Identify an appropriate topic that includes a decision point faced by primary care physicians and patients in the course of patient care, and is clinically important, with a sufficient literature base to support a review.
Identify a discussant who is a recognized authority on the subject and who has no disqualifying conflicts of interest.
Contact JAMA (Margaret Winker, MD; margaret.winker@jama-archives.org) to discuss the priority of the topic for JAMA, the potential discussant, and related issues such as any conflicts of interest and funding source.
Identify a patient with the condition who is willing to potentially have his or her medical history and interview published as part of an article in JAMA. Personal details are removed, but patients may still be identifiable to themselves and family members. The patient must sign the JAMA patient consent form and informed consent as required by the institution. If the primary care physician is interviewed, the physician also needs to complete the JAMA consent form.
For the patient case description, summarize the patient's history and physical examination, including the crossroads the patient faces; the disease status; pertinent physical findings, laboratory values, and diagnostic tests; patient's concerns or issues, including personal, socioeconomic, or environmental; and medications. The description should frame the clinical question to be addressed.
Interview the patient regarding the condition and clinical question, including what questions the patient has for the discussant, and provide a transcript of the interview for the discussant. Videotape or audiotape of the interview is useful for the Grand Rounds. The primary care physician may be interviewed and transcript provided as for the patient.
Develop the questions for the discussant to address.
Provide the materials to the discussant, including these instructions, the patient interview, and the questions, well before the Grand Rounds.
If the patient is inclined to do so, the patient should attend the Grand Rounds and ask questions.
At the Grand Rounds, the patient case description is presented followed by the edited patient interview.
The Grand Rounds question-and-answer session should be recorded and transcribed for the manuscript and provided to the discussant.
The discussant should prepare the manuscript including (in order): the title and author (including financial disclosures), word count of text only, an unstructured abstract no longer than 150 words, patient case description, patient interview, questions for the discussant, the review discussion itself, specific recommendations for the patient, the question-and-answer section (with references added as appropriate), references, and any tables and figures. Length of text only should be 3000-4000 words. The Clinical Crossroads organizers and conference date and location should be provided in the Acknowledgment.
The discussion should be based on a systematic review of the best available evidence, focusing on randomized controlled trials and meta-analyses whenever possible. Briefly describe search strategy and inclusion criteria. When discussing studies, include (where possible) study design, sample size, and relevant points about the study methodology; point estimates of risk ratios with 95% confidence intervals; absolute as well as relative rates and/or numbers needed to treat; and adverse events. A table of studies summarizing the available evidence is often helpful. When treatments are compared, approximate costs of treatment generally should be provided. Original illustrations may be developed by the JAMA Graphics Department, if appropriate, but JAMA generally does not republish tables or figures from other sources.
The discussion should consider the patient's perspective and refer to the patient wherever relevant, including what unique aspects of the patient's situation may affect particular diagnostic or treatment options (such as other medical conditions, allergies, ability to afford medications, or insurance status). The final section of the discussion (before the question-and-answer section) should include specific recommendations for the patient based on the best available evidence.
Funding sources for the conference and manuscript may be government, not-for-profit, or private and should be listed in the manuscript. Commercial funding sources are not acceptable.
The manuscript should be reviewed by the Clinical Crossroads organizers for completeness and editorial flow and by the patient if requested. If suitable, the discussant should then submit the manuscript to JAMA, along with completed authorship, copyright transfer, and conflict of interest forms; patient consent; any financial support received; and role of the sponsor.
The manuscript will undergo internal review and, if considered potentially appropriate for JAMA, sent for external peer review. If review supports pursuit of revision, the author will receive a revision letter from JAMA along with the reviewers' comments. The author is expected to revise the manuscript and provide a cover letter detailing the point-by-point responses to the requests for revision. There is no guarantee that the manuscript will be accepted for publication in JAMA.