---
name: nejm-writing
description: Use to structure and tighten an NEJM Original Article into terse IMRAD — short main text (~2700 words), limited references, claim-first results, and a sober discussion with explicit limitations and calibrated clinical implications. Enforces NEJM's plain, concise house style.
---

# Main-Text Writing (nejm-writing)

## When to trigger

- The main text is bloated, or you are unsure of the article type.
- The Discussion over-states the implications or omits limitations.
- The Introduction starts with a literature review instead of the clinical question.
- Methods detail belongs in the protocol/supplement, not the body.

## Article type first

- **Original Article** — definitive trials / major studies; full IMRAD; structured abstract.
- **Brief Report** — a smaller but important finding; substantially shorter; fewer items.
- **Review** — commissioned/vetted clinical synthesis (different structure).

Confirm length and reference caps against the current author guidelines. For an Original Article, design for a **short main text (often ~2700 words)** and a **limited reference list (on the order of ~40)** — NEJM is deliberately terse.

## IMRAD, the NEJM way

### Introduction (short)
Two to three paragraphs. State the clinical problem, the gap, and the specific question the study answers. End with the objective. No exhaustive background — move detail to references.

### Methods
Design, setting, participants (eligibility), intervention/comparator, randomization and blinding, outcomes (primary pre-specified, then secondary), and the statistical analysis (ITT primary; multiplicity; pre-specified subgroups). Push full procedural detail to the **protocol and supplementary appendix**; the body states what a clinician needs to judge validity. Reference the reporting guideline (CONSORT/STROBE).

### Results
**Claim-first, numbers-led.** Open with enrollment and the analysis population (tie to the CONSORT flow diagram). Report the **primary outcome with effect size + 95% CI**, then key secondary outcomes, then safety/adverse events. Do not interpret here — that is the Discussion. Tables carry the detail; text states the headline.

### Discussion
- Open with what the study found, in one or two plain sentences.
- Place it among prior evidence — without re-reviewing the field.
- State **clinical implications soberly**: what should change, for whom, and what should not.
- A dedicated **limitations** paragraph is expected (generalizability, open-label bias, follow-up duration, missing data, power).
- Do **not** over-state: avoid causal language for observational data; do not extrapolate beyond the population studied.

## NEJM house style (terse and plain)

- Short sentences; plain words; minimal hedging stacks.
- Define each abbreviation once; avoid acronym soup.
- Past tense for what was done and found; present tense for established facts.
- No "novel", "robust", "interestingly" as filler; let the numbers carry the claim.
- Active voice where it reads naturally; first-person plural is acceptable.

## Over-claiming watch (NEJM-specific)

The fastest way to lose a clinical reviewer is a Discussion that outruns the data. Match every implication sentence to the strength of the design: a single trial supports a conclusion in its population, not a universal recommendation. Surrogate outcomes do not license patient-outcome claims.

## Output format

```
【Article type】 Original Article / Brief Report / Review
【Main-text length】 N words vs target (~2700 for Original Article) → ok / over
【Reference count】 N vs ~40 cap → ok / over
【IMRAD check】 intro=question? methods→protocol? results claim-first+CI? discussion sober?
【Limitations paragraph present】 yes/no
【Over-claiming flags】 [...] (causal language / extrapolation / surrogate→outcome)
【Next】 nejm-statistics
```

## Anti-patterns

- **Do not** pad the Introduction into a mini-review — state the question and stop.
- **Do not** keep full procedural detail in the body when it belongs in the protocol/supplement.
- **Do not** interpret results inside the Results section.
- **Do not** omit the limitations paragraph or soften it into a throwaway sentence.
- **Do not** let the Discussion recommend practice changes the single study cannot support.