Metlit-01 Misconduct - Prof. Dr. Sudigdo S, SpA(K)

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    Many people say that

    it is the intellectwhich makes a great

    scientist.

    They are wrong: it ischaracter

    A lbert Eins tein

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    Lies, damn lies, statistics

    Mark Twain

    Lies, damn lies,

    science

    NN

    No, its

    Shania!

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    Plagiarism. http:/www.ehhns.cmich.edu/ ~mspears/whatis.html

    Educating professionals. http://www.unisa.edu.au/adminfo/policies/manual/misconduct.htm. Accessed June 2004

    Jones R. Research misconduct. Fam Pract 19:123-4, 2002.

    Addison PA. Academic misconduct, definitions, legal issues, and management.

    Available from http://cea.curtin.edu.au/tif2001/ addison2.html. Accessed June2004

    Plagiarism, cheating and misconduct. Available from

    http://www.wuc.edu.au/call/index.htm. Accessed June 2004

    The University of ChicagoReports of the Provost s Committee on Academic

    Fraud. www.uc-edu.sci

    Academic honesty. University of Massacchusetts Amherst - Undergraduate

    Rights and Responsibilities 2001-2002.

    Decker C, Burgess C. A taxonomy of plagiarism and academic fraud. Language

    Machine, 2003.

    Selected references

    http://www.unisa.edu.au/http://www.unisa.edu.au/adminfo/policies/manual/misconduct.htmhttp://www.unisa.edu.au/adminfo/policies/manual/misconduct.htmhttp://cea.curtin.edu.au/tif2001/addison2.htmlhttp://www.wuc.edu.au/call/index.htmhttp://www.uc-edu.sci/http://www.uc-edu.sci/http://www.uc-edu.sci/http://www.uc-edu.sci/http://www.wuc.edu.au/call/index.htmhttp://cea.curtin.edu.au/tif2001/addison2.htmlhttp://www.unisa.edu.au/adminfo/policies/manual/misconduct.htmhttp://www.unisa.edu.au/adminfo/policies/manual/misconduct.htmhttp://www.unisa.edu.au/
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    Ethical Question: Why Did the

    Chicken Cross the Road?

    Plato:For the greater good.Shakespeare:To cross or not to cross, thatis the question.

    Einstein:Whether the chicken crossed theroad or the road crossed the chickendepends on your frame of reference.Darwin: It was the logical next step aftercoming down from the trees.Graduate student:Was that regular orextra-crispy?

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    Research Code of Scientific Ethics

    I dedicate myself to the pursuit, promotion, andadvancement of scientific knowledge.

    I will conduct, manage, judge, and report scientific

    research honestly, thoroughly, without conflict ofinterest

    I will prevent abuse of all resources entrusted to meand endeavor to treat subjects humanely, following

    established guidelines where they are available.I will not willfully hinder the research of others norengage in dishonesty, fraud, deceit,misrepresentation, or other professionalmisconduct.

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    I will welcome constructive criticism of mypersonal scientific research and offer the sameto my colleagues in a manner that fostersmutual respect amid objective scientific

    debate.I will recognize past and present contributorsto my research and will neither accept norassume unauthorized and/or unwarranted

    credit for another's accomplishments.I will claim authorship for a research productonly if I am willing to be held responsible forboth the interpretation of the data and theconclusions as presented.

    Research Code of Scientific Ethics

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    I will claim authorship for a research product only ifI have made a major intellectual contribution (aspart of conception, design, data collection, dataanalysis, interpretation) and made significant

    contributions to its preparation (write, review, edit).I will not publish or use original ideas, researchdata, or unpublished findings of others withoutwritten approval.

    I will refrain from duplicative publication of thesame research findings as original.

    I will show appropriate, diligence toward preservingand maintaining resources, such as data recordsentrusted to me.

    Research Code of Scientific Ethics

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    Cheating

    Defined by its general usage

    A major academic misconduct

    Technique:

    Taking small notes Directly see others work Communicating with other students during exam Using false identification during exam

    Using electronic devices & other sophisticatedmethods

    Should have severe penalty (graded, dependingon the frequency and severity)

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    !!!Severe penalty (up to

    discontinuation of thestudy program) will be

    applied to those who

    cheat in whatevertechnique(s) used!

    WARNING

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    Scientific misconduct =

    FFP

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    Definition of Scientific

    Misconduct

    Scientific misconduct is fabrication,

    falsification, or plagiarism in proposing,performing, or reviewing research, or inreporting research results.

    Federal ResistorOctober 14, 1999

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    Scientific misconduct /

    Fraud

    Misconduct in research is defined as"fabrication, falsification, plagiarism, or otherserious deviation from generally acceptedpractices in proposing, conducting, or reportingresearch.

    It does not includeerrors of judgment, error in

    recording, selection, or analysis of data,differences in opinions involving theinterpretation of data, or misconduct unrelated tothe research process.Nat Acad Press 1992

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    Honest error - examples

    Improper use of statistical test: usingindependent t-test for paired data

    Poor understanding of research methodsprinciples: Consider alternating assignment as

    a valid technique for randomizationWrong interpretation: r = 0.16, P= 0.002

    Conclusion: There is a significant correlationbetween abdominal circumference and HDL

    cholesterol level.(The correct interpretation should be: Thereis NOcorrelation between abdominal circ.

    And this result is very unlikely caused by play

    of chance).

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    Misconduct / Fraud (contd)

    plagiarism,or other serious deviationfrom generally accepted practices..

    stealing idea or data during the peer review

    processdishonesty in authorshipillegal use of research budget

    it does not include.interpretation of data, or

    misconduct unrelated to the research process.sexual harassment, crude behavior, etc.

    Nat Acad Press 1992

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    May occur from idea, proposaldevelopment, study execution, data

    analysis, publicationMay be intentionalor non-intentional

    Non-intentional misconduct is treated and

    managed as severe as intentionalmisconduct, especially after being warnedor done repeatedly

    Misconduct in research

    Nat Acad Press 1992

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    The Tuskegee Syphilis

    Experiment: Extraordinary misconduct

    In 1932 the American Government promised 400men - all residents of Macon County, Alabama, allpoor, all African American - free treatment for BadBlood, a euphemism for syphilis which wasepidemic in the county.

    Treatment for syphilis was never given to the men

    and was in fact withheld. The men becameunwitting subjects for a government sanctionedmedical investigation

    The Study of Untreated Syphilis in the Negro Male

    lasted for 4 decades, until 19721998-2003.thetalkingdrum.com.

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    On July 23, 1973, Fred Gray a prominent civilrights lawyer, brought a $1.8 billion class actioncivil suit

    Gray demanded $ 3 m for each living participantand the heirs of the deceased. The case nevercame to trial.

    In 1974, the government agreed to a $10 million

    out of court settlement. The living subjects eachreceived $ 37,500, the heirs of the deceased,$15,000.

    PHS officers felt no guilty; on the contrary, theyfelt they were acting good conscience. No

    The Tuskegee Syphilis Experiment

    1998-2003.thetalkingdrum.com.

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    In engineering, the term "fabrication"has abenign connotation, meaning to make

    something.In research ethics the term "fabrication"means making up data, experiments or,other significant information in proposing,conducting, or reporting research.

    Fabrication

    Nat Acad Press 1992

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    John DarseeJohn Darsee(born 1948) was a medical researcherwith an impressive publications (>100) but found tohave fabricated data.

    He worked at Harvard, as research fellow at theCardiac Res Lab, and considered as the most

    remarkable of the 130 fellows who had worked at thelab

    Some colleagues caught him labeling data from oneshort measurement as if it had been data from

    several experiments collected over weeks. Darseehad previously used false data between 1966 &1970. Many papers had to be retracted incl. fromEmory & Harvard Universities.

    Darsee had to give up his research career andbecame a critical care specialist.

    http://en.wikipedia.org/wiki/Harvard_Universityhttp://en.wikipedia.org/wiki/Harvard_University
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    HIV/AIDS research controversy

    In 1984, Gallo and co. published a series of 4papers in Sciencearguing that HIV, aretrovirus that had recently been identified in

    AIDS patients by Luc Montagnierand his

    collaborators at the Pasteur Institutein Paris,was the cause of AIDS.

    Today it is generally agreed that Montagnierfirst identified HIV, although Gallo's group is

    credited not only to the science which madethe discovery possible, but also significantly todemonstrating that it causes AIDS. The twoscientists continued to challenge each other's

    claims until 1987, when they agreed to share

    http://en.wikipedia.org/wiki/1984http://en.wikipedia.org/wiki/Science_%28journal%29http://en.wikipedia.org/wiki/HIVhttp://en.wikipedia.org/wiki/Luc_Montagnierhttp://en.wikipedia.org/wiki/Pasteur_Institutehttp://en.wikipedia.org/wiki/Parishttp://en.wikipedia.org/wiki/Parishttp://en.wikipedia.org/wiki/Pasteur_Institutehttp://en.wikipedia.org/wiki/Luc_Montagnierhttp://en.wikipedia.org/wiki/HIVhttp://en.wikipedia.org/wiki/Science_%28journal%29http://en.wikipedia.org/wiki/1984
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    William Summerlinworked at the MemorialSloan-Kettering Cancer Center. He claimed thathe could transplant tissue from unrelated animalsby keeping the tissue in culture for four to six

    weeks. He used white mice with patches of blackfur which he had colored with a black permanentmarker.

    In 1974, Summerlin was discovered when he

    made a presentation to immunologist RobertGood; lab assistants noticed that the patches hadbeen drawn on the mice and could be removedusing alcohol. The forgery was attributed to a

    mental health problem. Author J. Hixson wrote a" "

    William Summerlin

    http://en.wikipedia.org/wiki/Memorial_Sloan-Kettering_Cancer_Centerhttp://en.wikipedia.org/wiki/Memorial_Sloan-Kettering_Cancer_Centerhttp://en.wikipedia.org/wiki/1974http://en.wikipedia.org/w/index.php?title=Robert_Good&action=edithttp://en.wikipedia.org/w/index.php?title=Robert_Good&action=edithttp://en.wikipedia.org/w/index.php?title=Robert_Good&action=edithttp://en.wikipedia.org/w/index.php?title=Robert_Good&action=edithttp://en.wikipedia.org/wiki/1974http://en.wikipedia.org/wiki/Memorial_Sloan-Kettering_Cancer_Centerhttp://en.wikipedia.org/wiki/Memorial_Sloan-Kettering_Cancer_Centerhttp://en.wikipedia.org/wiki/Memorial_Sloan-Kettering_Cancer_Centerhttp://en.wikipedia.org/wiki/Memorial_Sloan-Kettering_Cancer_Center
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    Andrew Wakefield(born 1956), best known asthe lead author of a controversial 1998 researchstudy, published in The Lancet, which reportedbowel symptoms in a selected sample of twelvechildren with autistic spectrum disorders andother disabilities, and alleged a possibleconnection with MMR vaccination. In a pressconference Dr. Wakefield recommendedseparating the components of the injections by at

    least a year. The recommendation wasresponsible for a decrease in immunization ratesin UK. The section of the paper setting out itsconclusions, known in the Lancet as the

    "interpretation", was subsequently retracted by

    The MMR ~ Autism controversy

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    A panel from Seoul National University has beenexamining the work of Hwang Woo-suk, hithertoregarded in South Korea as a hero for bringing thecountry to the forefront of stem-cell and cloning

    studies -- and the world the first cloned dog.

    Scientist fabricated stem-celldata: panel (Reuters) -South Korea's most famous

    scientist quit under a cloud onFriday and could faceprosecution after said results ina landmark 2005 paper on

    producing`tailored embryonicstem cells were intentionallyfabricated.

    http://search.news.yahoo.com/search/news/?p=South+Koreahttp://search.news.yahoo.com/search/news/?p=South+Korea
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    Falsification

    In research ethics the term "falsification"means changing or misrepresenting dataor experiments, or misrepresenting other

    significant matters, such as the credentialsof an investigator in a research proposal.

    Unlike fabrication,distinguishing

    falsification of data from legitimate dataselection takes judgment and anunderstanding of statistical methods.

    Nat Acad Press 1992

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    Falsification

    BF: Ive done research for 40 years, almost all fromgovernment grants. The charges of scientific misconductwere brought against me by an official of the National

    Cancer Institute (NCI), bringing the charge to the Officeof Research Integrity (ORI). I was accused of havingused falsified data in my publicationsnot my falsifieddatabut data which had been falsified by anotherinvestigator from St. Luc Hospital in Montreal, Canada...http://www.physiciansnews.com/spotlight/497wp.html

    Bernard Fisher, M.D.,is Distinguished

    Service Professor of Surgery, University ofPittsburgh School of Medicine, andScientific Director of the National Surgical

    Adjuvant Breast and Bowel Project(NSABP). He is one of three researchers

    who were exonerated from nationallypublicized scientific misconduct.

    http://www.physiciansnews.com/spotlight/497wp.htmlhttp://www.physiciansnews.com/spotlight/497wp.htmlhttp://www.physiciansnews.com/spotlight/497wp.htmlhttp://www.physiciansnews.com/spotlight/497wp.html
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    What is the scientific worlds attitude onscientific misconduct?

    Unfortunately, medicine and biology,

    especially, have been hit hard by fraud. Onestudy found 94 cancer papers likely

    contained manipulated data. Two yearslater, many of the papers were still notretracted. This confirms the conclusion thateven when scientific misconduct is proven,

    no reliable mechanism exists to remove bad

    information from the literature.

    Sanctions of scientific misconduct

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    Plagiarism

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    Plagiarism

    defined

    If you want to converse with me,define your term (NN)

    Every definition is dangerous (NN)

    To be intelligible one must be inaccurate,

    to be accurate one must be unintelligibleBertrand Russell

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    If you steal from one author,

    it is plagiarismIf you steal from many,

    it is research

    Wilson Mizner

    Plagiarism

    defined

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    Plagiarism: What is it?

    The unacknowledged use, as ones own, of work ofanother person, whether or not such work has beenpublished (University of Malta Regulations, 1997)

    To take someone elses words or ideas and presentthem as your own without proper acknowledgment(Marshall & Roland, 1998)

    The use another persons idea or a part of their

    work and pretend that is your own

    The reproduction, in whole or essential part, of aliterary, artistic or musical work by one who falselyclaims to be its creator http://auth.grolier.com/>

    http://dictionary.cambridge.org/http://auth.grolier.com/http://auth.grolier.com/http://dictionary.cambridge.org/
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    Plagiarism: What is it?

    Plagiarisme adalah tindakan yang dapat diartikansebagai pencurian ide atau hasil pemikiran dan tulisan

    orang lain yang digunakan dalam tulisan seolah-olah

    ide atau tulisan orang lain tersebut adalah ide atauhasil tulisannya sendiri untuk keuntungannya sendiri

    sehingga merugikan orang lain baik materiil maupun

    non-materiil, atau plagiarisme dapat berupa pencurian

    sebuah kata, frase, kalimat, atau alinea, atau bahkanpencurian suatu bab dari sebuah tulisan atau buku

    seseorang, tanpa menyebut sumber yang dicuri. (Draft

    SK Rektor UI)

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    Plagiarism is submitting or presenting

    someone elses idea or words without

    proper acknowledgment(UBC Calendar)

    No!!!

    Is publication a prerequisite

    for plagiarism?

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    Classification of plagiarism

    According to aspects plagiarized idea substance or content words, sentence, etc

    According to intentionality deliberate / intentional plagiarism reckless plagiarism

    According to the proportion of plagiarizedmaterials:

    mild < 30% moderate 30-70% severe / complete >70%

    According to mode plagiarism: word-for-word plagiarism mosaic plagiarism

    Self / autoplagiarism

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    Plagiarism of others idea

    Research replication is encouraged inmedicine (to lesser extent: in biologicalsciences)

    Large variations related to age, sex, race,study setting, individual responses make itimportant to verify previous study in differentpopulations

    The report should explicitly indicates thatsimilar work has been done in the past, andthe present study was done to verify theresults in other setting or population;otherwise the author confines to plagiarism

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    Plagiarism of words,sentence, etc

    Quoting directly, paraphrasing or writing

    about someones ideas without giving areference

    Using an authors exact words without

    indicating they are quoted and referencedPresenting your own version of otherpeoples ideas without acknowledgment

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    Arjuna mencari cintaPlagiarism in film, painting, etc

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    Transcribing or modifying text from anyprinted material (books, magazines,encyclopedias, newspapers)

    Using photographs, video or audio withoutpermission

    Using another students work and claimingit as your own is plagiarism, also knownas collusion

    These are

    plagiarisms

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    Literal translation from one language toanother is NOT using your own words; thus it

    is plagiarismUsing an essay that you wrote for anotherclass without permission from the professor isknown as self-plagiarism or autoplagiarism. Italso means submitting or publishing the yourown published materials without indicatingthat the work has been presented or

    published.

    These are

    plagiarism

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    Taking an image, diagram, or artwork fromanother source without acknowledgement

    Collaborating inappropriately with otherstudents when individual work is required

    Copying another students work or

    someoneelses work and submitting it as your own

    These are

    plagiarism

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    Deliberate plagiarism

    Buying, stealing, or using somebodyelses brain-power to do your work for

    you are all acts of deliberate plagiarismYou can expect the most severe ofpenalties

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    Avoid accidental plagiarism

    You probably dont want to get into trouble

    for accidental plagiarism

    I didnt mean tois not an excuse, andmay be punished as severely as adeliberate act of plagiarism

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    Severity of plagiarism

    < 30% - mild

    30-70% - moderate>70% -severe/complete

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    Why plagiarize?

    Misunderstand how to use academicconventions appropriately

    Have poor writing skillsAre too busy to study and have otherdistractions

    Are unmotivated

    Lack confidence or have a fear of failure

    Find the material complex and abstractand struggle to grasp the meaning.

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    If the information is found in severalsources, it can be considered commonknowledgeand probably does not need tobe cited (UI: > 5 sources).

    If the information is a specific authors

    research, you must create a citationwithin the paper and include the source inthe References List

    Common knowledge /

    Public domain (1)

    C k l d /

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    Examples of common knowledge

    Aorta arises from the left ventricle andsupplies blood throughout the tissues of the

    bodyIn metabolic acidosis the pH, PCO2, andbicarbonate decrease, while inuncompensated metabolic alkalosis the

    reverse are trueBut if it is specific for other research,

    referencing is a must:

    Recent data indicate that the incidence ofasthma in rural area has increased from 5 to

    Common knowledge/Public domain (2)

    C k l d /

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    Writing a textbook with usual arrangements(Title, Definition, Etiology, Pathogenesis,

    Clinical Manifestations, etc) is notplagiarism of idea

    Writing a research report with standardformat is not plagiarism

    Re-drawing figure(s), if not original orspecific is not plagiarism (e.g., diagram ofclinical trial process, illustration of cardiac

    malformation, etc.)

    Common knowledge /Public domain (3)

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    Evidence-based medicine is defined as

    The conscientious, explicit, and judicioususe of current best evidence in makingdecisions about the care of individualpatients1,2

    Evidence-based medicine, whichunderlines the importance of explicitly and

    judiciously using current best evidence inpatients management1,2 has gained itspopularity in the last decade.

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    Clinical governance is a framework of qualityimprovement process of clinical care that should

    be implementation in all levels of medicalservices. Excellence in clinical care can beachieved by creating an environment thatpromotes high standard of care (NIH, 1996)

    According to National Institute of Health (1996)Clinical Governance is a framework through

    which NHS organizations are accountable forcontinuously improving the quality of theirservices and safeguarding high standards ofcare, by creating an environment in which

    excellence in clinical care will flourish.

    This passage was originally written by

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    Although correspondence with authors, ethicscommittees, university departments, and

    hospitals can be a painstaking and thanklessbattle with bureaucracyjust like seekingethics committee approvalwe believe thateditors have a duty to take on issues of

    unethical audit or research. Our motivation isnot to seek punishment for the authors but toprevent future unethical clinical practice andto protect patients.

    This passage was originally written by

    Kamran Abbasi and Iona Heath, and

    published in BMJ 2005;330:431-432.

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    Although correspondence with authors,

    ethics committees, university departments,and hospitals can be a painstaking andthankless battle with bureaucracyjust likeseeking ethics committee approvalwebelieve that editors have a duty to take onissues of unethical audit or research. Ourmotivation is not to seek punishment for the

    authors but to prevent future unethicalclinical practice and to protect patients.

    (Plagiarism, because of no reference)

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    Although correspondence with authors,ethics committees, university departments,and hospitals can be a painstaking andthankless battle with bureaucracyjustlike seeking ethics committee approvalwe believe that editors have a duty to take

    on issues of unethical audit or research.Our motivation is not to seek punishmentfor the authors but to prevent futureunethical clinical practice and to protect

    patients (Abbasi and Heath, 2005).[Plagiarism despite referencing

    because the author(s) used others

    exact words]

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    Correspondence with authors and other

    relevant sources (including ethicscommittees, university departments, andhospitals) should be performed to make surethat unethical audit on research is incorrect.Editors should try their best despite manyobstacles that may prevent them from gettingthe information easily. The primary aim is to

    prevent future unethical clinical practice andto protect patients (Abbasi and Heath, 2005).

    [No plagiarism because of paraphrase andreference

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    Abbasi and Heath (2005) believe thatAlthough correspondence with authors,

    ethics committees, university departments,and hospitals can be a painstaking andthankless battle with bureaucracyjust likeseeking ethics committee approvalwebelieve that editors have a duty to take onissues of unethical audit or research. Ourmotivation is not to seek punishment for theauthors but to prevent future unethicalclinical practice and to protect patients.

    [No plagiarism because the use of

    quotation mark and reference]

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    What about Paraphrasing?

    Paraphrasing is using someones ideasbut putting it in your own words.

    This is a very common and standard partof writing research reports. There is a rightway and a wrong way to paraphrase. Youstill have to acknowledge the source.

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    Tips on Paraphrasing Correctly

    Be sure that you are not just rearrangingor replacing a few words.

    Read over what you want to paraphrasecarefully; cover up the text with your hand,or close the text so you can't see any of it(and so aren't tempted to use the text as a"guide"). Write out the idea in your ownwords without peeking.

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    Check your paraphraseagainst theoriginal text to be sure you have notaccidentally used the same phrases or

    words, and that the information is accurate

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    Remember

    Create Bibliography as you goall

    sources!

    Write down the page numbersQuote someones exact words & (cite it)

    Cite uncommon knowledgeideas,

    opinions & interpretations, little knownfacts

    Paraphrasing is more than re-wording. Put

    it in your own words and cite it.

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    If You Borrow:

    words, ideas,theories, opinions

    even paraphrased

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    Cite It!

    Example of plagiarism from internet

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    p p g

    source:

    Loose citation of web sources

    Persons who are right-brain dominant tendto process the emotional and artistic

    aspects of an advertisement better thanpersons who are left-brain dominant(yahoo.com).

    Plagiarism: Reference is far tooambiguous. Use the FULL, COMPLETEweb page address and date accessed.

    (http://www.csun.edu/brucelammers/mkt348/splitbrain.doc,

    accessed June 12, 2004).

    Wh t b t lid f

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    If not accompanied by full-text article, allspecific information should be referenced onthe slide

    If the materials have been presented in othermeeting(s), information to the audience (toavoid autoplagiarism) is recommended. This

    also applied for updated case seriesUsing (stealing) slides from other authorwithout proper credit is a kind of plagiarism

    No references are needed for commonknowled e

    What about slides forpresentation? (Personal v iew)

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    Authorship

    An "author"is generally consideredto be someone who has made

    substantive intellectualcontributions to a published study

    International Committee of Medical Journal Editors, 2006

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    Authorship

    Authorship credit should be based on

    1. substantial contributions to conceptionand design, or acquisition of data, or

    analysis and interpretation of data;2. drafting the article orrevising it critically

    for important intellectual content; and

    3. final approval of the version to bepublished.

    Authors should meet conditions 1, 2, and 3

    International Committee of Medical Journal

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    Authorship

    The order of authorship on the bylineshould be a joint decision of the co-authors.Authors should be prepared to explain the

    order in which authors are listed. (Scientificintegrity!!!)

    All contributors who do not meet the criteria

    for authorship should be listed in anacknowledgmentssection

    Ghost authoris unacceptable

    International Committee of Medical Journal Editors, 2006

    Wh t i i ht?

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    What is copyright?

    Copyright is legal ownership of a work, whetherprinted or online. A work's author "has theexclusive right to control how a work, includingany derivative works, is reproduced, published,

    and performed. A work is protected undercopyright for the life of the author plus 70 years.

    Anything that you post on the Web is

    immediately covered by copyright law, even ifyou don't append a copyright statement to it. Ifyou want to allow certain uses for your work(such as educational ones), you can add a

    statement to that effect on your pages.

    Role of Research Ethics

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    Role of Research Ethics

    Committee

    Research Ethics Committeeor InstitutionalReview Board (IRB)has the obligation toreview that all researches involving human

    participants should be done in accordancewith Declaration of Helsinki

    Protects participants, public, researchers,

    institutions, and scienceInclude methodological aspects: ascientifically unsound research isautomatically unethical (WHO)

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    If you are not

    confused,you are not

    well-

    informedThank you