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

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.

Triage gate log

Run this gate sequence on any incoming clinical draft before routing. Answer each in order; the first NO names the next skill. Keep the filled-in log with the manuscript so co-authors see why work is sequenced this way.

NEJM ROUTING TRIAGE — complete top to bottom, stop at the first NO
─────────────────────────────────────────────────────────────────
[ ] G1  Practice-changing? Would a clinician act differently on
        this result, and is it definitive enough to justify that?
        NO → nejm-fit (and consider a sibling journal instead)
[ ] G2  Prospectively registered, with protocol + SAP in hand?
        NO → nejm-study-design (surface this before any writing)
[ ] G3  Correct EQUATOR checklist chosen; flow diagram drafted?
        NO → nejm-reporting
[ ] G4  Main text terse IMRAD, near the ~2700-word Original
        Article norm, discussion free of over-claims?
        NO → nejm-writing
[ ] G5  CIs alongside P values; ITT stated; subgroups
        pre-specified and not over-read?
        NO → nejm-statistics
[ ] G6  Table 1 / Kaplan–Meier / forest plot / CONSORT diagram
        built to house conventions?              NO → nejm-figures-tables
[ ] G7  IRB, consent, ICMJE disclosures, data-sharing statement
        all present?                             NO → nejm-ethics
[ ] G8  Structured abstract ≤250 words with registration number?
        NO → nejm-abstract   (late polish only — after G1–G7)
[ ] G9  References in Vancouver / ICMJE numbered style?
        NO → nejm-citation   (late polish only)
ALL YES → nejm-submission; after reviews arrive → nejm-rebuttal

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.