---
name: nejm-workflow
description: Use when deciding which nejm-* sub-skill to invoke next, or when sequencing a clinical manuscript from significance test through response to reviewers for The New England Journal of Medicine. Routes — it does not replace — the specialized skills.
---

# NEJM Workflow Router (nejm-workflow)

## Overview

This is the router. It does not replace any specialized skill. It tells you **which nejm-* skill to use at the current stage** of a manuscript aimed at *The New England Journal of Medicine* (NEJM).

Default assumption: unless the user states otherwise, the target is **NEJM** (the flagship clinical journal), not *NEJM Evidence*, *NEJM AI*, or *NEJM Catalyst*. Those siblings share house style but differ in scope and audience — flag the difference if the user names one.

## When to trigger

- "What should I do next with this clinical manuscript?"
- A draft arrives and you must diagnose the current bottleneck.
- The user is switching between trial conduct, writing, and revision and has lost the thread.
- Reviews arrive from NEJM (often including a statistical reviewer) and you need to switch into response mode.

## The single most important gate

NEJM **rejects the large majority of submissions without external review**. The editorial bar is **practice-changing clinical impact backed by methodological rigor**, not merely a sound study. So the first question is never "is the analysis right?" — it is **"would this change how clinicians practice, and is it definitive enough to do so?"** Route to `nejm-fit` first, always.

## How NEJM differs from Lancet / JAMA / BMJ

- **NEJM**: famously **terse and plain**; Original Articles run a short main text (often ~2700 words); very high bar; **single-blind** review; favors large, definitive, practice-changing trials and landmark studies.
- **The Lancet**: similarly high bar, broader global-health and advocacy framing, structured abstract conventions of its own.
- **JAMA**: high bar with a strong structured-abstract and key-points discipline; large US clinical audience.
- **BMJ**: open-access, strong methods/registration culture, patient-partnership and open-data emphasis.

All four enforce ICMJE policy (trial registration, disclosures, data sharing), so the registration/reporting/ethics work transfers — but **format and tone do not**. Do not port a JAMA-styled manuscript across without re-styling abstract, references, and length.

## Article types (route by type)

- **Original Article** — definitive trials / major studies; full IMRAD; structured abstract.
- **Brief Report** — a smaller but important finding; shorter.
- **Review Article** — commissioned or vetted clinical synthesis.
- **Perspective / Editorial / Correspondence** — opinion and short-form; not original data.

## Routing table

| Current symptom                                                       | Next skill            |
|-----------------------------------------------------------------------|-----------------------|
| Not sure the result is practice-changing / definitive enough          | `nejm-fit`            |
| Trial not registered, or no protocol / statistical analysis plan ready | `nejm-study-design`  |
| Unsure which reporting checklist + flow diagram applies               | `nejm-reporting`      |
| No structured abstract; over 250 words; missing registration number   | `nejm-abstract`       |
| Main text bloated, over length, IMRAD unclear, discussion over-claims | `nejm-writing`        |
| P values without CIs; ITT unclear; subgroups over-interpreted         | `nejm-statistics`     |
| Need Table 1 / Kaplan–Meier / forest plot / CONSORT diagram done right | `nejm-figures-tables` |
| Missing IRB / consent / ICMJE disclosures / data-sharing statement     | `nejm-ethics`         |
| References not in Vancouver / ICMJE numbered style                     | `nejm-citation`       |
| About to submit; need a clinical preflight checklist                   | `nejm-submission`     |
| Received reviews (incl. a statistical reviewer) / an R&R decision       | `nejm-rebuttal`       |

## Default order

1. `nejm-fit` — clear the practice-changing / clinical-impact bar first
2. `nejm-study-design` — confirm registration + protocol + SAP and design rigor
3. `nejm-reporting` — pick the EQUATOR checklist and build the required diagram
4. `nejm-writing` — choose article type and hold the terse IMRAD form
5. `nejm-statistics` — CIs, ITT, multiplicity, pre-specified subgroups
6. `nejm-figures-tables` — Table 1, Kaplan–Meier, forest plots, CONSORT diagram
7. `nejm-ethics` — IRB, consent, ICMJE disclosures, data-sharing statement
8. `nejm-abstract` — structured ≤250-word abstract with registration number (late polish)
9. `nejm-citation` — Vancouver / ICMJE reference style (late polish)
10. `nejm-submission` — preflight (bundles cover letter + checklist templates)
11. `nejm-rebuttal` — after review

> `nejm-abstract` and `nejm-citation` are **late-stage polish**. Do not perfect the abstract before significance, design, and reporting are settled.

## Anti-patterns

- **Do not** skip `nejm-fit` and start polishing prose — the modal outcome is desk rejection.
- **Do not** start writing a trial up if it was **never prospectively registered** — route to `nejm-study-design` and surface that problem first.
- **Do not** draft a response to reviewers before the manuscript is actually revised.
- **Do not** assume Lancet/JAMA/BMJ formatting carries over unchanged.