General guidance on honorary (gift) authorship treats it as a roughly one-in-four to one-in-three problem across biomedical publishing. Surgical subspecialties do not fit that baseline. Discipline-specific surveys of corresponding authors in cardiothoracic surgery, orthopedic/sports medicine, and spine journals report prevalence rates well above the cross-specialty average — high enough, and consistent enough across independent studies, that surgical authorship culture deserves its own analysis rather than a footnote on a general honorary-authorship page.
The numbers: discipline-specific prevalence in surgical journals
Three independent survey-based studies, each using corresponding authors’ own accounts of their most recent publication, put concrete figures on how common honorary authorship is in these fields:
- Cardiothoracic surgery — 62.7% / 25.3%. A survey of corresponding authors across five cardiothoracic surgery journals, published in the Journal of Thoracic and Cardiovascular Surgery, found that 62.7% of the 590 respondents (28.9% response rate from 1,511 authors contacted) reported that at least one of their co-authors had performed only non-authorship tasks — work that does not meet the ICMJE criteria for authorship. Separately, 25.3% of respondents believed their own article contained at least one honorary author when asked directly. The gap between those two figures is itself informative: authors more readily recognize a co-author’s non-qualifying contribution than they label that inclusion “honorary authorship” outright.
- Orthopedic surgery and sports medicine — 41.9% / 14.7%. A survey of 479 corresponding authors (34.4% response rate from 1,392 contacted) of 2019 articles across six orthopedic-dedicated journals found a 41.9% prevalence of guideline-based honorary authorship — meaning 41.9% of articles had at least one author who did not meet all four ICMJE criteria when checked against the guideline directly — versus only 14.7% self-perceived prevalence, the same recognition gap seen in the cardiothoracic data.
- Spine-dedicated journals — reported at approximately half. A survey-based analysis of honorary authorship in leading spine-dedicated journals is reported in the literature as finding ICMJE-defined honorary authorship in roughly half of surveyed articles, broadly consistent with the cardiothoracic and orthopedic figures above. CASRAI was unable to independently retrieve the full primary text of this study at time of writing (paywalled); treat the specific spine figure as a secondary-source approximation rather than a confirmed statistic, and consult the original study before citing it precisely.
For comparison, the honorary-authorship literature across biomedical publishing generally cites a wide 25%–63% range depending on specialty and definition — surgical subspecialties consistently land at or near the top of that range rather than in the middle, and the pattern holds across three independently conducted studies rather than a single outlier survey.
Why surgical subspecialties specifically
The same three studies, and the broader authorship-integrity literature, point to features of surgical training and practice — not just publishing norms in general — that push honorary authorship higher in these fields:
Hierarchical, apprenticeship-based training
Surgical residency and fellowship run on a steep hierarchy: attendings, division chiefs, and program directors supervise trainees closely across years of training, and that relationship often extends automatically into the author list. The orthopedic study identified this directly — having a senior figure who is automatically included on every manuscript submitted from a lab, division, or service was associated with significantly higher odds of honorary authorship. A trainee weighing whether to list a supervising surgeon who reviewed a case but did not meet the ICMJE criteria is not making a purely academic-integrity decision; it is entangled with evaluation, reference letters, and fellowship or job placement.
Large, multi-surgeon procedural teams
A single case series or outcomes study in cardiothoracic, orthopedic, or spine surgery frequently draws on a full operative team — the primary surgeon, one or more assistant surgeons, anesthesia, and sometimes a device representative or proctor — plus referring physicians who contributed patients to the cohort. Performing or assisting with the procedures that generated the data feels, to many surgeons, like a natural basis for authorship even when it does not involve the conception, analysis, drafting, or revision ICMJE actually requires. This is precisely the “solely non-authorship tasks” pattern the cardiothoracic study measured directly.
An awareness paradox, not an awareness gap
Both the cardiothoracic and orthopedic studies found high stated familiarity with ICMJE’s authorship guidelines (77.1% and 91.6% of respondents, respectively) alongside much lower awareness of honorary authorship as an issue in their own work (47.0% in cardiothoracic surgery). Surgeons are not, on the whole, unaware that ICMJE criteria exist — they are far less likely to recognize that a specific, familiar practice in their own department (crediting the attending, crediting the referring surgeon) is an instance of the problem the guideline is meant to prevent. This distinguishes the surgical-subspecialty pattern from a simple knowledge deficit that more ICMJE training alone would fix.
Publication-volume pressure in surgical academic promotion
Academic surgical departments, like most academic medicine, weigh publication count and h-index heavily in promotion and tenure decisions. Where a division’s culture already treats inclusion on trainee- or fellow-authored papers as a customary courtesy to supervising faculty, that norm compounds with promotion incentives on both sides — trainees gain a mentor’s imprimatur and a longer author list is read as more substantial, and faculty accumulate more indexed publications, all without a change in what any individual actually contributed to conception, analysis, drafting, or revision.
Industry and device-sponsor relationships
Orthopedic and spine surgery in particular involve close, disclosed relationships with device and implant manufacturers — consulting arrangements, royalty agreements, and company-sponsored case series are common and are generally handled through conflict-of-interest disclosure rather than authorship itself. But the same commercial relationships that create disclosure obligations can also create informal pressure to credit a company-affiliated proctor, trainer, or liaison who facilitated a study without meeting ICMJE’s substantive-contribution threshold — a distinct, industry-adjacent driver on top of the training-hierarchy and team-size factors above.
What this changes about how the problem should be addressed
Because the drivers above are structural — hierarchy, team size, promotion incentives, industry relationships — generic “know the ICMJE criteria” guidance under-addresses the problem in surgical subspecialties specifically. The orthopedic study’s own finding that 91.6% of respondents already knew the guideline, yet 41.9% of articles still failed it, is the clearest evidence that an awareness campaign alone will not close this gap. What the literature and CASRAI’s own standards work point toward instead:
- A written departmental or divisional authorship policy, set at the level a trainee cannot easily override with a senior colleague’s informal expectation, that states plainly that supervisory or procedural-team roles alone do not qualify for authorship and specifies acknowledgment as the correct alternative.
- CRediT contribution statements at submission, which force an explicit, per-person accounting of what each listed author actually did (see CASRAI’s Contributor Roles Taxonomy coverage) — a structural check that is harder to satisfy with a courtesy inclusion than a bare byline is, though it is not a complete substitute for departmental policy since a contribution statement can still be filled out loosely.
- Explicit acknowledgment language for supervisory and procedural-team roles that do not meet all four ICMJE criteria, rather than silent omission or default inclusion as an author — see CASRAI’s comparison of acknowledgments vs. authorship for who should be listed where.
- Journal-level verification at submission, following COPE’s own flowchart for suspected ghost, guest, or gift authorship, rather than relying entirely on author self-report.
How this relates to general honorary and gift authorship guidance
This page is deliberately narrower than CASRAI’s general authorship-integrity content. If you need the underlying definitions and ICMJE/COPE framework first, start with the dictionary entries on gift authorship and ghost authorship, or the comparison of ghost authorship vs. gift authorship. For whether “honorary” and “gift” authorship are handled differently by editors and institutions, see Honorary Authorship vs. Gift Authorship: Is There a Legal Distinction? — the short answer is no, COPE and ICMJE treat them as the same underlying violation. For the editorial process once a case is suspected, see COPE’s Flowchart for Suspected Ghost, Guest, or Gift Authorship. For industry-sponsored research specifically, see Industry-Sponsored Research Authorship: Avoiding Ghostwriting and Honorary Authorship. What none of those pages cover is discipline-specific prevalence data or the surgical-culture-specific drivers documented above — that gap is what this page addresses.
Frequently asked questions
Why is honorary authorship so much more common in surgery than in other biomedical fields?
The three factors the underlying studies point to most consistently are the steep supervisory hierarchy of surgical training (attendings and division chiefs are often included by default), the size and structure of surgical procedural teams (performing or assisting with a procedure feels authorship-qualifying even when it isn’t, under ICMJE’s actual criteria), and a documented awareness paradox — most surgeons know ICMJE’s criteria exist but do not recognize familiar departmental practices as violating them.
Does performing the surgery that generated the study data qualify someone for authorship?
Not on its own. ICMJE’s authorship criteria require substantial contribution to conception, design, or analysis/interpretation of the work; drafting or critically revising it; final approval of the published version; and accountability for the work — all four, not just one. Performing a procedure is real, valuable clinical work, but by itself it is a “solely non-authorship task” under the ICMJE test, the exact category the cardiothoracic-surgery study measured at 62.7% prevalence. The correct venue for that contribution, absent the other three criteria, is a named acknowledgment.
Is automatically listing your attending or division chief as an author considered honorary authorship?
Yes, if that person did not independently meet all four ICMJE criteria on that specific manuscript. The orthopedic-surgery study found that having a senior figure automatically included on every manuscript from a division was itself associated with significantly higher odds of honorary authorship — a supervisory relationship or departmental custom is not, by itself, a basis for authorship under ICMJE’s framework, regardless of how normalized the practice is locally.
Can a CRediT contribution statement fix honorary authorship in surgical departments on its own?
It helps but is not a complete fix. Requiring every listed author to specify which CRediT roles they actually performed makes a courtesy inclusion harder to justify on paper than a bare byline does, and creates an auditable record. But a contribution statement can still be completed loosely if departmental culture and journal-level verification don’t reinforce it — the studies above found high ICMJE awareness alongside persistently high honorary-authorship rates, suggesting structural incentives, not just documentation gaps, need to be addressed directly.
What should a trainee do if a supervisor expects to be listed as an author without qualifying contributions?
This is precisely the scenario COPE’s guidance on authorship disputes is designed for. Where possible, raise the specific ICMJE criteria and CRediT roles directly and propose acknowledgment as the accurate alternative before submission; where power dynamics make that difficult, journal editorial offices and institutional research-integrity offices are the intended escalation points, following the process in COPE’s flowchart for suspected ghost, guest, or gift authorship linked above.
