Perceived Unethical Authorship Practices: A Survey Among Medical Students Interested in Plastic Surgery

Abstract

Purpose:

Authorship plays a crucial role in academic medicine. It significantly impacts residency placement for students, especially in competitive specialties like plastic surgery. Despite the existing guidelines, widespread ethical concerns remain unsettled. This study aimed to explore the understanding, perceptions, and attitudes of authorship practices among medical students interested in plastic surgery to evaluate the need for more comprehensive analysis and to generate hypothesis-driven insights to enhance research integrity.

Design:

An IRB-approved, anonymous 29-question survey was distributed to medical students interested in plastic surgery to explore their understanding, perceptions, and attitudes in authorship practices.

Results:

A total of 46 students met inclusion criteria. Although 82.6% reported awareness of authorship criteria, only 21.7% reported receiving any formal training. Misconceptions were common, as many students endorsed non-qualifying contributions as sufficient for authorship. Perceived unethical authorship practices, including ghost and honorary authorship, were reported by 32.6% and 52.2% of respondents, respectively. These were often reported to be driven by seniority, institutional norms, and publication pressure. More than a third of respondents reported experiencing unfair authorship orders. Over a quarter had experienced disputes, yet few were aware of or utilized institutional resources.

Conclusion:

Medical students interested in plastic surgery report frequent challenges related to authorship in research. These findings likely reflect a combination of misunderstandings of authorship criteria and true deviations from established standards, both of which have important implications for ethics education, mentorship, and institutional policies. As a preliminary analysis, these results support the need for further large-scale investigation to validate findings.

Keywords

authorship honorary authorship ghost authorship

Introduction

Authorship in academic medicine is a central marker of scholarly contribution and academic advancement. It not only acknowledges those who have made substantial contributions to a project but also establishes accountability for the integrity and accuracy of the published work.^1,2 Proper attribution ensures transparency and fairness, reinforcing trust within the academic community.¹ According to the International Committee of Medical Journal Editors (ICMJE), designated authors should meet the following criteria³:

(i) “Substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work; AND

(ii) Drafting the work or reviewing it critically for important intellectual content; AND

(iii) Final approval of the version to be published; AND

(iv) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.”

In theory, this framework aims to ensure that writers are appropriately credited and held accountable for the actual integrity of their work. However, despite widespread citation of ICMJE guidelines, research has shown that unethical authorship practices remain prevalent across scientific disciplines.^4
-6 Ghost authorship refers to the failure to name an individual who provided substantial contributions to the research or writing of the manuscript as an author.² On the other hand, honorary authorship refers to naming an individual who does not meet authorship criteria as an author.² One landmark study found that a substantial portion of peer-reviewed medical articles contain authorship misappropriation. Nineteen percent have honorary authors, 11% having ghost authors, and 29% having both.² Such practices inflate the number of authors listed, thereby blurring accountability and the recognition of genuine contributions.^2,7 Moreover, studies have demonstrated that the majority believe that the authorship order failed to reflect the extent of contribution.⁸ Even with the adoption of contribution declarations such as Contributor Roles Taxonomy (CRediT), concerns persist that these systems have done little to deter misattribution or ensure transparency in the authorship process.^5,9 Unfortunately, these issues may disproportionately affect medical students as they are particularly vulnerable to power imbalances and hierarchical pressures.

Within the field of plastic and reconstructive surgery (PRS), research productivity plays a crucial role in residency applications. This, in turn, shapes both opportunities and career trajectories for medical students. Publication output has become an essential component of success for applicants to plastic surgery programs, with matched candidates reporting some of the highest scholarly outputs among all specialties, averaging 28 scholarly works.¹⁰ Such pressure to publish may heighten medical students’ exposure to ethical dilemmas surrounding authorship. In a survey of plastic surgery residents and fellows, one-third of respondents endorsed authorship for scenarios that failed to meet formal ICMJE standards.¹¹ Such findings underscore a potential gap between awareness of guidelines and practice adherence, thereby raising broader questions about how early trainees understand and experience ethical authorship.^5,12,13

Understanding how medical students perceive, experience, and navigate these challenges is critical to initiating a more transparent and equitable research culture within the specialty. However, there is a relative paucity of literature specifically examining authorship perceptions and experiences among medical students, particularly within plastic surgery. The present study was designed as a preliminary, exploratory analysis to identify potential trends in authorship understanding and perceived experiences among medical students interested in plastic surgery. By capturing these early perspectives, this work seeks to evaluate the need for more comprehensive analysis and to generate hypothesis-driven insights that may inform educational strategies, mentorship practices, and institutional policies that promote research integrity and uphold ethical standards in academic publishing.

Methods

This study used a cross-sectional survey design to provide insight into the understanding, perceptions, and attitudes of authorship practices among medical students interested in plastic surgery. Eligible participants included medical students aged 18 years or older who were involved in research and interested in plastic surgery as a potential career. Interest in plastic surgery, rather than prior publication within the specialty, was selected as an inclusion criterion to capture students actively considering a career in the field and who may be more directly influenced by specialty-specific expectations surrounding research productivity and authorship. This approach was intended to reflect perceptions among trainees navigating these pressures throughout medical training, rather than limiting the sample to those with prior publication history, which may not align with long-term career intent. The survey was distributed electronically via surgery and/or plastic surgery student interest groups across 3 U.S. accredited medical schools. Medical schools were selected based on geographic proximity within the investigators’ local region and were not intended to be representative of the broader population, but rather to identify initial trends that would inform the need for more exhaustive, multi-institutional investigation. The sample included 1 allopathic (MD) program, 1 osteopathic (DO) program, and 1 institution with both MD and DO training pathways. One of the institutions was affiliated with an academic medical center with an integrated plastic surgery residency program. Participation was voluntary and anonymous. No compensation was provided. Completion of the survey implied informed consent. This study was reviewed and approved by the institutional review board (IRB #20250459).

A 29-item questionnaire was developed to assess five primary domains: (1) demographics characteristics, (2) research experience, (3) awareness and understanding of authorship guidelines, (4) exposure to unethical authorship practices (ghost and honorary authorship), and (5) attitudes toward ethical conduct in research (Supplemental File 1). Question format included multiple-choice, Likert-scale (1-5), binary response, and open-ended formats. The survey was piloted among a small group of medical students to ensure clarity prior to distribution. The final survey was hosted on Qualtrics (Qualtrics, Provo UT), a secure web-based platform, and remained open for approximately 12 weeks. Two reminder invitations were sent to encourage participation. No personal identifiers were collected to ensure confidentiality.

Open-ended responses were analyzed thematically to identify recurring patterns and insights. Descriptive statistics were reported as frequencies and percentages. Continuous variables are described as means with corresponding standard deviations (mean ± SD) or medians with interquartile ranges (p25, p75) depending on the distribution. Respondents were further stratified by training level to assess the effect of experience on perceptions and beliefs. Students were grouped into lowerclassmen (medical student year 1 [MS1] and year 2 [MS2]) and upperclassmen (year 3 [MS3], year 4 [MS4], and research year) given small sample sizes. Normality was assessed using the Shapiro-Wilk test, which indicated that continuous data were not normally distributed. Consequently, comparisons between groups were performed using the Mann-Whitney U test for continuous variables. For categorical variables, chi-squared tests of independence were applied, and Fisher’s exact test was used when expected cell counts were small. Statistical significance was defined as exact p < 0.05 (2-tailed). All analyses were conducted using SPSS 31.0.0.0 (IBM Corp., Armonk, NYU).

Results

A total of 77 respondents completed the survey, 31 of which were excluded because they indicated that they were either not involved in research or were not interested in plastic surgery. Because survey distribution occurred through student interest groups and distribution lists were not accessible, the total number of students who received the survey invitation was unknown, and a formal response rate could not be calculated. Of the 46 included respondents, most (n = 38, 82.6%) reported awareness of established authorship criteria (Table 1). Only 21.7% (n = 10) had received formal training on authorship guidelines. Familiarity with ICMJE standards was also mixed: 18 students (39.1%) reported being completely unfamiliar, 10 (21.7%) not very familiar, 6 (13.0%) unsure, 9 (19.6%) somewhat familiar, and only 3 (6.5%) very familiar. A similar pattern was observed regarding familiarity with institutional-specific authorship guidelines. Eleven students (23.9%) reported being completely unfamiliar, 12 (26.1%) not very familiar, 8 (17.4%) unsure, 11 (23.9%) somewhat familiar, and 3 (6.5%) very familiar.

Table 1.

Participant Characteristics (n = 46).

Program type, n (%)
MD	43 (93.5)
DO	3 (6.5)
Home institution plastic surgery program, n (%)
Yes	32 (69.6)
No	9 (19.6)
Unsure	5 (10.9)
Year in school, n (%)
MS1	18 (39.1)
MS2	13 (28.2)
MS3	8 (17.4)
MS4	5 (10.9)
Research year	2 (4.3)
Number of publications, n (%)
0	11 (23.9)
1-4	25 (54.3)
5-10	5 (10.9)
>10	5 (10.9)
Self-reported research experience (1-5 scale)
Mean (SD)	3.6 (0.9)

When asked which criteria they believed were necessary for authorship, majority of students endorsed substantial contributions to study design or analysis (n = 41, 89.1%), drafting or revising the manuscript (n = 41, 89.1%), accountability for the work (n = 32, 69.6%), and final approval of the research (n = 26, 56.5%). However, a notable proportion of students also considered data collection alone (n = 18, 32.1%), supervision without direct involvement (n = 10, 21.7%), securing funding (n = 10, 21.7%), or providing technical or administrative support (n = 6, 13.0%) as sufficient for authorship, suggesting misconceptions of standardized criteria.

Notably, 32.6% of respondents (n = 15, 32.6%) believed they had witnessed or experienced ghost authorship. The most frequently cited reasons were seniority pressures (n = 11, 23.9%) and lack of clear guidelines (n = 4, 8.7%). Others attributed it to limited authorship space (n = 3, 6.5%), multi-institution collaborations (n = 2, 4.3%), or avoidance of accountability (Figure 1A). One student described the issue as stemming from a lack of authorship discussions early on and absence of follow-up throughout project stages.

Figure 1.

Reported underlying contributors by medical students for (A) ghost and (B) honorary authorship.

Perceived experiences with honorary authorship were more common with 52.2% (n = 24) believing they had observed or experienced inclusion of individuals without sufficient contribution, while 8 students (17.4%) were unsure. The most common explanations included institutional or cultural norms (n = 16, 34.8%), senior figures being added to enhance credibility (n = 15, 32.6%), reciprocal authorship expectations (n = 10, 21.7%), and pressures to publish (n = 8, 17.4%; Figure 1B). Less commonly, a lack of clear guidelines (n = 2, 4.3%) and external stakeholder influence (n = 2, 4.3%) were reported. One student noted that they believed that “there is an expectation to publish large quantities of papers that results in more honorary authorship than ghost authorship, so that everyone is meeting research quotas.”

Authorship fairness was a commonly reported issue: 17 students (37.0%) felt that authorship order was unfair in at least one project, and 13 (28.3%) reported being directly involved in authorship disputes. Despite this, only 3 students (6.5%) were aware of institutional dispute-resolution mechanisms. Only a single student had utilized such processes. Students generally perceived authorship disputes as moderately significant in plastic surgery relative to other specialties, with a mean rating of 3.1 ± 1.2 on a five-point scale (1 = not significant, 5 = very significant). Transparency of authorship practices was rated lower, averaging 2.7 ± 0.8 on a five-point scale (1 = not transparent, 5 = very transparent). Only 56.5% of participants (n = 26) believed that their medical school adequately prepares them for ethical authorship publication practices.

When stratified by year in school, upperclassmen had significantly higher ratings of reported research experience (p = 0.011), yet there were no significant differences in awareness of any authorship criteria (p = 1.000; Table 2). Interestingly, there were statistically significant differences in the belief that medical school adequately prepares them for ethical publication practices, with older students feeling less confident than younger students (p = 0.037).

Table 2.

Perceptions and Beliefs of Medical Students When Stratified by Year in School.

Perception or belief	Lower-classmen^a	Upper-classmen^b	p
N	31	15	—
Aware that any authorship criteria exist; n (%)	26 (83.9)	12 (80.0)	1.000
Believe that medical school adequately prepares for ethical publication practices; n (%)	21 (67.7)	5 (33.3)	0.037*
Self-reported research experience; median (p25, p75)	3.0 (3.0, 4.0)	4.0 (4.0, 5.0)	0.011*
Rank of significance of authorship disputes in PRS; median (p25, p75)	3.0 (3.0, 4.0)	3.0 (2.0, 4.0)	0.880
Rank of transparency of authorship in PRS; median (p25, p75)	3.0 (2.0, 3.0)	2.0 (2.0, 3.0)	0.333

Medical students in their first or second year of medical school.

Medical students in their third or fourth year of medical school or in a research year.

Indicates statistical significance (p < 0.05).

A total of 33 respondents (71.7%) reported observing or using artificial intelligence (AI) tools in research. Most common uses were improving readability or editing (n = 26, 56.5%), literature review or summarization (n = 19, 41.3%), data collection or analysis (n = 15, 32.6%), and drafting manuscript text (n = 12, 26.1%). One respondent reported using AI to search and retrieve relevant articles. While most students supported the use of AI in drafting manuscripts if properly disclosed (n = 29, 63.0%), a smaller proportion were aware of formal guidelines on AI in research (n = 20, 43.5%).

Of the 46 included respondents, 11 (23.9%) provided free-text comments when asked about additional resources or support that would help navigate authorship considerations. Overall, qualitative responses emphasized the need for more structured education in research ethics and authorship (n = 5). This included calls for a dedicated class, brief formal training, or incorporation of comprehensive research training within the medical curriculum. Several students (n = 3) recommended practical tools, like standardized written guidelines or authorship agreements, to promote accountability and fairness. A subset (n = 2) advocated for initiating authorship discussions early in a project to reduce conflict and clarify authorship order. Additional suggestions included guidance on the responsible use of AI in research (n = 1) and the creation of a designated institutional point-person or office responsible for research standards (n = 1).

Discussion

As the competitiveness of plastic surgery residency applications continues to increase, so has the pressure to publish among medical students, creating conditions that may foster unethical authorship practices. This study offers initial insights into how these pressures manifest among students aspiring to enter the specialty. Results demonstrated that perceived unethical authorship practices were common among respondents, with nearly one-third reporting experiences of ghost authorship and half reporting experiences of courtesy authorship. Greater than a third felt that authorship order was unfair in at least 1 project.

Despite many students reporting general awareness that formal authorship guidelines exist, familiarity with the ICMJE criteria remained more limited, and misconceptions regarding what constitutes legitimate authorship remained prevalent. Many students incorrectly identified data collection alone, supervision without direct involvement, or securing funding as sufficient for authorship despite these contributions not independently satisfying established ICMJE criteria. In such instances, the acknowledgments section serves an important role in recognizing meaningful contributions that do not meet formal authorship criteria, thereby ensuring transparency.³ Importantly, this discrepancy between theoretical awareness and accurate understanding may skew the true prevalence of unethical authorship practices. For instance, some students could perceive that they were wrongfully excluded from authorship when their contributions did not meet criteria, thereby overestimating inappropriate ghost authorship. Conversely, limited understanding of criteria may cause underestimation of honorary authorship if students fail to recognize inappropriate inclusions.

In part, these misconceptions may be linked to a lack of structured education on research and publication ethics at the medical student level.¹⁴ This was also reflected in students’ qualitative responses, with several reporting a desire for a more structured curriculum. Because this study did not assess respondents’ prior exposure to or completion of formal ethics training programs (e.g., Collaborative Institutional Training Initiative [CITI]), it is not possible to determine the extent to which these findings are attributable to limitations in training, lack of exposure to training, difficulties applying ethical principles in practice, or other factors. However, the lack of differences between underclassmen and upperclassmen may suggest that perceptions surrounding authorship challenges persist throughout medical training. Moreover, despite similar levels of reported self-knowledge across training stages, upperclassmen who had greater research experience were significantly less likely to feel that their medical school adequately prepares them for ethical publication practices. This decline in perceived preparedness may reflect growing awareness of authorship challenges as students’ progress through their medical education and highlights that students may gain experience, but not necessarily guidance. These findings also raise the question of whether misconceptions about authorship are limited to early trainees or instead persist across career stages.

Beyond potential educational gaps, these issues may be compounded by larger systemic pressures within academic medicine. Over recent decades, the total number of publications has grown exponentially,¹⁵ not due to a surge in research productivity, but rather the expansion of co-authorship and the number of authors per article.^12,16,17 This phenomenon, often referred to as “publish or perish,” reflects an environment where publication output functions as a key currency for career progression.^18,19 For medical students, this pressure is particularly acute. The transition of the United States Medical Licensing Examination (USMLE) Step 1 to pass/fail scoring has increased the emphasis on research productivity as a differentiating factor in residency selection.²⁰ In several competitive specialties, including dermatology and urology, applicants in the post-pass/fail era have demonstrated significantly higher research output.^21,22 Additionally, the growing availability of AI tools in research may further amplify publication volume by streamlining manuscript drafting and data analysis.¹⁹ As publication expectations rise, trainees may feel compelled to join as many projects as possible or accept questionable authorship practices as a necessary part of being a competitive applicant.

Power dynamics further amplify these challenges. Our data revealed that students often believe seniority and institutional norms often drive honorary authorship. Medical students are uniquely vulnerable as they often lack the leverage to challenge authorship decisions or negotiate authorship order. This is particularly a concern when future letters of recommendation, rotation performance assessments, or residency opportunities may depend on these same mentors. Prior studies among surgical faculty echo this trend with 70% of junior faculty feeling pressured to include senior colleagues as authors, compared to 45% of senior faculty.¹³ This asymmetry may explain how courtesy authorship persists through entrenched hierarchies rather than isolated individual choices.²³

Although the present study focused on the perspective of medical students, it is important to recognize that these systemic pressures are not unique to students, as senior investigators themselves may face similar pressures. In many institutions, decisions concerning promotion or grant funding, as well as perceived professional prestige, are strongly influenced by an individual’s publication output.^23,24 Moreover, authorship inflation has been shown to be most prevalent in high-impact journals, where visibility and academic capital are highest.¹⁷ This practice may be especially common for authors from low- or middle-income countries,²⁵ where including well-known authors can be viewed as a way to enhance the perceived legitimacy and acceptance of the manuscript.²³ While the creation of open access journals sought to increase access to research, it has also paved the path for proliferation of predatory journals which have flooded the academic landscape with outlets that prioritize speed and profit over scientific rigor.²⁶ As a result, researchers may face pressure to keep up with quantity and ensure their work is published in high-prestige, reputable journals to remain competitive for funding, promotion, or program placement.

Interestingly, Condron et al. reported similar findings amongst first and senior authors with the primary justification for honorary authorship being avoiding awkwardness (64%), avoiding retaliation (46%), and expecting reciprocal authorship (26%).²⁷ Similarly, Al-Herz et al. determined that the primary reasons for adding honorary authorship among corresponding authors were complimentary (~40%), to avoid conflict (~16%), and to facilitate article acceptance (~7%).²⁸ These findings highlight that senior authors are also governed by cultural expectations and professional norms, rather than individual misconduct.

Importantly, it is not possible in this study to distinguish between objectively verifiable authorship misconduct and perceived slights based on misunderstanding. Nevertheless, both scenarios are meaningful. Misconceptions regarding authorship criteria underscore gaps in education, whereas true deviations from established standards reflect broader systemic challenges. Notably, recent evidence suggests that formal contribution reporting does not fully mitigate these issues, with studies demonstrating persistently high rates of honorary authorship even when contributions are explicitly documented.⁹ In this context, the frequency of reported experiences in our cohort, regardless of underlying cause, points toward a broader issue in how authorship is understood, communicated, and operationalized within academic research environments.

Though this study did not seek to identify the predominant factors underlying students’ perceptions, findings allow us to hypothesize about potential areas for reform at multiple levels (Figure 2). At the trainee level, it is necessary to further evaluate the efficacy of current structured curricula on research and publication ethics. Currently, standardized training modules like CITI provide foundational instruction in research ethics. However, the extent to which students complete these trainings and how effectively such trainings translates into understanding and application of authorship principles remains unclear. Future studies should more directly evaluate whether misconceptions stem from lack of completion of formal ethics education, limitations in retention, or challenges applying ethical principles in practice. If future studies demonstrate that students are not completing formal ethics training modules, reform efforts may need to focus on improving exposure to and completion of such training. Alternatively, if students complete formal training yet continue to report difficulties navigating authorship issues, this may suggest challenges in applying ethical principles within real-world research environments, particularly if power dynamics influence decision-making. Additionally, refresher courses may be completed only every 3 to 4 years,²⁹ potentially serving as another source that limits retention. In this case, incorporating supplemental longitudinal strategies involving case-based discussions or scenario-based learning could reinforce existing research curricula and help bridge the gap between knowledge and application. Furthermore, given that trainees may view institutional administrations as ill-equipped or unwilling to adjudicate authorship disputes,^30,31 institutions should aim to provide clear, visible mechanisms for conflict resolution. These could include confidential anonymous reporting pathways and standardized authorship agreements at project initiation, to empower students to advocate for fair credit.

Figure 2.

Summary of trainee-, institutional-, and journal-level interventions to address unethical authorship practices.

At the institutional level, academic culture should value integrity, transparency, and meaningful contribution, rather than volume and prestige. Policies should address these incentive structures, including how publications are weighted in residency applications, promotions, and funding decisions. For example, programs may consider allowing applicants to submit a capped number of “representative works” with contribution statements, rather than total publication tallies. In fact, the Association of American Medical Colleges (AAMC) recently announced upcoming changes in the Electronic Residency Application Service (ERAS) research and scholarly work section, effective for the 2027 application cycle.³² Applicants will now be required to list only publications and presentations that have undergone a peer-review process. This will eliminate entries such as blog posts, student-run publications, and duplicate listings of posters or presentations presented at multiple venues. Moreover, students can indicate their three “most meaningful” scholarly works. Although these changes do not cap the number of reported publications, they represent a step toward emphasizing quality over quantity in scholarly activity. Courses or lectures on publication ethics, which have been shown to correlate with lower perceptions of honorary authorship,³³ should be routinely offered or required for new research investigators. Likewise, institutions can educate trainees and faculty about identifying and avoiding predatory journals.

Finally, at the journal level several reforms may strengthen transparency. Although PRS journals often cite ICMJE in authorship guidelines, they may consider revising such guidelines to take on a more educational stance, like that of medical schools.³⁴ Double-blinded peer review could help mitigate prestige bias and reduce the need to include well-known senior authors simply to improve the manuscript’s chance of acceptance. Some studies centered around PRS journals have not demonstrated a significant improvement in review quality with double blinding,³⁵ potentially due to the small community and ability to recognize authors anyways.³⁶ However, even in the absence of measurable differences, double-blinded review processes remain a meaningful mechanism to reduce the visibility of prestige signals and create a more level playing field for authors.³⁷ Additionally, journals could implement audits of contribution statements to compare declared roles against supporting materials to promote accountability and accuracy in reporting.²³ Over time, regular auditing programs may help identify systemic patterns of misattribution and guide policy refinement.

This study has several limitations. Sample size was limited to three medical schools within a single geographic region, and responses may not be generalizable to all medical students, particularly those outside of plastic surgery or in different institutional environments. As such, findings should be interpreted preliminarily. The survey relied on self-reported data, which may be subject to recall bias or underreporting of sensitive experiences. Because recruitment occurred through medical student interest groups, membership counts and message reach were not available to the study team. Thus, the total number of students invited was unknown and a formal response rate could not be calculated. This convenience sampling strategy may introduce selection bias, as students with a stronger interest in surgery, research, or authorship concerns may have been more likely to respond. Additionally, this recruitment strategy may have inadvertently excluded students interested in plastic surgery who are not affiliated with formal interest groups. Moreover, respondents spanned all years of medical school training. While involvement in research was a requirement for inclusion, exposure to research and authorship decisions may vary with training stage.

This study provides insight into trends of the understanding and perceptions of authorship practices among medical students interested in pursuing plastic surgery and hypothesizes about potential areas for reform that warrant further investigation. Future studies should expand this work using larger, multi-institutional samples to assess generalizability of trends and enable more granular comparisons by training stage, research experience, and institutional environment. Extending this survey across multiple specialties would also help determine whether unethical authorship practices reflect issues unique to plastic surgery culture or instead represent broader norms in academic medicine, particularly within other highly competitive fields. Additionally, administering similar questionnaires to residents, fellows, and senior faculty would clarify whether misconceptions regarding ICMJE authorship criteria resolve with experience or persist across career stages, potentially becoming normalized and perpetuated through training hierarchies. Finally, interventional studies evaluating curricula supplementation are needed to identify evidence-based strategies that could help improve accountability and reduce ghost and honorary authorship.

Conclusion

This preliminary study provides insight into the understanding, experiences, and perceptions of ethical authorship practices among medical students interested in plastic surgery. Despite high levels of awareness about the existence of authorship criteria, formal training remains limited, and misconceptions about legitimate contributions persist. Respondents frequently reported experiences consistent with unethical authorship practices (i.e., ghost and honorary authorship), which may reflect a combination of misunderstandings of authorship criteria and true deviations from established standards, both of which carry meaningful implications for educational and systemic reform. Moreover, the underutilization of institutional resources to resolve authorship disputes underscores challenges in access to and/or awareness of formal systems to support students navigating research dynamics. These early findings primarily serve to highlight the need for further investigation. Larger, multi-institutional studies are warranted to evaluate these trends more comprehensively, better delineate their underlying drivers, and inform targeted interventions.

Supplemental Material

sj-docx-1-fac-10.1177_27325016261455706 – Supplemental material for Perceived Unethical Authorship Practices: A Survey Among Medical Students Interested in Plastic Surgery

Supplemental material, sj-docx-1-fac-10.1177_27325016261455706 for Perceived Unethical Authorship Practices: A Survey Among Medical Students Interested in Plastic Surgery by Sara E. Munkwitz, Hana Shah, Nicholas A. Mirsky, Wrood M. Kassira and Seth R. Thaller in FACE

Footnotes

Acknowledgements

We thank Dr. Thilani Samarakoon, PhD for statistical support for this research.

ORCID iD

Sara E. Munkwitz

Ethical Considerations

This study was reviewed and approved by the institutional review board (IRB #20250459).

Consent to Participate

Consent was obtained via survey completion as reviewed and approved by the institutional review board.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data may be available upon request.

Supplemental Material

Supplemental material for this article is available online.

References

Vasilevsky

Hosseini

Teplitzky

, et al. Is authorship sufficient for today’s collaborative research? A call for contributor roles. Account Res. 2021;28(1):23-43. doi:10.1080/08989621.2020.1779591

Flanagin

Carey

Fontanarosa

, et al. Prevalence of articles with honorary authors and ghost authors in peer-reviewed medical journals. JAMA. 1998;280(3):222-224. doi:10.1001/jama.280.3.222

International Committee of Medical Journal Editors (ICMJE). Defining the role of authors and contributors. Who is an author; 2026.

Marušić

Božikov

Katavić

Hren

Kljaković-Gašpić

Marušić

Authorship in a small medical journal: a study of contributorship statements by corresponding authors. Sci Eng Ethics. 2004;10(3):493-502. doi:10.1007/s11948-004-0007-7

McClellan

Mansukhani

Moe

, et al. Courtesy authorship in academic surgery publications. JAMA Surg. 2019;154(12):1110-1116. doi:10.1001/jamasurg.2019.3140

Picciariello

Dezi

Altomare

DF.

Undeserved authorship in surgical research: an underestimated bias with potential side effects on academic careers. Updates Surg. 2023;75(7):1807-1810. doi:10.1007/s13304-023-01581-w

Pruschak

Hopp

And the credit goes to . . . ghost and honorary authorship among social scientists. PLoS One. 2022;17(5):e0267312. doi:10.1371/journal.pone.0267312

Yank

Rennie

Disclosure of researcher contributions: a study of original research articles in the Lancet. Ann Intern Med. 1999;130(8):661-670. doi:10.7326/0003-4819-130-8-199904200-00013

Meursinge Reynders

Ter Riet

Di Girolamo

Cavagnetto

Malički

Honorary authorship is highly prevalent in health sciences: systematic review and meta-analysis of surveys. Sci Rep. 2024;14(1):4385. doi:10.1038/s41598-024-54909-w

10.

Gursky

Camacho

Patel

Reghunathan

Gosman

Hinchcliff

Exploring the 6-year trend in dedicated research years among integrated plastic and reconstructive surgery residents. Plast Reconstr Surg Glob Open. 2024;12(10):e6208. doi:10.1097/GOX.0000000000006208

11.

Momeni

Hunter

Safa

Wan

Kneser

Opinions on authorship: a survey of plastic surgery residents and fellows. Ann Plast Surg. 2018;80(6):660-663. doi:10.1097/SAP.0000000000001396

12.

McDonald

Neff

Rethlefsen

Kallmes

DF.

Effects of author contribution disclosures and numeric limitations on authorship trends. Mayo Clin Proc. 2010;85(10):920-927. doi:10.4065/mcp.2010.0291

13.

Derickson

McClellan

Mansukhani

Kibbe

Martin

MJ.

Variations in courtesy authorship perceptions and practices among modern surgical journals: the generation gap. J Surg Res. 2020;254:242-246. doi:10.1016/j.jss.2020.04.034

14.

Karani

Ognibene

Fallar

Gliatto

Medical students’ experiences with authorship in biomedical research: a national survey. Acad Med. 2013;88(3):364-368.

15.

Sarewitz

The pressure to publish pushes down quality. Nature. 2016;533(7602):147. doi:10.1038/533147a

16.

Fanelli

Larivière

Researchers’ individual publication rate has not increased in a century. PLoS One. 2016;11(3):e0149504. doi:10.1371/journal.pone.0149504

17.

Papatheodorou

Trikalinos

Ioannidis

JPA

. Inflated numbers of authors over time have not been just due to increasing research complexity. J Clin Epidemiol. 2008;61(6):546-551. doi:10.1016/j.jclinepi.2007.07.017

18.

Lubowitz

Matzkin

Rossi

MJ.

Troubling trends in biomedical research publication: “Publish or Perish” results in a propensity for ethical violations. Arthroscopy. 2025;41(4):859-862. doi:10.1016/j.arthro.2024.12.017

19.

Arzilli

Di Maggio

De Angelis

, et al. A surge of AI-driven publications: the impact on health professionals and potential mitigating solutions. Front Public Health. 2025;13:1680630. doi:10.3389/fpubh.2025.1680630

20.

Raborn

Janis

JE.

Current views on the new United States medical licensing examination step 1 pass/fail format: a review of the literature. J Surg Res. 2022;274:31-45. doi:10.1016/j.jss.2022.01.002

21.

Whiteside

Bolen

Szymanski

, et al. Navigating the transition: the impact of step/level 1 pass/fail grading on dermatology residency match outcomes. Ski J Cutan Med. 2025;9(3):2310-2317.

22.

Musheyev

Ksido

Yomtov

, et al. Updated research publication standards and expectations for successful matching in urology residency following step 1 scoring changes. Urology. 2025;197:254-259. doi:10.1016/j.urology.2024.11.011

23.

Umutoni

Istl

Gellings

, et al. Authorship equity in academic surgery: barriers and pathways to parity. J Surg Res. 2026;320:132-140. doi:10.1016/j.jss.2025.06.087

24.

Angell

Publish or perish: a proposal. Ann Intern Med. 1986;104(2):261-262.

25.

Guragain

Ravi Shankar

Wilson

IG.

Examining authorship in publications in selected health professions education journals. Acad Med. 2024;1.

26.

Nydahl

Chahdi

Goetze

, et al. Scientific fraud and dubious publication practices. Med Klin Intensivmed Notfmed. 2025;121:372-377. doi: 10.1007/s00063-025-01307-3.

27.

Condron

Kibbe

Azarow

Martin

MJ.

Courtesy authorship practices among first and senior authors: evaluation of motivations, gender bias, and inequities. Ann Surg. 2021;274(3):434-440. doi:10.1097/SLA.0000000000004999

28.

Al-Herz

Haider

Al-Bahhar

Sadeq

Honorary authorship in biomedical journals: how common is it and why does it exist?

J Med Ethics. 2014;40(5):346-348. doi:10.1136/medethics-2012-101311

29.

CITI. Responsible conduct of research (RCR). 2026. Accessed April 17, 2026.

30.

Ashkenazi

Olsha

Authorship disputes in scholarly biomedical publications and trust in the research Institution. Rambam Maimonides Med J. 2023;14(3). Epub 20230731. doi:10.5041/RMMJ.10503

31.

Faulkes

Resolving authorship disputes by mediation and arbitration. Res Integr Peer Rev. 2018;3(1):12.

32.

Jonas

MyERAS® enhancements: highlighting research and scholarly work. AAMC; 2025. https://vimeo.com/1129670590?share=copy&fl=sv&fe=ci

33.

Eisenberg

Ngo

Bankier

AA.

Honorary authorship in radiologic research articles: do geographic factors influence the frequency?

Radiology. 2014;271(2):472-478. doi:10.1148/radiol.13131710

34.

Mirsky

Munkwitz

Kassira

Pathagamage

Coelho

Thaller

SR.

Evaluating authorship guidelines of top medical schools and plastic surgery journals: a comparative analysis. Ann Plast Surg. 2025;95(5):e53-e63. doi:10.1097/SAP.0000000000004435

35.

Chung

Shauver

Malay

Zhong

Weinstein

Rohrich

RJ.

Is Double-blinded peer review necessary? The effect of blinding on review quality. Plast Reconstr Surg. 2015;136(6):1369-1377. doi:10.1097/PRS.0000000000001820

36.

Hwang

SH.

Is Double-blinded peer review necessary? The effect of blinding on review quality. Plast Reconstr Surg. 2016;138(1):161e-162e. doi:10.1097/PRS.0000000000002284

37.

Subramanian

Maisner

Patel

, et al. A comparison of plastic surgery authorship trends under single versus double-blinded review. J Surg Res. 2024;298:260-268. doi:10.1016/j.jss.2024.03.012

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.02 MB

0.00 MB