Who Goes on the Paper

There is a conversation that happens in academic medicine all the time, in corridors and conference rooms and over coffee, but almost never in writing. It is about who goes on the paper, in what order, and what you do when the expectations around that feel wrong.

I am going to put it in writing.

Authorship is one of the most consequential decisions you make on any paper, and most people make it by feel, by habit, or by institutional pressure rather than by any clear framework. That ambiguity is where most of the problems live. So let me give you the framework I use, built on the ICMJE criteria, which are the international standard and worth knowing cold.

Authorship should be earned by contribution, not granted by position, friendship, or expectation. The clearer you are about this from the start of a project, the fewer uncomfortable conversations you will have at the end.

According to the ICMJE, a legitimate author must meet all four of these criteria, not just one or two. This is the part most people do not know.

Everyone who meets all four criteria should be an author. Anyone who does not meet all four should not be, regardless of their seniority. Contributions that do not meet the full threshold, such as providing funding, supervising a department, or collecting samples, belong in the acknowledgements section, not the author list.

Now, author order. This is where most of the tension lives.

The convention in biomedical research is clear even if it is rarely stated. First author is the person who did the primary intellectual and writing work. Last author is typically the senior investigator who supervised the project and takes overall responsibility. The middle positions reflect descending contribution. Corresponding author is a separate designation indicating who handles journal communication, which is often but not always the last author.

The practical rule: agree on author order before the project ends, ideally before it begins.

Waiting until submission to discuss order is where relationships get strained. By then everyone has formed an expectation, and those expectations rarely match. A brief conversation at the start of a project, "here is how I am thinking about authorship and order, does that work for everyone," prevents almost every problem I have seen arise.

On gift authorship: it exists, it is common, and it is a genuine ethical violation according to every major guideline. A department chief who had no involvement in the work does not belong on the paper because of their position. I am not naive about the pressures that exist around this, particularly for trainees and IMGs who depend on the goodwill of senior colleagues. But I will say this clearly: every gift author on your paper dilutes your contribution in the eyes of readers, weakens your first-author claim, and creates accountability exposure if anything about the paper is ever questioned. Protect your work by protecting your author list.

The simplest system I know: at the start of every project, write down who is contributing what, and share it with the team. Not as a legal document, just as a shared understanding. It makes the final authorship conversation almost automatic, because everyone already knows what was agreed.

Authorship is not a bureaucratic formality. It is the record of who did the work. Getting it right is part of getting the science right.

Think through your author list →