How to Submit a Clinical Image to a Medical Journal

An image article is short, but editors judge it hard. The image must teach one clear point, the patient must have consented, and every file must follow the journal's rules.

Guide · 11 min read · Directive Publications Editorial Team

What a clinical image article is

Many medical journals run a short format built around a single picture: a skin lesion, a chest radiograph, a fundus photograph, a pathology slide, a still from an endoscopy video. The image carries the clinical point, and a brief text tells the reader what they are looking at and why it matters.

The format goes by different names. NEJM calls it Images in Clinical Medicine. BMJ Case Reports calls it Images in, and describes these articles as short descriptions of cases centred on relevant clinical images and videos. CMAJ publishes Clinical images. JAMA's Clinical Challenge works differently: it presents a case with a clinical image and asks the reader "What would you do next?", offering four possible courses of action before the diagnosis and the answer are explained.

For early career clinicians, clinical image submission is one of the most realistic first publications. You do not need a cohort or a grant. You need one excellent image, a patient willing to consent, and the discipline to explain the finding in very few words.

It is not a shortcut to a case report, though. NEJM states plainly that its image article type is not intended for case reports. If the value of your case lies in the diagnostic reasoning, the management or the literature, you have a case report, and our guide to writing a medical case report with the CARE checklist is the better route.

Is your image publishable?

Editors are not looking for any interesting picture. They are looking for an image that teaches something at a glance. CMAJ describes its choices as images that are particularly intriguing, classic or dramatic, and says it prefers common presentations of important rare conditions and important unusual presentations of common problems. That is a useful test for any journal.

Ask four questions before you invest time:

1. Does the image show the finding clearly without the text? A reader should see the abnormality before reading the legend. If the finding is subtle, the image may need labels, a comparison panel, or a better example.
2. Is it original? NEJM requires images that are free of content submitted or published elsewhere, and JAMA's Clinical Challenge requires images that have not been published previously. An image already in a poster, a slide deck shared online, or another article may not qualify.
3. Is it high quality? Blur, glare, poor lighting, cluttered backgrounds and low-resolution screenshots are common reasons an image is not taken further.
4. Is the diagnosis secure? The legend has to state a diagnosis, and readers will expect it to be supported by the clinical course, histology, imaging or another reference standard.

Specialty matters for quality. In dermatology, include a scale and photograph under even light against a plain background. In radiology, choose the single most telling slice and window, and add a comparison image only if it sharpens the point. In pathology, state the stain and magnification, and the ICMJE recommendations ask for internal scale markers on photomicrographs. In endoscopy and ophthalmology, the still frame you pick from a longer recording is the whole article, so choose the clearest frame, not the first.

How the main formats compare

Each journal sets its own limits, and they differ enough that a legend written for one rarely fits another. The table summarises the published instructions of four well-known journals at the time of writing. Check the current version before you submit, because these details change.

Two practical points sit behind the numbers. BMJ Case Reports runs on a Fellowship model, and its instructions say the corresponding author must be or become a Fellow, either individually or through an institution, so check access before you write. NEJM says that if editors judge an image unsuitable, authors are notified in approximately one week, and that potentially suitable images go to peer review and then to a monthly editorial meeting.

Consent and de-identification

Consent is where image submissions most often go wrong, because authors assume that a cropped image is anonymous. The standard is stricter than that.

The ICMJE recommendations on protecting research participants set the baseline: no identifying photographs without written informed consent, and masking the eyes does not make a patient anonymous.

Journal policies build on that baseline in different ways:

• JAMA says black bars across the eyes are not acceptable, that cropping may be acceptable if the condition and necessary landmarks remain visible, and that permission is required if the person is possibly identifiable, including by themselves.
• NEJM asks you to remove all identifying information, such as name, medical record number and hospital name. If that is impossible, the patient must sign NEJM's release form for photographs of identifiable patients.
• CMAJ asks authors of articles based on real patients to obtain consent before submission. If a patient asks for a photo to be altered, CMAJ wants the unaltered photo for peer review and will make the alteration itself if the article is accepted.
• BMJ Case Reports accepts only its own consent forms, or forms containing all of the same clauses, and expects the patient to read and approve the manuscript before signing.

The safe working rule is simple: assume you need written consent on the journal's own form, and get it before you submit. Our guide to patient consent for publication covers deceased patients, children and adults without capacity.

De-identification is also a file problem, not just a picture problem. Radiology screenshots often show the patient's name, date of birth, record number or scan date in the corners. Images exported from imaging systems in DICOM format carry header fields that can hold the same details, and phone photographs can store the date, time and sometimes location. Export a clean copy, crop out on-screen text, and check the properties of every file before upload.

Preparing the image files

Start with the technical instructions of your target journal, then work through these points.

Resolution and format. Submit the original high-resolution file, not a screenshot of a screen. JAMA, for example, asks for photographs and clinical images at 350 ppi or more, while CMAJ asks for clinical images at 300 dpi or greater. The ICMJE recommendations ask for high-resolution photographic files for radiological and other clinical images, pathology specimens and photomicrographs.

Labelled and unlabelled versions. NEJM asks for one version with arrows and labels identifying the relevant structures, labelled Panel A, B and so on when there are several panels, and a second version with no labels or arrows. Even where a journal does not ask for both, keep a clean original so the journal's art team can relabel it.

Arrows and labels. Use as few as the point requires. The ICMJE recommendations ask that symbols, arrows and letters on photomicrographs contrast with the background, and that every one is explained in the legend.

Editing limits. JAMA permits adjustments to brightness, contrast or colour only when they are applied uniformly to the whole image and do not highlight, misrepresent, obscure or remove clinical elements. Selective adjustments and moving, deleting or inserting elements are not permitted. Our guide to image manipulation screening explains how journals check for this.

Writing the title and legend

In NEJM's Images in Clinical Medicine, the title and legend are the whole written article, so every word has to work. Other formats add a short text: CMAJ asks for a brief case description and an explanation of why the images matter, within 300 words, while BMJ Case Reports and JAMA use longer templates. Follow the structure of your target journal.

The title should name the finding or diagnosis, not tease it. JAMA's Clinical Challenge is the exception: its title must describe the disease entity or case presentation and must not include the diagnosis. NEJM limits titles to eight words.

The legend follows a predictable order. NEJM's instructions ask it to cover:

1. Relevant clinical information: the important features of the history, where the patient presented, physical and laboratory findings, clinical course, response to treatment and condition at last follow-up.
2. Every labelled structure, matched to its panel.
3. A teaching point that makes the clinical importance clear.

A useful skeleton:

A [age range] [patient description] presented with [symptom and duration]. [Key examination or laboratory finding.] [Imaging or photograph] showed [finding] (Panel A, arrow). [How the diagnosis was confirmed.] [Treatment and response.] At follow-up after [interval], [condition]. [One sentence on what clinicians should take from the image.]

In a legend-only format such as NEJM's, cut anything a reader does not need to interpret the image. Where a format asks for a short discussion, as CMAJ's does, keep it inside the limit and tied to what the image shows. Write the teaching point last, and make sure the image actually shows what the sentence claims.

Submitting step by step

1. Choose an image that teaches one point. Original, high quality, and clear before anyone reads the legend.
2. Pick the journal and read its format rules. Note the word, author, reference and image limits, and any fees or membership requirements.
3. Get consent and remove identifiers. Use the journal's own form, and strip names, numbers, dates and hospital details from files and metadata.
4. Prepare labelled and unlabelled files. Export at the required resolution, and keep any adjustments uniform across the whole image.
5. Write the title and legend. Stay inside the limit and end with the teaching point.
6. Submit and track the decision. Choose the image article type in the submission system, upload each file separately, enter author details, and complete the competing interest and consent declarations.

Authorship deserves a moment of thought. Image formats often allow only two or three authors, so agree who will be named before you submit. BMJ Case Reports requires the lead clinician responsible for the patient's care to be a co-author, and expects corresponding authors who are medical students, foundation year doctors or interns to copy that clinician on journal correspondence.

Why image submissions fail

Most rejections of image articles come down to a handful of avoidable problems:

If an image is rejected, it is free to go elsewhere, but you will usually need to rewrite the legend to the new journal's limits, and you may need a new consent form if the first was journal-specific.

Before you submit

1. The image shows the finding clearly without the legend
2. The image is original, unpublished and not under consideration elsewhere
3. Written consent is on the journal's required form and matches the final text
4. Names, record numbers, dates and hospital details are removed from images and file metadata
5. Labelled and unlabelled versions prepared, at the required resolution
6. Every arrow and label is explained in the legend
7. Title and legend are inside the journal's limits
8. Author list fits the format's limit and includes the responsible clinician where required

A strong clinical image submission is short, but it is not quick. The hours go into choosing the right image, securing consent properly, and cutting the legend until only the teaching point remains. When you are ready to publish full-length work, Directive Publications sets out its requirements in its author guidelines.