervisory role, although not always explicitly fulfilling the 4 aforementioned criteria. Honorary authorship is frequently used to obtain un-merited academic promotion or research funding and also takes advantage of junior researchers.75 On the other hand, junior researchers may use honorary authorship to improve the chances of their manuscripts being accepted for publication.76 This phenomenon is more widespread in Asia and Europe than in North America.75,77 Al-Herz et al,78 on surveying 1246 corresponding authors (response rate, 15.75%), reported that 33.4% admitted to adding individuals not worthy of being considered authors. Reasons for adding honorary authors included to be complimentary (39.4%), to avoid conflict at work (16.1%), to facilitate article acceptance (7.2%), and other (3.6%). In retrospect, 75% of the corresponding authors indicated that they would remove individuals not worthy of being authors. To minimize this phenomenon, many journals now request that authors include a list of their specific contributions on manuscript submission.

Image Manipulation

The widespread use of photo-editing software has given birth to yet another form of scientific misconduct—image manipulation. This type of fraud includes the following: (1) splicing different images together to represent a single experiment; (2) partially changing brightness or contrast; and (3) concealing information included in an image or showing only part of an image.79–83 A striking example involves a published paper that contained almost 20 separate instances of image fraud from a molecular experiment.84,85

Redundant Publications

Redundant publications occur when 2 or more papers share the same hypothesis, data, discussion points, or conclusions and do not disclose this at the time of submission.86–96 Common types of redundant publications are listed in Table 4.86–99 The classic type of self-citation is direct self-citation—an author citing his or her previous work in subsequent scholarly articles.97 On the other hand, in coauthor self-citation, 1 or more coauthors write subsequent papers without the previous primary author, citing their common work. These constitute direct self-citations for the coauthors but indirect ones for the primary author. A similar phenomenon on a larger scale, regarding larger groups of researchers, is termed collaborative self-citation.98 In coercive induced self-citation, the citing scientists are neither coauthors nor collaborators of the cited scientist. They are induced to cite a paper under some form of coercive pressure (eg, from peer reviewers or editors during manuscript revisions, grant reviewers, institutions, or other influential entities).99

Common Types of Redundant Publications

Table 4:

Common Types of Redundant Publications

If done occasionally, self-citation may be acceptable. It may be reasonable for authors to refer to their previous work if the publications resulted from a series of consecutive efforts in a specific field of research; the new paper reports a continuation of previous studies; the authors' contribution to the field of study is unique; or the previous publications include methodology used in the new paper. However, self-citation can be abused by some authors for altruistic reasons and for quantification of citations for their specific discipline and academic performance and by some editors in an attempt to increase the IF of their journal.100–104 An example of this involved an editorial published by a speciality journal in 2007 that cited all of its articles from 2005 and 2006. This editorial was intended to protest the IF game. It increased the journal's IF from 0.66 to 1.44. In its attempt to send a message, the journal was penalized by not being included in the 2008–2009 Journal Citation Reports.103,104


The scientific community has moved toward fraud prevention and detection. A robust peer-review process put forward by most scientific journals constitutes the first obstacle for potential fraud. Furthermore, regulatory bodies with established guidelines have been instituted around the world. In addition, whistleblowers are now protected by clauses of confidentiality. To avoid fabrication and falsification, many journals validate research results with a dedicated statistical analysis. Independent auditing tools and data verification algorithms have been instituted in an attempt to empower the peer-review and publication processes. Data analysis can be accomplished by obtaining raw, de-identified data and submitting them to a verification algorithm.105 One such algorithm uses the principle of Newcomb's law, according to which distributions found in nature are asymmetrical. As a result, the 10 digits do not occur with equal frequency. Thus, an unexpected preponderance of “non-natural” numbers should elicit further investigation.105 Another policy helpful in identifying fraud is to directly contact all coauthors of a manuscript. Direct contact is maintained with each coauthor throughout the peer-review process, helping to ensure that all played a role in manuscript preparation and assume responsibility for the accuracy of the content.

Editorial misconduct may be reduced by adopting free self-citation metrics and altmetrics.25,31,37–40,100,106–108 Plagiarism can be detected by software programs such as Turnitin (iParadigms, Oakland, California), SafeAssign (Blackboard Inc), CrossCheck (iParadigms), HelioBLAST (HelioText, Blacksburg, Virginia), and iThenticate (iParadigms). Forensic tools have been developed to detect image fraud. These include Forensic Droplets (Adobe Systems Inc, San Jose, California), Adobe Bridge (Adobe Systems Inc), and ImageJ ( http://imagej.nih.gov/ij). Forensic Droplets has been available on the Office of Research Integrity website since 2005.106 Further, the Office of Research Integrity has discovered several cases in which researchers used embedded formulae in an Excel (Microsoft Corp, Redmond, Washington) spreadsheet that calculated backwards (ie, a formula was used to calculate the raw data values based on the claimed final result). All of the formulae in a spreadsheet can be displayed by pressing the “Control” and “∼” keys simultaneously, and relatively simple software programs can be used to convert graphs and error bars back into spreadsheet values to verify them.107


Fraud is significant and widespread. To combat fraud, robust peer review, careful statistical validation, anti-plagiarism and image-fraud detection software, and better metrics to rank journals are required. Bad references will eventually be cited and may point scientific research in the wrong direction. In the current scientific environment of academic careers driven by prolificity, it is essential that researchers focus on quality.


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Common Types of Plagiarism

CloneSubmitting someone else's work, which is just transcribed, as one's own
Ctrl-CCopying most of the text from a single source, without alterations
Find-ReplaceChanging key words and phrases, but retaining a substantial part of the content of the primary sources
RemixParaphrasing multiple sources, which are arranged so as to complement each other
RecycleUsing one's own work (ie, the article has been published but not cited)
HybridCombining perfectly cited sources with material copied without citation
Mash-upBlending material copied from multiple sources
Error 404Quoting nonexistent or inaccurate sources
AggregationProperly citing sources, but including almost nothing from them
Re-tweetProperly citing sources, but using too much text from them
Citation plagiarism, citation amnesia, disregard syndrome, or bibliographic negligenceFailing to appropriately credit prior discoverers, so as to give an improper sense of priority
Matthew effect or Stigler's lawInadvertently reassigning credit from the original discoverer to a better-known researcher

Common Authorship Issues

Guest authorshipThe name of a well-known researcher is used to change the status of an article and increase the chances of publication
Gift authorshipAuthorship is offered as a gift to receive a gift in return, to encourage future collaborations, to maintain good relations, or to return a favor
Ghost authorship or ghostwritingSomeone other than the named authors makes a major contribution but is not included in the list of authors. Typically done to mask a contribution from the pharmaceutical industry, so as to hide a potential conflict of interest (synonymous with the presence of unethical conflicts of interest).
Coercion authorshipSuperiors with no direct involvement in a given research project demand to be or presume that they should be authors of an article originating within their department. The same principle applies when a senior researcher forces a junior researcher to include a gift or guest author.
Honorary authorshipCombined guest, gift, and coercion authorship

The International Committee of Medical Journal Editors Criteria64 for the Role of Author and Contributor

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work

Drafting the work or revising it critically for important intellectual content

Final approval of the version to be published

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

Common Types of Redundant Publications

Salami publishingDividing the results of a research project into a series of least publishable articles to maximize the number of potential publications
TemplatingUsing the same format or structure or similar phrasing without copying the ideas, methods, or science of a paper. Often used by inexperienced, non–English-speaking authors.
ShotgunningSimultaneously submitting the same research article to multiple journals (the Ingelfinger rule)
Self-citationCiting one's own work

The authors are from the First Department of Orthopaedics (AFM, PDM), National and Kapodistrian University of Athens, School of Medicine, Athens, Greece; the Department of Orthopaedic Surgery (GNP), University of Pittsburgh, Pittsburgh, Pennsylvania; the Department of Psychiatry (VNP), Washington University, St Louis, Missouri; the Department of Orthopaedic Surgery (CM), Denver Health Medical Center, Denver, Colorado; the Hampshire Clinic (AQ), Basing-stoke, Hampshire, England; and the Clinique St Michel (MMS), Toulon, France.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Andreas F. Mavrogenis, MD, First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri St, 15562, Holargos, Athens, Greece ( afm@otenet.gr).

Received: March 16, 2017
Accepted: June 19, 2017
Posted Online: January 29, 2018


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