• AFP Authors' Guide

    American Family Physician is a semimonthly, editorially independent, peer-reviewed journal of the American Academy of Family Physicians. AFP’s chief objective is to provide high-quality continuing medical education for more than 190,000 family physicians and other primary care clinicians. The editors prefer original articles from experienced clinicians who write succinct, evidence-based, authoritative clinical reviews that will assist family physicians in patient care. AFP considers only manuscripts that are original, have not been published previously, and are not under consideration for publication elsewhere. Articles that demonstrate a family medicine perspective on and approach to a common clinical condition are particularly desirable.


    Article Proposals

    Authors are strongly encouraged to discuss their article ideas with the editor before beginning work on a manuscript. This step allows tailoring of the topic to AFP’s needs and prevents content overlap with recently published manuscripts or articles in preparation. Authors must be able to demonstrate expertise in their area of interest or manuscript topic. Clinical reviews, editorials, and other submissions with medical student or other student authors are not considered for publication. Exceptions to this policy are FPIN’s Clinical Inquiries and Help Desk Answers, Photo Quiz, where students can be coauthors, and Letters to the Editor.  It is required that resident physicians, if involved with the manuscript, work with an experienced attending physician who should generally serve as first and corresponding author. We expect the experienced author to take the lead in evaluating the available evidence and writing the manuscript. An Author Credentialing Form should be completed and returned by the lead author when submitting an article proposal. We expect articles to be written by one to (at most) three authors. In our experience, including more than three authors leads to an uneven quality paper. Topic proposals should be submitted via email to afpjournal@aafp.org with the words “Article Proposal for AFP Editor” in the subject heading.

    Note: To avoid bias or the perception of bias, AFP will not consider manuscripts sponsored directly or indirectly by a pharmaceutical company, medical education company, or other commercial entity or those written by an author who has a financial relationship with or interest in any commercial entity that may have an interest in the subject matter of the article within the previous 36 months or in the foreseeable future.


    Articles and Departments

    Authors may submit manuscripts in one of the following categories. All articles should be submitted to Sumi M. Sexton, MD, Editor-in-Chief, via AFP's Editorial Manager online submission system, unless otherwise noted in this document. For detailed instructions on manuscript submission, see Submitting the Manuscript. Updated information about AFP's acceptance rates and timelines to publication is also available.

    Clinical Review Articles

    Most articles in AFP are evidence-based clinical reviews. AFP focuses on clinical conditions that are encountered frequently by practicing family physicians, with an emphasis on diagnosis and treatment of common, important diseases. Clinical reviews generally should be 1,500 to 1,800 words in length.

    AFP does not publish original research articles. Although case reports are not featured as articles, a brief case summary may be submitted in the form of a Letter to the Editor (see also Curbside Consultation and Diary of a Family Physician).

    Authors are expected to reply to published letters about their article, especially any that question the science involved. Failure to do so will disqualify an author from future publication in AFP.

    Curbside Consultation

    Curbside Consultation is a feature that addresses legal, psychological, and ethical issues physicians may encounter in their day-to-day practice. Each article contains a brief case scenario, followed by a commentary section written by one of our consultants who responds to the particular issue addressed in the case scenario. A collection of Curbside Consultation is available at http://www.aafp.org/afp/curbside.

    Authors may submit a case scenario and clinical question to Caroline Wellbery, MD, Associate Deputy Editor of AFP (afpjournal@aafp.org). Materials are edited to retain confidentiality. An expert clinician will provide a commentary in response to the question.

    Diary of a Family Physician

    AFP is pleased to bring back a beloved series from years ago, “Diary From a Week in Practice,” now titled "Diary of a Family Physician." The goal is to share experiences and foster a sense of camaraderie among readers.

    We’re looking for stories that provide a real-life flavor to day-to-day practice. These may reflect the broad range of experience in family medicine and diverse clinical settings (such as solo or group practice, rural, urban, hospitals, nursing homes, emergency department/urgent care, house calls, telehealth, residency programs, community health centers, universities). Submissions should be sent to afpjournal@aafp.org. From these submissions we will select a few regular authors along with some guest authors to ensure we are covering a full spectrum of family medicine. 

    Below are some examples of Diary entries published previously to serve as a guide, followed by some general principles on content:

    https://www.aafp.org/afp/1998/0101/p54.html

    https://www.aafp.org/afp/2005/1215/p2467.html

    Content focus:

    1. The joys and challenges of everyday family practice. The stories can incorporate perspectives on how practice was prior to the current pandemic and/or how day-to-day practice has changed.
    2. Clinical treatment tips (based on evidence, not anecdote or hearsay) with citation.
    3. Noteworthy personal experiences with patients and their families, reflecting our dedication to treating the whole person. Show by example how knowing a patient and/or their family made it easier to manage a medical problem.
    4. Diagnostic puzzles that can be addressed adequately in the space provided (perhaps with their Eureka! solutions).

    Some do’s and don’ts:

    1. Keep it short, simple, and personal. The length should be 100 to 200 (maximum) words per entry. Six to seven entries should be provided in a submission (representing different hours or patient encounters on a busy day in family medicine with the inclusion of an evening hour if appropriate to describe a longer day or interesting personal or family event).
    2. Avoid providing any information that might allow anyone to identify a patient. Ask for a signed permission when the diary requires details.
    3. Avoid any stories that promote a specific commercial product.
    4. Tell a story that speaks for itself. Avoid philosophizing or pontificating about a subject. Keep it concrete rather than abstract.
    5. First person is preferred when referring to yourself, but third person may be acceptable in certain cases, such as when referring to the patient.
    6. Avoid relating tales along the lines of "here's something I heard about, so I tried it and it seemed to work for me." We must keep this evidence-based: when relevant, please provide references to support any "here's what I did" practices. We don't want readers trying something questionable for their patients based on hearsay.
    7. Avoid writing about clinical scenarios that would require a lot of explanation or details about the evaluation and treatment because those scenarios are often too progress-note like and too long to fit in the provided space. 
    8. Avoid writing about political opinions. The focus should be on the clinical experience. Whereas diverse perspectives are welcome, the intent is not to start a political debate or to invite readers to question your views and the way you practice medicine.  

    Editorials

    Most editorials in AFP are solicited by the editors; however, freestanding editorials are occasionally accepted. Editorials should range from 250 to 750 words in length and may include six to 12 references. Submit editorials via email to afpjournal@aafp.org with the subject heading "Editorial."

    Letters to the Editor

    Letters to the editor are published in most issues of AFP. Some letters may be published online only; online letters will be listed in the table of contents of the print version. Authors may comment on a previously published article or present a freestanding letter on an important clinical topic. Letters should be fewer than 400 words in length, with a limit of one table or figure, six or fewer references, and no more than three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission.

    Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. Letters will be edited to meet style and space requirements. Send letters to Kenny Lin, MD, Associate Deputy Editor for AFP online (afplet@aafp.org). Letters submitted via regular mail should be sent to 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672.

    Photo Quiz

    Photo Quiz presents readers with a clinical challenge based on a photograph or other figure. Submissions should conform to AFP guidelines. Send submissions to Photo Quiz, AFP Editorial Office, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672 (afpphoto@aafp.org).

    Photo Quizzes should be original articles that have not been published previously and are not under consideration for publication elsewhere. Articles that demonstrate a family medicine perspective on and approach to a common clinical condition are particularly desirable.

    Authorship:

    Images:

    • Authors should submit original color photographs, slides, radiographs, or digital images that conform to the illustration guidelines outlined in "Figures" under Preparation of the Manuscript.
    • Figures should be original images. Do not obtain images from textbooks, journals, the Internet, etc. Acceptance of your Photo Quiz constitutes transfer of copyright.
    • They must be in focus and clearly show the feature you describe for readers.
    • If you add wording, arrows, etc., also provide a clean image for our production department to work with.
    • Each figure should be submitted as a separate digital file, not embedded in a Word document.
    • Photographs in which a patient is identifiable (i.e., the patient would be able to identify himself or herself) must be accompanied by a signed Consent for Publication form granting AFP permission to publish the photo. Please note that obscuring the eyes does not provide adequate anonymity.

    Text:

    The text of your Photo Quiz should include the following elements: 1) title, 2) introduction paragraph presenting the clinical scenario, 3) a question with one correct and three or four incorrect answers, 4) discussion of correct answer, 5) brief explanation of incorrect answers, and 6) a differential diagnosis table. The following are specific instructions for each element (view manuscript template):

    • The Photo Quiz department intends to help our readers improve their clinical skills through learning about common clinical conditions with visual components. The primary avenues for this are images (e.g., a skin rash), radiographs, sonograms, and ECGs.
    • Photo Quiz is not a case report. It uses case-based teaching to illustrate and educate on a common clinical topic. Two primary criteria for publishing a Photo Quiz are 1) the problem is commonly seen by practicing family physicians and 2) the image shows a typical example. Thus, we prefer images that show typical pathology or common variants rather than “once-in-a-lifetime” cases.
    • The title should hint at the diagnosis without giving it away.
    • The introduction paragraph presents the scenario that goes with the image. Include clinical information that would logically be included for the presenting complaint.
    • The question should be one to four sentences in length and contain the appropriate information needed to answer the question using the image. The question can be arranged in any of the following formats:
      • Reader chooses the correct diagnosis: “Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis?"
      • Your answer choices can include other physical findings, laboratory values, typical pathology, appropriate treatment, typical clinical course, appropriate treatment setting, etc: “Based on the patient’s history and physical examination, which one of the following (physical finding, laboratory value, etc.) is most likely?”
      • Reader chooses the appropriate treatment for the condition: “Based on the patient’s history and physical examination, which one of the following treatment options is most appropriate?”
    • Please provide one correct and three or four incorrect answer choices. Answers should come from an appropriate differential diagnosis for the condition you present.
    • The discussion of the correct diagnosis should cover important key features of the diagnosis, including defining features, epidemiology, and clinical findings. Begin with a short explanation of why the photo makes the diagnosis correct. Please limit your discussion to 300–500 words.
    • Follow your discussion with brief (one to two sentences) explanations of each incorrect answer, describing why they are incorrect or not typical of the photo.
    • Create a “Selected Differential Diagnosis” table listing your answer choices and key characteristics of each (view table template). Because some clinical presentations may have more than four or five possible diagnoses, you may include other key diagnoses in your differential table. However, please limit this to the most common diagnoses because we do not need to list every possible differential.
    • Please avoid discussing how you treated your particular patient or managed his or her disease course.

    Submit Photo Quizzes to:

    afpphoto@aafp.org
    11400 Tomahawk Creek Parkway
    Leawood, Kansas 66211
    Phone: 800-274-2237, extension 5104
    Fax: 913-906-6086


    Preparation of the Manuscript

    Literature Search and Data Sources

    In a short paragraph, please succinctly describe your search strategy, the key word(s) used, the date(s) of the search, and the data sources you accessed in identifying the highest quality evidence on your topic. By "data sources," we mean sources such as Cochrane, Clinical Evidence, and the National Guideline Clearinghouse. Do not list the actual references you found in each source; simply include them in your bibliography.

    We strongly recommend that you search the following freely accessible evidence-based sources of information and also consult our EBM Toolkit.

    Websites for Sources of Evidence-Based Clinical Information:

    Free Access Sites

    ACCESSSS

    McMaster University’s compendium of pre-appraised evidence to support clinical decisions.  Content is presented in a hierarchical way, with the highest level of available evidence listed first.

    Agency for Healthcare Research and Quality
    In particular, see AHRQ’s Effective Healthcare Reports on various clinical topics.
    Note: many of  these reports are published in AFP under the “Implementing AHRQ Effective Health Care Reviews” department collection.

    Cochrane Database of Systematic Reviews
    Free for abstracts only, which in most cases provide the key findings of interest. The complete review requires a subscription. The Cochrane database contains systematic reviews of narrowly focused clinical questions (e.g., “Colchicine for treating acute gout attacks”) as opposed to broad, general reviews of topics (e.g., “Management of an acute gout attack”).
    Note: AFP publishes summaries of Cochrane abstracts in “Cochrane for Clinicians.”

    ECRI Guidelines Trust

    Repository of evidence-based clinical practice guidelines, appraised using the National Academy of Medicine’s Standards for Trustworthy Clinical Practice Guidelines. 

    National Center for Complementary and Integrative Health
    Although NCCIH has been criticized for political interference and questionable science, we include it in this list because there are few freely available comprehensive sources of information in this field.

    Trip (Turning Research Into Practice)
    Contains links to a wide range of journal articles, medical organization clinical guidelines, online medical references, and other sources.  A limited version is freely available; additional content requires an annual subscription.

    U.S. Preventive Services Task Force
    Premier source of evidence-based, graded recommendations for clinical preventive services.
    Note: AFP publishes Recommendations and Reports from the USPSTF as well as CME case studies in the Putting Prevention Into Practice series.

    Subscription Required Sites

    Most of these are point-of-care clinical information and decision support tools. These sites provide important background information, but authors should review the primary source to use as a citation for the article.

    DynaMed

    Essential Evidence Plus
    Includes POEMS (collections of patient-oriented evidence that matters).

    Natural Medicines Comprehensive Database
    Reviews of the use of natural medicines in the treatment of various diseases.

    Natural Medicines
    Database of dietary supplements, natural medicines, and complementary, alternative, and integrative therapies.

    PEPID

    UpToDate

    To ensure adequate searching on your topic, we strongly recommend that  the above sources be reviewed, in addition to a PubMed search using the Clinical Query function. This is done by using the provided link, or by going to the PubMed home page, and selecting “Clinical queries” from the lower center of the screen.

    Sample Data Sources paragraph:

    Data Sources: A PubMed search was completed in Clinical Queries using the key terms gout and hyperuricemia.  The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were the Agency for Healthcare Research and Quality Effective Healthcare Reports, the Cochrane database, DynaMed, and Essential Evidence Plus. November 18, 2017.

    Manuscript Format

    Manuscripts formatted to conform to the “Uniform requirements for manuscripts submitted to biomedical journals1 are acceptable for submission. AFP endorses these guidelines. Format the manuscript with margins of 1 1/2 inches on all sides. Double-space the entire manuscript, including components, and arrange the manuscript in the following sequence, with each section beginning on a new page:

    • Title page
    • Abstract
    • Text
    • Literature Search and Data Sources
    • References
    • Tables, including an Evidence Table (each table begins on a new page)
    • Figures
    • Acknowledgments
    • Biographic sketch

    The title page, abstract, text, references, and tables should be contained in a single word processor document, ideally in Microsoft Word (DOC) or Rich Text Format (RTF). The acknowledgments and the biographic sketch should be in a separate file in order to accommodate blinded peer review. Each figure should be submitted as a separate computer file as described in this document under Figures.

    Number pages consecutively in the upper right-hand corner, beginning with the title page. To accommodate blinded peer review, place the names of authors only in the biographical sketch for each author. See the section on Submitting the Manuscript for details on how to submit your manuscript to AFP.

    Please carefully review the detailed instructions for each section that follows:

    Title Page

    This page should contain only the title of the manuscript and the word counts (word count for the entire manuscript and word count for text only--excluding abstract, references, tables, figures). This is to facilitate blinded peer review of the manuscript in the Editorial Manager system. Pertinent information such as names of authors, institutional affiliation, and contact information is entered into Editorial Manager by the authors and will be placed in a pre-formatted cover sheet for editorial use.

    Sources of support in the form of grants, equipment, or drugs should be mentioned in the Conflict of Interest Form; this information will be included as a footnote to the article. For details, see the Conflict of Interest section.

    Abstract

    Include an abstract of 150 to 250 words, depending on the length of the text. The abstract should provide factual and specific (rather than general and nonspecific) information summarizing the main points of the manuscript. For example, instead of saying, “This article will describe the differential diagnosis of chest pain in adolescents,” say, “The most common causes of chest pain in adolescents include musculoskeletal strain, hyperventilation syndrome, and anxiety.” For clinical reviews, highlight key points in the diagnosis and treatment of the condition discussed.

    Text

    Article length should be 1,500 to 1,800 words (maximum 2,000 words, about six to eight manuscript pages of text), not including the title page, abstract, tables, reference list, etc. Manuscripts of more than 2,000 words of text are rarely accepted.

    Do not include a summary or conclusion section in your manuscript; anything that you would ordinarily put in such a section should go into the abstract.

    Provide appropriate reference citations to support key clinical recommendations, statistical information, reports of previous studies, controversial statements, etc. Use the following guidelines in choosing references:

    • Avoid citing other clinical review articles—you should emphasize original research articles, systematic reviews, Cochrane Library reviews, citations from BMJ’s Clinical Evidence, validated clinical decision rules, randomized trials, and evidence-based practice guidelines where possible. Clinical review articles may be cited as sources for tables, figures, or general background information.
    • Emphasize recent references (within the past 10 years); in general, avoid letters to the editor, editorials, and references that are older than 10 years or of historic interest only.
    • Avoid references from obscure or non–English-language journals.
    • Do not cite abstracts, unpublished observations, manuscripts in preparation or submitted for publication, or personal communications.
    • To avoid plagiarism, do not to use the language, content, or concepts of another source without an appropriate reference. Do not use extensive verbatim or near-verbatim portions of text from another source, even with appropriate citation.

    Begin the writing process by identifying key clinical questions and controversies related to your topic, and then answer them with the best available evidence. Do not write the article and then find selected references to support your opinions!

    References

    Please number references in the text in the order of citation. Use double-line spacing in your reference list; arrange references numerically, not alphabetically. Do NOT use "Endnotes" or any other automated reference function in any word processor.

    Titles of journals should be abbreviated according to the style used in PubMed. If there are six or fewer authors, list them all; if there are more than six, list the first three followed by "et al." Please note that no periods are used after the authors’ initials. Include beginning and ending page numbers for journal and book references. The average number of references for a full-length article ranges from 15 to 30. Most articles will not exceed 35 references.

    References first cited in tables or figure legends must be numbered to remain in sequence with references cited in the text. Note the following examples of reference style:

    Standard Journal Article

    1. Weiss BD. Nonpharmacologic treatment of urinary incontinence. Am Fam Physician. 1991;44(2):579-586.
    2. Gold D, Bowden R, Sixbey J, et al. Chronic fatigue. A prospective clinical and virologic study. JAMA. 1990;264:48-53.

    Chapter in a Book

    1. Murray JL. Care of the elderly. In: Taylor RB, ed. Family Medicine: Principles and Practice. 3rd ed. New York, NY: Springer-Verlag, 1988:521-532.

    Website

    1. BMJ Publishing Group. Clinical evidence on tinnitus. Accessed November 12, 2013. http://www.clinicalevidence.com 

    Tables

    Authors should maximize the educational value of tables. Give complete reference data for each item in a table. For all tables that are borrowed or adapted from other sources, include scanned photocopies of the tables as they appeared in the original source, making sure that complete reference data are included for the original source.

    Do NOT attempt to obtain reprint permission from the original publisher. AFP will seek permission from the copyright owner to publish the material in print and other formats. However, it is possible that the rightsholder will not grant permission for use of copyrighted materials, and AFP reserves the right to withhold tables or figures from print and other formats based on the rightsholder’s terms. Due to the increasing difficulty with obtaining permission to adapt previously published material, we strongly encourage authors to create original tables and figures. See Tips for Creating Original Tables and Algorithms and How to Create an Algorithm in WordNote that tables and figures that were previously published, and for which we obtain reprint or adaptation permission, must be removed from AFP articles sent to content aggregators, such as EBSCO and MDConsult.

    Tables should be interpretable without reference to the text. Each table should have a title and be numbered sequentially with Arabic numerals. Put each table with double-line spacing on a separate page. Use the “Tables” function of your word processor to create the table rather than just using spaces and tabs (which quickly get out of alignment as the manuscript is transferred into other computer formats). In general, make tables part of your main document rather than creating a separate file for each table.

    For tables that include drug pricing, please use information from GoodRx to find representative undiscounted prices, not using GoodRx coupons.

    Clinical Decision Tools: Please mention and include links to relevant clinical decision tools and calculators, especially those published in AFP’s Point-of-Care Guides and on the medical calculator website MDCalc.

    Costs of laboratory tests, imaging studies, and clinical procedures: Where relevant, please include approximate, representative costs for tests or procedures, especially in tables where comparative cost is discussed.  We use Healthcare Bluebook as the source for pricing when possible: https://www.healthcarebluebook.com.  If you use another source, please provide a complete citation for it.

    SORT: Evidence Table of Key Clinical Recommendations

    We would like each article to include an Evidence Table (also called “SORT” or “Strength of Recommendations Table”). This table will help readers understand the main points of your article, and the strength of evidence that supports its recommendations. The table should contain the key clinical recommendations and strength of recommendation ratings for your article as shown in the sample below:

    CLINICAL RECOMMENDATION EVIDENCE RATING COMMENTS
    Obtain an ECG in patients presenting with chest pain.1,2 C Recommendation from consensus guideline based on observational studies
    Patients with two normal highly sensitive troponin tests an hour apart can safely be sent home.10 B Meta-analysis of randomized trials
    Patients with chest pain should immediately receive oxygen and if not allergic an aspirin tablet.17,18 A Consistent findings from randomized controlled trials and recommendation from evidence-based practice guideline

    ECG = electrocardiogram.

    A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

    The SORT table is intended to highlight the most important three to seven recommendations from your article for clinicians. Each recommendation must be accompanied by a SORT rating of A, B, or C. Your recommendations should emphasize interventions and approaches that improve patient-oriented outcomes (e.g. morbidity, mortality, quality of life) over disease-oriented evidence (e.g. biomarkers, surrogate endpoints).

    • You should have three to seven recommendations. Try to identify a range of recommendations, for example, one each about screening, prevention, diagnosis, and two about treatment.
    • Each statement should be in the form of a recommendation and should not just present a fact or piece of medical trivia. For example, “Use the Wells score to determine the risk of DVT in patients with leg pain” is a recommendation, while “Of patients presenting with leg pain, 16% have a DVT” is not.
    • An “A” recommendation should be based on consistent evidence of improved patient-oriented outcomes from well-designed studies. Use clear, directive language as this is a recommendation that should be applied to most patients, such as “Patients age 50 to 74 years should receive screening for colorectal cancer." 
    • A “B” recommendation is based on lower quality evidence of improved patient-oriented outcomes or inconsistent evidence. These statements should use language such as “Consider…” or “…is a practice option” or “…may be effective.”
    • A “C” recommendation is often something that is standard of care, but for which there have been no clinical trials or trials have only reported disease-oriented outcomes. In this case, the recommendation statement should reflect the strength of recommendation, and the “Comment” column should clarify that this is a recommendation “based on expert opinion in the absence of clinical trials” or “based on evidence from clinical trials with blood pressure reduction as the outcome.”

    If you are not comfortable assigning the strength of recommendation (below), our medical editors will do that for you.

    To rate the strength of evidence supporting key clinical recommendations, please use the following guidelines:

    STRENGTH OF RECOMMENDATION DEFINITION
    A Recommendation based on consistent and good quality patient-oriented evidence*
    B Recommendation based on inconsistent or limited quality patient-oriented evidence*
    C Recommendation based on consensus, usual practice, expert opinion, disease-oriented evidence,** and case series for studies of diagnosis, treatment, prevention, or screening
    * Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life.
    ** Disease-oriented evidence measures intermediate, physiologic, or surrogate endpoints that may or may not reflect improvements in patient outcomes (e.g., blood pressure, blood chemistry, physiological function, and pathological findings).

    Use the table below to determine whether a study measuring patient-oriented outcomes is of good or limited quality, and whether the results are consistent or inconsistent between studies:

    Type of Study
    STUDY QUALITY DIAGNOSIS TREATMENT/PREVENTION/SCREENING PROGNOSIS
    Level 1 Good quality patient-oriented evidence Validated clinical decision rule Systematic review/meta-analysis of randomized controlled trials (RCTs) with consistent findings Systematic review/meta-analysis of good quality cohort studies
      Systematic review/meta-analysis of high quality studies High quality individual RCT + Prospective cohort study with good follow-up
      High quality diagnostic cohort study * All or none study ++  
    Level 2 Limited quality patient-oriented evidence Unvalidated clinical decision rule Systematic review/meta-analysis of lower quality clinical trials or of studies with inconsistent findings Systematic review/meta-analysis of lower quality cohort studies or with inconsistent results
      Systematic review/meta-analysis of lower quality studies or studies with inconsistent findings Lower quality clinical trial + Retrospective cohort study or prospective cohort study with poor follow-up
      Lower quality diagnostic cohort study or diagnostic case-control study * Cohort study Case-control study
        Case-control study Case series
    Level 3 Other evidence Consensus guidelines, extrapolations from bench research, usual practice, opinion, disease-oriented evidence (intermediate or physiologic outcomes only), and case series for studies of diagnosis, treatment, prevention, or screening.

    * High quality diagnostic cohort study: cohort design, adequate size, adequate spectrum of patients, blinding, and a consistent, well-defined reference standard.
    + High quality RCT: allocation concealed, blinding if possible, intention-to-treat analysis, adequate statistical power, adequate follow-up (> 80%).
    ++ An all-or-none study is one where the treatment causes a dramatic change in outcomes, such as antibiotics for meningitis or surgery for appendicitis, which precludes study in a controlled trial.

    Consistency Across Studies
    Consistent

    Most studies found similar or at least coherent conclusions (coherence means that differences are explainable). 

    or

    If high quality and up-to-date systematic reviews or meta-analyses exist; they support the recommendation.

    Inconsistent

    Considerable variation among study findings and lack of coherence. 

    or

    If high quality and up-to-date systematic reviews or meta-analyses exist, they do not find consistent evidence in favor of the recommendation.

    Please use the following algorithm for determining the strength of a recommendation based on a body of evidence (applies to clinical recommendations regarding diagnosis, treatment, prevention, or screening). Although this provides a general guideline, authors and editors should adjust the strength of recommendation based on the benefits, harms, and costs of the intervention being recommended. Again, if you are unsure how to apply these ratings, the medical editors will do this for you. At a minimum, you should create a summary table with recommendations and references for each recommendation.

    For more information on how to apply these ratings, please see the explanatory article published in the February 1, 2004, issue of American Family Physician.

    Figures

    AFP encourages the submission of original figures that clarify the text. The term "figures" refers to illustrations, photographs, radiographs, scans, sonograms, diagrams, graphs, flow charts, algorithms, etc. AFP requires authors to transfer copyright ownership of original figures to the AAFP. For all figures that are borrowed or adapted from other sources, include scanned photocopies of the figures as they appeared in the original source, making sure that complete reference data for the original source are included. Clearly identify figures that have not been previously published and are supplied by a person other than the author and include complete contact information for the owner of the material. For figures supplied by your institution or a colleague, clearly indicate whether that institution/person is retaining copyright (in which case we will need to contact them) or whether copyright is being transferred to AFP with the article.

    Do NOT attempt to obtain reprint permission from the original publisher. AFP will seek permission from the copyright owner to publish the material in print and other formats. However, it is possible that the rightsholder will not grant permission for use of copyrighted materials, and AFP reserves the right to withhold tables or figures from print and other formats based on the rightsholder’s terms. Due to the increasing difficulty with obtaining permission to adapt previously published material, we strongly encourage authors to create original tables and figures. See Tips for Creating Original Tables and Algorithms and How to Create an Algorithm in WordNote that tables and figures that were previously published, and for which we obtain reprint or adaptation permission, must be removed from AFP articles sent to content aggregators, such as EBSCO and MDConsult.

    Each figure should be submitted as a separate digital file and numbered sequentially as it appears in the text. Diagnostic images (e.g., ECGs, sonograms, radiographs), artwork, line drawings, and nondigital photographs should be scanned at a resolution of at least 600 DPI before submission and saved as TIFF files. Only the following file formats are acceptable; others will be returned to the author for reformatting and resubmission.

    • TIFF (Tagged Image File Format)
    • PowerPoint (acceptable only for tables or algorithms; not acceptable for imported images)
    • JPG (only high-resolution images of at least 300 pixels or dots per inch [ppi or dpi])

    Image resolution is typically measured in pixels per inch, or ppi (some use the term "dots per inch," or dpi). The image’s resolution and its dimensions determine the overall file size of the image, as well as the quality of the output. Images with a resolution of 72 ppi (28.35 pixels per cm) are adequate for materials posted on the Web; however, this resolution is inadequate for print media. If your file size is less than 200 kb, it is almost certainly of too low a resolution for a print journal. For color and grayscale images of 3 to 5 inches, we recommend a resolution of 300 ppi (118.11 pixels per cm). Line drawings in black and white require a higher resolution of 600 ppi (236.22 pixels per cm). An image generated by a digital camera as a 72 ppi JPEG file may still be acceptable if it measures at least 14 inches wide or high.

    We strongly prefer original photographs/images because images downloaded from websites or taken from other publications rarely reproduce well, even if we are able to obtain permission to reprint them.

    Because the quality of original illustration varies, it may be necessary to have the art you supply redrawn to meet AFP’s artistic standards. AFP’s art department is available to assist authors in the creation of original, high-quality artwork to illustrate manuscripts accepted for publication. This service is provided at no charge to authors but is subject to editorial judgment.

    Other guidelines for artwork include the following:

    • Symbols, lettering, and arrows in figures should be clearly marked and large enough to remain legible if the size of the illustration is reduced for publication.
    • Photographs in which a patient is identifiable MUST be accompanied by the patient’s written permission for publication. "Identifiable" means that the person in the photo (or a parent of a child subject) could reasonably be expected to recognize himself/herself. A bar obscuring the eyes does not provide adequate anonymity and is not acceptable [see NEJM, August 24, 1989, p. 550].
    • Because of the poor quality inherent in reproducing previously published images, photographs and radiographic images from textbooks and journals cannot be reproduced in AFP, regardless of whether permission has been obtained from the publisher.
    • Do not save images within a Microsoft Word or PowerPoint document or use the “Drawing” features of your word processor.
    • The legends for each figure should be typed with double-line spacing and combined on a separate page at the end of the manuscript.

    If you are submitting figures in digital format, save each figure as a separate file. Each file should be saved with a name that includes the AFP manuscript number and figure number as referenced in the manuscript. Files should be uploaded at the time of manuscript submission in AFP's Editorial Manager site and clearly labeled.

    Acceptance of a manuscript for publication is contingent on provision of artwork that meets the above specifications. If you have any questions about the preparation of art or digital images for your manuscript, contact Dave Klemm, AFP Medical Art Coordinator, at afpjournal@aafp.org. After your manuscript has been accepted for publication, address questions about art to the medical editor.

    Acknowledgments

    You may acknowledge professional help in the preparation or review of your manuscript. Written permission is required to publish the names of persons acknowledged. See Author Statements Form.

    Biographic Sketch

    Please complete a brief Biographic Sketch form for each author, which includes information on medical training, current position, and academic appointments.

    Author's Guide References

    1. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. http://www.icmje.org/index.html. Accessed June 17, 2010.

    Style Guidelines

    1. Headings. Use ALL CAPITALS to indicate major sections of a paper, and Initial Capitals to indicate subsections.
    2. SI units. Include SI units in parentheses after conventional units (https://jamanetwork.com/journals/jama/pages/instructions-for-authors).
    3. Measurements. Do not put periods after metric measurements (e.g., 3.5 mmol per L, 11.6 mg per kg).
    4. Numbers. Spell out numbers one through nine. Use numerals for 10 and higher. Exception: Always use numerals in dosages, percentages, degrees of temperature, and metric measurements.
    5. Drug names. Use the generic name for all drugs. Include the trade name in parentheses after the first mention of a drug in the text. Trade names used in AFP are the first brand approved. If a drug is not available in the United States, indicate so in parentheses after the name.
    6. Abbreviations. Except for units of measurement, abbreviations are discouraged. When first used, an abbreviation should be preceded by the words for which it stands.
    7. Percentages. Use the percent sign (%) rather than the word “percent."
    8. Style questions. For questions about medical writing style, consult the American Medical Association Manual of Style.1 
    9. Formatting text. Note the following general text formatting guidelines: (1) do not justify the right margin; (2) do not use bold print or italics; and (3) use a single, standard typeface of letter quality, such as Times New Roman or Arial 12 point.

    Author's Guide References

    1. Christiansen S, Iverson C, Flanagin A, et al. American Medical Association Manual of Style. 11th ed. Oxford University Press, 2020.

    Submitting the Manuscript

    Please submit the manuscript via AFP's Editorial Manager system. The following file formats are acceptable:

    • Microsoft Word (DOC or DOCX) [preferred]
    • Rich Text Format (RTF)
    • Word Perfect (WP5)

    View thorough instructions for submitting the article in Editorial Manager. These instructions show how to create a login and password for first-time users and explain each stage of the submission process in detail.

    Please see the guidelines regarding figures for information on file formats for art work and photographs. Remember that figures should not be embedded in the word processor document or created using the “Drawing” tools of your word processor.


    Author Statements

    Manuscripts submitted for publication must be accompanied by an Author Statements Form signed by all authors. This form includes an authorship statement, a copyright transfer statement or a statement of federal employment, and an acknowledgment statement. The signed form should be scanned and submitted in Editorial Manager or should be faxed to 913-906-6086.

    Copyright Transfer

    Each author who was not an employee of the U.S. federal government during preparation of the manuscript must sign the copyright assignment statement in the Author Statements Form, which assigns, transfers, and conveys all rights, title, and interest in the work and its accompanying original tables and figures (photographs, radiographs, scans, sonograms, diagrams, graphs, flowcharts, algorithms), including copyright ownership, to the AAFP in the event that the work is published by the AAFP. All accepted manuscripts become the permanent property of the AAFP and may not be published elsewhere without written permission from the AAFP.

    Federal Employment

    Each author who was an employee of the U.S. federal government during preparation of the manuscript must sign the statement of federal employment in the Author Statements Form, which indicates that the work is not protected by the Copyright Act and that no copyright ownership can be transferred.

    Acknowledgment

    The corresponding author must sign the acknowledgment statement in the Author Statements Form, which affirms that all persons who have made substantial contributions to the work but who are not authors have been named in the acknowledgment and have given their written permission to be named.


    Conflict of Interest Policy

    The AAFP requires all authors to disclose any commercial association that might pose a conflict of interest in connection with the submitted manuscript. Each author must sign the Conflict of Interest Form, with any financial interest or arrangement disclosed in a separate attachment. To avoid bias or the perception of bias, AFP will not consider manuscripts sponsored directly or indirectly by a pharmaceutical company, medical education company, or other commercial entity or those written by an author who has a financial relationship with or interest in any commercial entity that may have an interest in the subject matter of the article within the previous 36 months or in the foreseeable future. It also includes serving on a commercial speaker’s bureau or advisory board or receiving commercial research support related to the subject matter of the article, as well as other relationships detailed on our conflict of interest form. If you have any questions about this policy, please contact us first, so as to a avoid writing an article that we will not be able to consider. Manuscripts that are not accompanied by Conflict of Interest forms signed by all authors will not be considered for peer review.

    All funding sources supporting a work should be acknowledged on the title page of the manuscript. The editorial staff may inquire further about financial disclosure after the manuscript is submitted. If the manuscript is accepted for publication, any nondisqualifying financial disclosure or potential conflict of interest will be acknowledged at the end of the manuscript text.


    Manuscript Processing and Review

    Acknowledgment and Manuscript Number

    When the manuscript is initially submitted, the corresponding author will receive an automated email from the Editorial Manager system with a notification that the manuscript has been received. After it has been processed by editorial staff, the corresponding author will receive an automated email from Editorial Manager that contains the manuscript number. Please refer to this number in any communication about the manuscript. Details about timelines of the various stages of review can be found within an updated report of AFP's acceptance rates.

    Peer Review

    Manuscripts are initially reviewed by the editors for suitability and adherence to the guidelines. Acceptable manuscripts are reviewed by at least one family physician and one expert in the subject discussed. The latter may be a family physician or a subspecialist in another discipline.

    Editorial Decision

    A decision about acceptance, revision, or rejection is sent to the corresponding author, generally within eight to 12 weeks of receipt of the manuscript. All acceptable manuscripts require some revision based on reviewers' comments and medical editor guidance. Instructions, showing how to handle each comment, and a sample response letter are provided in the Authors' Responses to Reviews.

    Return of Manuscripts and Illustrations

    If submitted, hard copies of original artwork, photographs, slides, and other illustrations will automatically be returned if the manuscript is not accepted for publication. For manuscripts accepted for publication, any hard copies of illustrations submitted will be returned after the article is published.

    Manuscript Editing

    When a manuscript is accepted, it will be edited to conform to AFP’s style as well as to improve its educational value. An edited manuscript will be sent to the corresponding author for review before publication. Authors are responsible for all statements made in their work, including any changes made by the editors and authorized by the corresponding author.


    Checklist

    Please review this checklist carefully before submitting your manuscript to ensure its completeness and conformity with AFP style.

     

    1. The Conflict of Interest Form has been previously completed and signed by each author and sent in, or is scanned and uploaded in Editorial Manager at the time of submission or faxed to 913-906-6086.
    2. The Author Statements Form is signed by each author and scanned and uploaded in Editorial Manager  at the time of submission or faxed to 913-906-6086. This form covers the authorship statement, copyright transfer statement or statement of federal employment, and acknowledgment statement.
    3. The manuscript’s first and corresponding author is the person who initially was approved to write and submit the review article.
    4. There are no student authors on the manuscript.
    5. The literature search includes at least four sources of pre-appraised evidence from the list of recommended sources of evidence-based medicine (see Literature Search and Data Sources).
    6. The literature search includes the Evidence Summary sent by AFP’s medical editors, when applicable, as well as the guidance provided for the slant of the article.
    7. A Table of Key Clinical Recommendations is included, and the quality of evidence supporting key recommendations on diagnosis and treatment is rated using the SORT evidence rating system (see SORT table). This table is not numbered and is placed after the references and any other tables that may be included.
    8. The text word count is within the maximum specified in the solicit/proposal letter.
    9. For purposes of blinded peer review, identifying information is removed from the manuscript, such as not having authors’ names on the title page and not putting an author’s name in the document’s file name.
    10. The entire manuscript has 1.5 inch margins and is double-spaced throughout (including abstract, references, tables, and figure legends).
    11. The manuscript is arranged and numbered in the following sequence: title page, abstract, text, literature search/data sources, references, tables, and figure legends. Acknowledgments and biographic sketches for each author should be in a separate document.
    12. Title page has full title of the article, along with word counts for the entire article and the text alone (not including title, abstract, tables, references, etc).
    13. An abstract of 150-250 words is included in the manuscript file after the title page. It is fact-filled and specific (rather than general and nonspecific), and rather than saying what will be discussed, summarizes the key points of diagnosis and/or treatment.
    14. A Literature Search and Data Sources section is included, indicating the search strategy, the key words used, the key sources accessed (i.e., PubMed, Cochrane, AHRQ), and the date(s) of the search.
    15. Reference citations are included within the text, along with a corresponding reference list, typed double-spaced, in numerical—not alphabetical—order. Recent references from systematic reviews, original research studies, and evidence-based guidelines preferred (from the past 10 years). Usual range, 15-30; maximum, 35.
    16. Citations: Do NOT use "Endnotes" or any other automated reference function.
    17. Each table is on a separate page placed at the end of the text, after the references, and not within the text itself. Tables are part of the manuscript file and are not uploaded as separate files. Tables are formatted in Word and not Excel or as embedded images. All tables and figures have titles, and all figures and other illustrations have descriptive legends. All tables, figures, and illustrations are cited at the appropriate places in the text.
    18. Each figure is submitted as a separate JPG, TIFF, or PowerPoint file. Photos and other illustrations meet the resolution and quality criteria specified in the Figures section of the Author's Guide.
    19. Figures are not downloaded from the Internet or photographed from other articles or textbooks.
    20. A signed Photo Release is submitted as a separate file for any photographs in which a person is identifiable. Masking the eyes is not sufficient.  
    21. Complete citations and scanned photocopies of any tables or figures taken from other sources are included. Do not attempt to obtain permission to reprint these; AFP editors will seek permission to reproduce copyrighted material.  (Note: Original tables/figures are strongly preferred because it has become increasingly difficult to obtain permission to reprint tables and figures from other sources.)
    22. Style guidelines have been reviewed (e.g., SI units included, right-hand margins unjustified, no bold or italic typeface used, no shading in tables).