What are the most common reasons for a manuscript to be rejected (and how can they be avoided)? In their article on handling manuscript rejection, Woolley and Barron1 offer the following soothing advice: Authors, particularly inexperienced authors, may take comfort in knowing that manuscript rejection is common. The rejection rate for many journals is over 50%, and for top-tier journals, it can be over 90%.2–6 Some of the reasons for these rejections are under the control of the medical writer, whereas others are not. Regardless, medical writers should be aware of the main reasons to minimize their occurrence and to be able to give practical advice to the authors and other contributors.