A Dirty Look at the AMA Manual of Style

Remember how much fun you had reading The Elements of Style? How about the times you yukked it up over the ambiguity examples in Warriner’s English Grammar and Composition? Here is a classic to jog your memory:

As soon as the students had left the classrooms, the custodians cleaned them.

That’s entertainment!

You can revisit those days of abandon in the quest for clear writing, even if no one seems to chuckle when they consult the AMA Manual of Style. Maybe this owes to its being a behemoth. If you wish to consult the manual with a smile instead of grim determination, the opportunities are there.

Every so often, a nonassociation style guide becomes a bestseller. Such a chartbuster assumes that usage matters, and that correct usage rules and examples entertain and inform. Authors have climbed the list with pragmatism (thanks, Susan Thurman), charm (hi, Mary Norris), innuendo (I’m talking to you, Lynne Truss), or light-heartedness (howdy, Bill Bryson).

Some even go dirty, quick and dirty, as in Mignon Fogarty’s amazing Grammar Girl. I understand this. A down and dirty read (a basic, practical review and not a backstreet editing assignation) is often called for when deadlines loom.

But pragmatic or dirty, these bestsellers put their readers in good hands. That they entertain and inform offers a springboard for a quick dive into the ways that the style manual, in addition to assuring you that you’re in good hands, can entertain as it informs. Here is a representative down and dirty look at a portion of the manual.

If you hand out Halloween candy, you have seen the proverbial “fun size,” a bite that only leaves you wanting more unless it is a Butterfinger. My idea of fun size would be a candy bar as big as my arm. However, any amount of candy is fun (except a Butterfinger), so in that spirit, small can be fun size. By my original standard, the 1010-page Manual of Style is already fun size, but chapter 11 offers the overlooked qualities of being thought-provoking and entertaining. (So do chapters 7-10, 12, and 13, but that is another post.)

The online manual can take you right to 11 without the papercuts, but the idea is to look at its alignment with the tone of popular usage books. From a certain vantage, this chapter could stand as a compact usage book alongside other usage books that sell well. A fun size AMA style guide!

The “Correct and Preferred Usage” chapter starts with 2 fun quotations, one with empathy for proofreaders and another that mentions a porcupine. The entries begin with word choice examples aplenty (similar to Bryson’s look at troublesome words), with italicized labels and directives that establish a hierarchy (Incorrect, Correct, Also Correct, Avoid, Preferred, Also, and the apotheosis of middle ground, Acceptable).

Sometimes a truth plainly spoken is in itself amusing, and that truth can orient you toward correcting descriptive language. The entry “abnormal, normal, negative, positive” indicates “Examinations and laboratory tests and studies are not in themselves abnormal, normal, negative, or positive.” If you have gone around allowing authors to describe tests as negative, it can be bracing to see such clear direction.

The entry for Jargon offers a similar plain-spokenness. “….[D]rugs are usually neither systemic nor local but are given for systemic or local effect.” Parallelism can sharpen a keen awareness of specificity.

Because redundant words are always funny according to natural law, section 11.2, with its eye-opening list of redundancies, expendable words, and incomparable phrases, can supply abundant levity. You will also encounter a well-known quotation from Yogi Berra.

The legal profession once advocated plain language (ha ha!). Everyone talks about jargon, but the AMA Manual of Style does something about it. Granted, you can violate the manual’s jargon directives and still be allowed to walk around freely, vote, and drive a car, but if you see what Morris Fishbein wrote on page 408, you will never want to use jargon again. Even by accident or in an emergency.

Chapter 11 contains scores of other usage grace notes. Shakespeare’s Polonius says, “brevity is the soul of wit,” and you can verify that by looking up “describe, report” for an example. Even one of the longer entries (“because of, caused by, due to, owing to”) ends with a lovely Clue to usage (a one-off category) that brings it all home in 3 lines.

One-off labels nod toward the gray areas of usage, which are usually skillfully handled in style guides. The manual may be a behemoth, and another one-off category, Possible exception, under “adherence, compliance,” may help explain why. This example shows its accommodation of nuance. Nuance can take space.

Across its chapters, the manual draws from literature (Alexander Pope, Samuel Johnson, Mark Twain, Toni Morrison) for contextual quotations. Medical editing embraces the humanities in its quest for clarity.

For a good time, read chapter 11 of the AMA Manual of Style.  It shares some of the endearing qualities of the bestselling usage guides (except, I think, innuendo). Review the material when you aren’t searching for an answer. It’s not just for reference anymore.—Timothy Gray


Yet Another Top 10 List

It is officially the Week of Way Too Many Top-10 Lists and Year-End Wrap-ups, but maybe you can stand one more, from your pals at AMA Style Insider. Below are some links to our most popular (by number of views) posts of 2017.

In order of popularity…

  1. The clear fan favorite: Tracy’s post on the singular “they.” (Some of you got pretty heated about this—as moderator/managing editor, I even had to “decline” a few abusive comments. Pretty sure singular “they” is the future though, so maybe try to cope?)


  1. A post on the “death dagger” from me. I am not kidding myself; the puppy photo is the real draw here.


  1. A post on not even remotely understanding what you’re editing, also from me.


  1. The (in-)appropriate use of cause-and-effect language from Paul. Every editor here at JAMA Network can empathize with this one.


  1. Amanda’s post on “people-first language.” Stay woke, editors.


  1. A post worth revisiting, especially if you use the New Year to declutter your living space: “Discard the Rest.” Let’s get rid of junk: in our closets and in our manuscripts!


  1. How in the world do you capitalize “per” in different contexts? What even is “per”? Tim ponders the deep questions.


  1. Punctuation makes the news.


  1. Sex, gender, and scientific tables.


  1. Sara visits our old friend the forest plot.


That will do it for the year! GOODBYE 2017! GOODBYE FOREVER! We look forward to bringing you fresh new content relating to all things AMA style in 2018.—Brenda Gregoline, ELS



Magic or Medicine?

I am a serious news junkie these days, and I am never satisfied by the stripped-down daily brief or casual perusal of the headlines. I want the digging-into-the-deep-marrow kind of in-depth reporting that seems to be in decline in our instant-gratification-obsessed culture—the kind that takes months of investigation and hard work to uncover, and real talent to produce and present cohesively. I have found that one of the most enjoyable ways to quench my thirst for this type of journalism is in the form of podcasts. For culture and politics The Center for Investigative Reporting’s Reveal is absolutely on point, as is Politico’s the Global Politico. If you are a health care policy wonk, the new podcast put out by vox called the Impact produces very compelling stories on how policy impacts human lives. Oh  hey, and did you know that the JAMA Network also produces a podcast series where you can catch up on the research, opinion, and educational content from across all our journals while on your daily commute or during your workout?

For me though, the absolute best example of the kind of work that a podcast can do is to be found in WNYC’s Radiolab. This is a highly entertaining and effective show where culture, science, and the humanities converge in ways that are entertaining, enlightening, and often deeply moving.

It was on Radiolab that I encountered a fascinating story that encompassed some of the questions central to my own scholarly interests: ancient texts and the intersections between superstition and science, magic and modernity. The episode is called Staph Retreat, wherein we learn of 2 researchers at the University of Nottingham who make a surprising medical discovery in an enigmatic 1000-year-old text called Bald’s Leechbook.

The story centers around a bioscientist who studies history as a hobby and a historian who dabbles in bioscience in her spare time. The pair share a fascination with the medical text and decide to use their combined talents to put one of the remedies to the test in a scientific study. The remedy is for what appears to be a staph infection.

Remarkably, they found that the remedy was efficacious in treating Staphylococcus aureus in an in vitro model of soft tissue infection and even killed  methicillin-resistant S aureus (MRSA) in a mouse wound model. You can find the peer reviewed findings of their study published under an open access license in mBio here.

At a time when the dangers of antibiotic-resistant bacteria are becoming more apparent and urgent, is it possible that ancient texts may hold novel approaches to keeping our armamentarium apace with the evolution of these resistant infections? That may be a stretch, but it does open up a whole new area of study, ancientbiotics, which could theoretically yield new treatment options for increasingly resistant bacterial infections.

Perhaps equally important,  this scholarship has implications that pertain to our modern conceptions of premodern physicians and caregivers. These researchers discovered that the efficacy of the remedy was decreased if any one of the ingredients was removed, implying a synergistic activity of the entire combination. This highlights a level of rational methodology that is often denied to premodern medical professionals by modern medical historians.—Gabriel Dietz


Dial “A” for Author

It’s a cold winter day, and the wind is howling. You are at your computer quietly editing a manuscript while sipping your coffee. Maybe you are in a cube at an office surrounded by matching cubes occupied by your colleagues. Maybe you are in your home office with your cat snoozing on your lap. Suddenly, you are startled by a noise. Brring, brring…brrring, brrring. Your cat springs off your lap; you spill your coffee on the keyboard. Gasp, it’s the phone! You look at the caller ID, and it’s an author to whom you recently sent an edited manuscript with many queries. Your heart races. What should you do? Should you answer? Should you pretend you’re not there, curl up in a ball with the cat under your desk, and wait for a voicemail?

I think that many of us at some point in our careers have felt dread when the phone rings. We may fear that an author is going call us to express disapproval or even anger about our edits and want to fight about style. And some of us are so introverted, we don’t like talking on the phone in general. The author call can be daunting, but remember that copy editors and authors have the same goal–to communicate the authors’ research accurately, consistently, clearly, and according to AMA style.

I find that most author phone calls are simply for clarity about the edits or for questions about publication information. However, in some instances, authors will insist on providing their comments on all of the edits over the phone. Communicating more than a few changes over the phone leaves a lot of room for error, can be time consuming, and relies on good note-taking. To avoid this situation, I usually suggest to the author that they provide their edits in an email or a marked-up version of their manuscript to ensure that their edits are accurately incorporated into the document.

On (hopefully) rare occasions, authors will call to express distaste with the edits. My strategy is to be calm, listen, and wait for the author’s exasperation to pass. We may need to negotiate with authors. If they insist on using a term that is contrary to style that I can’t budge on, I offer them a style variation that they want elswehere in the manuscript for which the rules are less strict. But if the author is really disrespectful, I let the appropriate person know. It’s not fair to be belittled for doing our job.

Then there are the authors who enjoy a personal connection and just like to chat. I recently had an author call me and tell me about his chihuahua. I am always up to talk about pets in the midst of reading about medical conditions all day. Even though the call required some time out of my busy day, the author was appreciative of my willingness to chat.

It’s always possible that you will work with an author again in the future, so it’s never a bad idea to establish a cordial, trusting relationship through open communication. So we must take a deep breath, answer that phone, put on our best nice voice, and be ready to cite the AMA Manual of Style.—Sara M. Billings

Living With Style

Did you know that the Chicago Museum of Science and Industry doesn’t follow AMA style? Here’s proof:

There are a few things I would change if I could edit that. Amanda, author of “People-First Language,” texted this to me and a few other JAMA Network editors a few weeks ago. It got me thinking about some stuff. Namely: am I becoming a style snob?

I know I’m not a grammar snob. I’m a lazy talker who don’t always speak good. No matter how many times I’m corrected, “my friends and I” never hang out, but “me and my friends” do. I don’t really care about parallel structure or flat adverbs when talking because—when it comes to speech—I think communication is more important than talking proper.

But that’s grammar. Like Amanda, I’m noticing style in everyday life, and I can’t not want to correct it. Whenever my girlfriend talks about side effects, I mutter “adverse” under my breath. I joke with a friend that she isn’t “suffering” through the day but simply “experiencing” it. I’m starting to change “compared to”s to “compared with”s on the fly when reading children’s books aloud. Seriously: I’m starting to change children’s books to style.

All of this is pretty harmless, and I’d imagine my manager is happy that some style changes are becoming automatic. But outside of work? I don’t want to be so automatic that I change, for example, “Alzheimer’s” to “Alzheimer,” shifting the focus of the conversation from illness to eponyms and the nonvirtue of ’s. I don’t want to derail trains of thought because I keep mumbling corrections when listening to people talk. I don’t want to be a style snob.

I’ve only been editing exclusively to AMA style for 2 years. For those with more time dedicated to one style guide: how bad have you gotten? Leave us a comment!—Kevin Brown

Get to the Point!

Here comes Hank. Too late, he’s spotted you, and now you’re in for another story—or rather, a litany of unnecessary details. “I said this, and she said that, and then I said, ‘Really!’” Hank never edits himself; he simply tells you E-V-E-R-Y-T-H-I-N-G until you’re screaming inwardly, “Get to the point!”

While editing manuscripts, I periodically encounter a “Hank” author. Every tidbit of information is important and, in his view, absolutely necessary. Along with his manuscript, which includes the maximum-allowed 5 tables and/or figures, he provides a Supplement that comprises 3 eMethods sections, an eResults, 14 eTables, and 9 eFigures. Data, data, and more data, until the Supplement resembles a closet stuffed by an 8-year-old who was told to clean her room. Everything. It’s all in there.

Consider the busy physician-reader. After perusing the array of freshly published articles in the journal website’s New Online section, she may click on Hank’s title and see that long list of supplemental material populating the scholar’s margin. However transparent the author endeavored to be by providing so much information, she doesn’t have time to read it all now; she needs summaries.

AMA style advocates that “tables and figures demonstrate relationships among data and other types of information” and that “a figure should be used if the relationships are complex….Like a paragraph, each…figure should be cohesive and focused.”

With that reader in mind, the manuscript editor reformats the author’s originally supplied figures to journal style and hones each one to present the material clearly. No chartjunk, no extraneous elements, no distracting line treatments.

Flow diagrams show the numerical progression of patients through the study: the number screened for inclusion, the number excluded for these reasons, the number enrolled, and the number at each stage, with those excluded or lost to follow-up at each stage also accounted for. The last box shows how many patients made it to the end of the study or were included in the primary analysis. From top to bottom, the progression of numbers makes perfect arithmetic sense.

Figures of multiple clinical, radiologic, or histologic images are labeled to guide the reader: before surgery, 6 months after surgery, 2 years later; magnetic resonance images of brains from patients 1 and 4; or specimens from a healthy individual and a patient with disease preceding another from the patient 1 year after treatment.

Graphs are appropriate to the data presented: bars for frequencies, data markers and error bars for summary data, forest plots for meta-analyses. All axes and ticks are clearly labeled, curves are identified by direct labeling or by the inclusion of concise figure keys, and bars and data markers are a solid color for the patients who received treatment and without color for those who received placebo. The numbers of patients at risk at each time point lend additional meaning to Kaplan-Meier survival curves. Forest plots include numerical data in addition to the illustrated plot points, with labels on either side of the graph’s vertical line at 1.0 to indicate whether each data marker’s location favored treatment or no treatment.

Back to our reader. Time is short, so she starts with the abstract. Words are read quickly, their meaning filtered through her years of accumulated knowledge and absorbed. She takes in the tables next. Row upon row of data; numbers represent baseline characteristics, laboratory results, and statistical analysis. Again, the numbers are filtered for meaning and digested for information that can help the reader treat her own patients. She studies the figures, and their meaning is immediately apparent: the bar for affected patients from one age group is taller, a survival curve is higher and longer for patients who received the lower dosage, the difference between 2 clinical images before and after treatment is obvious. No filter needed. Instantly clear. Results from years of the author’s research are visually summarized, seen by the reader, grasped, and understood.

The Supplement stands ready for closer investigation, but first the point must not be obscured. State it—illustrate it—clearly.—Connie Manno, ELS




Quoth the Raven

The word impact as a verb comes up pretty often in the course of my work. I am not a fan (and neither is the AMA Manual of Style). I prefer to use affect instead, and when it comes to nouns I like effect better than impact, but I always had to stop and think about it and be sure that I was correctly using these words. I just could not remember. Then, a few weeks ago, I was poking around the internet and came across this useful mnemonic device, RAVEN.

“Remember: Affect is a Verb and Effect is a Noun.”

It’s not a new thing, but I hadn’t heard it before. It stuck in my mind because crows and ravens, those smart, handsome birds, are very interesting to me. Since then, I’ve noticed that the phrase popped into my head right away when I was confronted with the effect/affect question.

Happy Halloween!—Karen Boyd



Discard the Rest

For several years, I have had a healthy curiosity with minimalism. I’ve listened to TED talks and watched documentaries about the topic and pared down my items accordingly. Last year, I read The Life-Changing Magic of Tidying Up: The Japanese Art of Decluttering and Organizing by Marie Kondo. The author describes a process in which you go through every item you own, keep only what sparks joy or is necessary, and discard the rest. Once you have tidied up your belongings, your mind is free to tackle other issues. This process resonated with me, perhaps because it seemed quite similar to my approach to medical editing.

Part of our job as editors is to remove redundancy in manuscripts—to tidy it up, if you will. We go through a manuscript word for word and carefully discard what phrases or words that do not serve the science (with the author’s approval, of course). Omitting unnecessary words can improve readability. In making an author’s work clearer and more concise, readers are able to tackle other issues, such as responding to the research or designing their own studies. Moreover, scientific writing should be as precise as possible to avoid misinterpretation. Below are some tips, adapted from AMA Manual of Style 11.1.

Some common redundancies that can typically be avoided (redundant words are italicized):

  • first initiated
  • skin rash
  • herein we describe
  • past history
  • period of time, time period, point in time
  • whether or not [unless the intent is to give equal emphasis to the alternative]
  • younger [older] than 50 years of age

Here are some common words and phrases that can usually be omitted without affecting meaning:

  • as already stated
  • it goes without saying
  • it is important [interesting] to note
  • it was demonstrated that
  • take steps to

And here are some expressions to avoid and what to use instead:

Avoid Better
in terms of in, of, for
an increased [decreased] number of more [fewer]
as the result of because of
during the time that while
in close proximity to near
in regard to, with regard to about, regarding
the majority of most
have an effect [impact] on affect

When editing and reducing redundancy, a balance must be struck. Deleting or rewriting too much may lead to accidentally altering the author’s intended meaning, which could adversely affect the author-editor relationship or perhaps even result in a correction after publication. I have been tempted to rewrite sentences, but I have to remind myself that this is the author’s work, not mine. Our responsibility as manuscript editors is to make a research paper as readable as possible so the science is the main focus.—Iris Y. Lo

People-First Language

In the new Netflix series Atypical, a father attends a support group meeting for parents of children with autism. As he begins to describe how well his son has been doing lately as an “autistic person,” he is gently interrupted by the support group leader.  She stresses the importance of him using “people-first” language, that his son is not an autistic person, but rather a person with autism. When she intercedes again to remind him that his son can’t get “better” from autism, he stares at her blankly while his wife (who is more well-versed in the appropriate vocabulary) interjects with an explanation of their son’s recent progress using replacement behaviors.

The scene is played to parodic effect—the support group leader comes across as a pretentious pedant who pays more sensitivity to correct language use than to an exasperated father who is struggling to connect with his son. The insistence on using people-first language is seen as a distraction from what is really being communicated, and I couldn’t help but be reminded of similar reactions from authors over this same issue. How many times as a manuscript editor have I rolled my eyes when I’ve seen the phrase “the patient was diagnosed with” and known I’d have to significantly restructure the sentence? How many authors have been annoyed with the sea of red strikethroughs they encounter because their article is filled with “autistic patients” or “diabetics ” or “the disabled”?

But yet, whenever I explain to authors that AMA style is strict about not defining patients by their illnesses or survivors by their experiences, they get it. “Oh yeah,” they say, “that makes sense.” They understand that it’s important for patients to have autonomy and a sense of personhood, that it’s important to recognize that behind the data are human beings who trying to live their lives while facing all sorts of experiences, of which illness may only be one.

There has been considerable pushback from politicians, corporate leaders, and even comedians against what is seen as a culture of “political correctness,” with people bemoaning that there is a social imperative to use what they see as arbitrary substitutions for words that are considered insensitive or offensive. But what good word nerds know (and manuscript editors take that title with pride) is that words and the way we choose to use them are symbolic and communicate more than their definitions.  And that is why AMA style is committed to using its reputation as an industry standard to set a tone of inclusion and sensitivity for medical discourse, a tone that states that these values are not only accepted but required.—Amanda Ehrhardt

Singular They

One of the more common mistakes I come across while editing is improper use of the singular they. People use it all the time informally, so it often creeps up in more formal writing and authors don’t even know it’s incorrect. Sometimes it’s easy to rewrite the sentence as plural, but other times it’s a real struggle. That’s why I was excited about the recent trend toward allowing it in certain cases. Both the AP Stylebook and the Chicago Manual of Style updated their policies earlier this year to include a few exceptions when rewriting the sentence as plural would be awkward or unclear.

The AP Stylebook now includes 3 examples of when singular they can be used:

  1. A singular they might be used when an anonymous source’s gender must be shielded and other wording is overly awkward.
  2. When an indefinite pronoun (anyone, everyone, someone) or unspecified/unknown gender (a person, the victim, the winner) is used.
  3. In stories about people who identify as neither male nor female or ask not to be referred to as he/she/him/her.

The 17th edition of the Chicago Manual of Style now includes 2 ways in which they can have a singular meaning.

  1. When referring to someone whose gender is unknown or unspecified. This use of the singular is acceptable in speech and informal writing, but for formal writing, Chicago still recommends avoiding it, offering various other ways to achieve bias-free language.
  2. When a specific, known person does not identify with a gender-specific pronoun such as he or she. This usage is still not widespread either in speech or in writing, but Chicago accepts it even in formal writing.

The AMA Manual of Style will follow suit with the next edition, allowing the use of plural pronouns with singular indefinite antecedents (eg, Everyone allocates their time) in an effort to avoid sex-specific pronouns and awkward sentence structure.

Even though there’s more flexibility with the singular they than before, in most cases rewording usually is possible and still always preferable, especially in formal writing.—Tracy Frey