Questions From Users of the Manual

Q: If I have a title with a colon, is the first word after the colon capitalized or lowercased?

A: If you are speaking about title and subtitle on the manuscript itself, every major word in the title and subtitle, as well as the first word of title and subtitle, would begin with a capital letter.

Endless and Essential:  The Tug-of-War Over Off-Label Use

If you are speaking about the title and subtitle of a journal article as it appears in the reference list, only the first word of the title and any proper nouns would begin with a capital letter.

19. Incollingo J. Endless and essential:  the tug-of-war over off-label use. Cataract & Refractive Surgery Today. 2016;16(5):19-27.

More about capitalization of titles can be found in chapter 10.—Cheryl Iverson, MA

Quiz Yourself

There are 5 instances of jargon in the following sentence. Can you identify them all?

The patient’s physical exam findings were unremarkable and her labs were in the normal range, so she was released from the emergency room and prepped for surgery.

Highlight below for the answer:

The patient’s physical examination findings were unremarkable and her laboratory test results were in the reference range, so she was released from the emergency department and prepared for surgery.

Words and phrases that can be understood in conversation but are vague, confusing, or depersonalizing are generally inappropriate in formal scientific writing. See §11.4 of the AMA Manual of Style for a list of jargon.—Laura King, ELS

Questions From Users of the Manual

Q: Is it necessary to repeat the manufacturer name, city, and country after every repeated mention of a product, or is it sufficient to cite this information only after the first appearance?

A: Mention of the manufacturer’s name after the first mention should be sufficient. Also, please look at our (free) online Updates.

UPDATE:  Manufacturer information for Equipment, Devices, and Reagents:  In section 15.5 (page 583 in the print book), we will no longer require the inclusion of the location of the manufacturer. This is so easy to look up online, should anyone desire more specific details, that we believe it is not necessary to continue to require this. This change was made October 4, 2011.

You’ll see that we no longer require the manufacturer’s location to be included.—Cheryl Iverson, MA


Quiz Yourself

A scientist develops data while working at Harvard University. She then moves to Stanford University, where she publishes an article using the original data in JAMA. Who owns the data?

a. Harvard University
b. Stanford University
c. Scientist

Use your mouse to highlight the answer:   Harvard University

In scientific research, 3 primary arenas exist for ownership of data: the government, the commercial sector, and academic or private institutions or foundations. Although an infrequent occurrence, when data are developed by a scientist without a relationship to a government agency, a commercial entity, or an academic institution, the data are owned by that scientist. Any information produced by an office or employee of a government agency in the course of his or her employment is owned by the government. Data produced by employees in the commercial sector (eg, a pharmaceutical, device, or biotechnology company, health insurance company, or for-profit hospital or managed care organization) are most often governed by the legal relationship between the employee and the commercial employer, granting all rights of data ownership and control to the employer. According to guidelines established by Harvard University in 1988 and subsequently adopted by other US academic institutions, data developed by employees of academic institutions are owned by the institutions (§5.6.1, Ownership and Control of Data, pp 179-183 in print).—Laura King, ELS

Putting P Values in Their Place

Although I am not a statistician, I find something very appealing about mathematics and statistics and am pleased when I find a source to help me understand some of the concepts involved. One of these sources intersects with my obsession with politics: Nate Silver’s website Yesterday, during a scan of fivethirtyeight’s recent posts, this one by Christie Ashwanden caught my eye: “Statisticians Found One Thing They Can Agree On: It’s Time to Stop Misusing P-Values.”

P values and data in general are frequently on the minds of manuscript editors at the JAMA Network. Instead of just making sure that statistical significance is defined and P values provided, we always ask for odds ratios or 95% confidence intervals to go with them. P values are just not enough anymore, and Ashwanden’s article was really useful in helping me understand why these additional data are needed (as well as making me feel better about not fully understanding the definition of a P value—it turns out I’m not alone. According to another fivethirtyeight article, “Not Even Scientists Can Easily Explain P-Values”). One of the bad things about relying on P values alone is that they are used as a “litmus test” for publication. Findings with low P values but not contextual data are published, yet important studies with high P values are not—and this has real scientific and medical consequences. These articles explain why P values only can  be a cause for concern.

And then there was even more information about statistical significance to think about. A colleague shared a link to a story on by Julia Belluz: “An Unhealthy Obsession With P-Values Is Ruining Science.” This article a discussed a recent report in JAMA  by Chavalarias et al “that should make any nerd think twice about p-values.” The recent “epidemic” of statistical significance means that “as p-values have become more popular, they’ve also become more meaningless.” Belluz also provides a useful example of what a P value will and will not tell researchers in, say, a drug study, and wraps up with highlights of the American Statistical Association’s guide to using P values.—Karen Boyd

Point of View: A Conversation With Cheryl Iverson

(Editor’s Note: Point of View is an occasional series that features an interview with someone in the world of publishing. You are already familiar with Cheryl Iverson from her thoughtful and well-reasoned answers to our “Questions From Users of the Manual” section—so it’s only fitting that she be the first victim participant.—Brenda Gregoline, ELS)

Cheryl Iverson does not peeve about her grammatical peccadilloes as one might imagine of a woman who has spent her career editing, overseeing editing, and serving as the AMA Manual of Style committee chair for the last 3 editions—she continues as co-chair of the 11th edition, a work in progress. Although one might say that she doesn’t have any major pet peeves when it comes to grammar, she does admit, “I still get aggravated at the incorrect use of apostrophes like I – t- apostrophe – s. Those are not things that I would be willing to treat lightly.”

But concerns about splitting an infinitive or ending a sentence with a proposition, “some of those rules that people learned in grammar classes in grade school 50 years ago,” would be better off forgotten. She speculates that people who no longer understand the reason for the rule will either avoid the use or argue adamantly about using, say, different from rather than different than when in the end it doesn’t matter if meaning is clear. “That’s what I think. It’s good that we’ve gotten away from these old rules without understanding where they came from, which makes it hard for people to know when to bend a rule or when to disregard a rule.”

However, such discretion at the start of her career was discouraged.

“When I was a new copyeditor, the stylebook was the Bible. It was all about ‘If you want to publish in our journals, this is what we do.’” The mandate was so deeply impressed on her that it wasn’t until her short stint at the University of Chicago Press in the books  department that she began to rethink the approach.

First, while editing a small book on ancient Egyptian irrigation systems, she assiduously looked up all the city names mentioned in the manuscript and changed them in accordance with her source, an effort that left the author less than pleased.  “He wanted them all reinstated.  He said that there is controversy about some of these names. ‘I don’t care if your source used X. I want Y.’”

The exchange made Iverson pause. “I stopped to think that consistency is far more important in a journal article because all of these articles that are edited by different people are grouped together, whereas a book stands alone, so if your author wants to use something quirky, that’s just that author and it’s just in that book.”

The vise grip of the conforming to the immutable-style-rules directive loosened again when an author challenged a style point, again while she was at the University of Chicago Press. So she brought her question to her supervisor and said, “I looked everywhere in the manual for this. I can’t find it. … This author wants to have such and such.”

“Cheryl,” the boss responded, “the manual is not a Bible. It’s just a guide.”

Iverson’s experience as a young copy editor is not uncommon. “When people are new, they want to know, What’s the rule? What’s the rule about? They want there to be a rule because rules help them”—especially when trying to explain their editing decisions to authors. “But then when you have been editing a while you’re more mellow. I don’t think it is a bad thing in other words. I don’t think it is a bad thing [to relax the rules] as long as you don’t get sloppy and let errors get through.”

Helping new copy editors navigate the rough terrain of medical articles that are filled with jargon, abbreviations, numbers, complex tables, and figures has been a singular pleasure. “I loved when a relatively new editor would learn the job,” Iverson said, describing how individuals would come to her and say, “‘I don’t know what to do with this table.’ Then later, they would come in and say, ‘This table is really difficult, but I thought I would do X.’ You could see that they were starting to develop their own judgment.” Although she remains in partial retirement, Iverson responds to questions from AMA Manual of Style users and posts answers on the AMA Style Insider blog. The questions range from as simple as how many spaces go after a period to as difficult as coaching a writer whose bosses disagree with a grammatical decision despite all kinds of evidence supporting her or his position. She responds to those questions with the same compassion and sense. And she receives the same pleasure in coaching them to resolution.

“I see [that] our job as editors is to facilitate reading so that you don’t have to stop and go back and say wait what did that say again?”

To illustrate her point she recalled a cartoon presented at a Council of Science Editors conference. In the cartoon, the characters debated, “Who is more important, the author or the editor?” Each character argued for the author or the editor until the final panel, which said “The reader is what is important. That’s who we are working for.”—Beverly Stewart



Quiz Yourself

Which of the following sentences is correctly punctuated?

We conducted a randomized placebo-controlled trial.


We conducted a randomized, placebo-controlled trial.


We conducted a randomized placebo-controlled trial.

When fewer than 3 modifiers are used, avoid adding a comma if the modifiers and the noun are read as one entity, such as randomized placebo-controlled trial.—Laura King, ELS

The Percolating Proofreader

(Editor’s Note: This month our favorite proofreader takes a bus journey and speedily ruminates on the Self, commas, exclamations, and the astonishing loveliness of ambiguity in a world [a style-manual world, anyway] that prioritizes precision.—Brenda Gregoline, ELS)

When last I percolated here, my dregs, if you got down to them—and how could you not, 3 tall paragraphs easier to guzzle than a brick, let alone the world and all its oceans, interconnected though they may be?—could have been read as “When you get right down to it, we are all raccoons.” That’s the thing about dregs: a hard stop at the bottom of the carafe, with nothing beneath but a countertop stretched over whatever doodads populate the ceiling of hell, doesn’t invite interpretation. As with tea leaves, you can rearrange the dreglettes, but even if you’re a fool for random patterns they’re not going to inspire sleepless nights or a revised liberal arts curriculum. Granted, we are nothing if not raccoons, but that’s not exactly a fresh thought. Einstein, Calamity Jane, the Dionne Quintuplets, and virtually everyone whose name is droppable has, if only for one brief sliming moment, accessed their inner round table and considered that the omnivore rattling around in their garbage can was essentially him- or her- or themself/selves. John Donne said as much, King Arthur sat as much, and various enlightened beings have lived as much, perfecting a state of oneness with raccoons, buzzards, pancakes, whatever illusory forms rattled, circled, were flooded with syrup, or in any other way made a specious case for their independent existence.

That’s not exactly where I was going last month, but the dregs said “Stop here or you’ll penetrate plexiglass (alteration of “Plexiglas” per Merriam-Webster’s).” I’ve no desire to penetrate anyone’s plexiglass, least of all my own, so I stopped there and am only now refilling my pot with a few words about our peculiarly human masks and tails. First, let’s play Us and Them. Splitting our cozy Self into species and regarding raccoons as the “other,” it becomes clear that they are the most punctuated animals in the forest, each tail a rhapsody of serial commas, each face a question mark verging on exclamation, flexible paws cradling dependent and independent clauses as easily as crayfish and stones. As they lope, their arched backs become semicolons on the move, and if you approach one from behind you’ll find the elegantly apportioned tail initiating a furry sentence that terminates in the most fulsome period this side of Go, Dog. Go! The inky button is positioned squarely (by which I mean roundly) beneath Dick Turpin’s gaze and pulses in crinkledom over Dracula pearls designed to puncture and sift all your trashcan allows. Since humans crawled out of their wormholes and began to strive for literacy and other forms of one-upsmanship, there has not yet been a sentence so well-turned that it could possibly be mistaken for a raccoon. Similarly, squirrels aren’t allowed to compete in the Olympics.

If no athlete’s grace and dexterity can rival a rodent’s and no sentence yet composed can achieve the pixie perfection of a thief bent on depriving the city dump of your pie crusts, then why don’t we just give up? I suppose every refugee from Eden has struggled with or, being nonsquirrels, clumsily scuffled with that question when they weren’t clumsily scuffling with the question of whether or not the world was about to end. If an answer occasionally emerges from the fray, it might be as simple as this: there’s something to be said for ambiguity, for breaking an apple’s perfect skin with your sawed-off fangs and wondering whether it was the right thing to do, knowing it might not have been. Like Simple Simon, who as a connoisseur of pies fruity and not was far more complicated than the legendary folk hero we celebrate April 1 and every other day dedicated to human inadequacy (which would be all of them so far, unless world hunger was eliminated yesterday), “ambiguity” as an answer to anything, including what it means to be human, is a hard stop that keeps on going.

A visit to the local library (imagine that!) suggests that there’s actually everything to be said for ambiguity and nothing much to be said for anything else, though if your library contains scientific journals such as the ones our Manual of Style is designed to tease into perfection you’ll find a compelling counterargument. A less compelling but more visceral argument for the existence of precise diction, at least in its ability to describe persons as the sum of one of their parts, may be encountered on the Chicago 66 bus. Sadly in the first case and ho-hummily in the second, those are exceptions. In language we seek and prize precision, as if it could possibly turn us into porpoises, but language itself thrives on ambiguity. Flush with multiple meanings, the thrill of the hint, subsurface innuendo erupting into a geyser of accusation, then freezing midair into flurries of doubt, ambiguity is an ever-expanding state of expression gobbling into its definition the essences of uncertainty, hesitation, disgruntlement, past and looming failure, vague gnawing the likes of which beavers and termites would surely deem unprofessional. At its ragged outer edges ambiguity encompasses a sadness only caffeine and the promise of love can dent, and then only till 3 o’clock in the afternoon or the recriminating hour before dawn, respectively.

Which leaves us with ourselves, such as we are and such as we conjugate, a pack of Dorothies with doubtflaked eyelashes batting away the overweening sun. Typically though not exclusively nocturnal, the raccoons we’re not are likely holed up in ancient stump craters or the deep crotches of forked trees, nowhere to be seen as we arise from our poppy fields and mommy complexes and head out to face what’s left of the world after the previous day’s reiteration of human inadequacies. All masked up with tails on the shake, we’re not exactly a pretty species but counter outward clunk with swagger and swag acquisition. Each swagheap, even the most ill-gotten, is marbled with an honest acquisition, the language with which we serenade and belittle one another, filling libraries with music and the CTA with pygmies. If, in our rush to compare, contrast, and explicate, we punctuate injudiciously and foster unwarranted division as often as we channel filtered sunlight, the moral weight of our punctuating decisions isn’t entirely hidden. As a child I read that bears lost their tails as a result of one particular bear’s tail freezing off in the natural course of a practical joke. I assumed something similar had happened with my parents. Then I grew up, or at least reached a plateau of some sort, and realized that our tails are merely obscure, ringed internally like oaks, years cramped together, styling us from the inside out. As each year’s punctuations congeal into unalterable consequences and 10 packs of 365/6 days squeeze into a decade like the proverbial 10 pounds of potatoes in a 5-pound sack, the rings grow closer together until they’re barely distinguishable. You don’t have to saw a person open to verify this; you just have to observe the drooping tails of your neighbors in crime, the beloved beneficiaries and victims of ennobling and enervating language. As years press memories and misdeeds into hardened pulp, human tails droop at increasingly oblique angles, such that presidential aspirants are able to sweep floors with the tips of their generously weighted conclusions. Such a gift. Just last week I picked up an apparently run-over broom (flattened handle, bristles caked with granulated autofudge) on the curb of Pulaski Road and realized, as I tenderly toted it home and nursed it back to an upright position from which it was almost as useless as when it lay stricken, what a thrill it would be to have a nice new broom, the kind you see at an otherwise boring store and think, sighing audibly, “Well, I already have a broom. But damn!”

There it is, not so much the nowadays mild curse but the punctuation mark coloring the word and wrenching it into a refined state of ambiguity. As Kay Francis once said to William Powell in the context of 2 characters united in love and destined for separate gallows, “This is living, isn’t it, Dan?” We punctuate; therefore we are. Are what? Raccoons, sure, but beyond that certainty a rash of beautiful bustling hesitations—saintly clause, fiendish fragment, each reinterpreting murk in the light of a moment just passed, anticipating and dreading the future, then, all too soon, drinking it in.—David Antos

Questions From Users of the Manual


Q: A colleague is adamant about citing page numbers even if the reference is used more than once in a paragraph. Is this necessary?

A: There is a little advice on citing page numbers in the manual, just above section 3.7.

If the author wishes to cite different page numbers from a single reference source at different places in the text, the page numbers are included in the superscript citation and the source appears only once in the list of references.  Note that the superscript may include more than 1 page number, citation of more than 1 reference, or both, and that all spaces are closed up.

Example: These pages showed no sign of proactive sphincteric adduction.3(p21),9

You’ll notice that it’s not mandatory and our style includes, “If the author wishes.”  Page number citation can be helpful to the diligent reader who wants to go to the source cited and find the exact mention of the quoted material.—Cheryl Iverson, MA

Quiz Yourself

Do you know the difference between the terms multivariable and multivariate? One term refers to multiple predictors (independent variables) for a single outcome (dependent variable), and the other term refers to 1 or more independent variables for multiple outcomes? Which is which?


Multivariable refers to multiple predictors (independent variables) for a single outcome (dependent variable). Multivariate refers to 1 or more independent variables for multiple outcomes. Therefore, analyses can be described as multivariable, to indicate the number of predictors, or as multivariate, to indicate the type of outcome.—Laura King, ELS