A Peek at a Trio of Homophones to Pique Your Interest and Provide Peak Enjoyment

Grammarians who pen English usage guides do not seem piqued at the misuse of the words peek, peak, and pique. Theodore M. Bernstein notes only that piqued “takes [the] preposition at or by.” Even college-level writers’ guides make little fuss. Flipping to the usage sections of several writers’ guides, one finds a no-show for the peeks. Webster’s Dictionary of English Usage, however, writes that “[t]hese homophones have a way of being muddled by nodding writers.” Relying on former newspaper columnist and grammarian James J. Kilpatrick, who had caught misuses among the peaks in various news publications, the entry notes that peak most frequently edged out its competitors and inappropriately made its way into print. The entry ends by warning writers “to keep the meaning in mind and match it to the correct spelling.”

English usage of peek is traced to 1374 and stems from the Middle English piken, which some sources speculate comes from the Middle Dutch kieken. Peek means “to glance at quickly, or to peer at furtively, as from a place of concealment.” As a verb, it means that something is “only partially visible…[t]iny crocuses peeked through the snow.” The expression peek-a-boo is “attested from 1599,” according to the Random House Dictionary.

Peak is traced to 1520-1530, perhaps from the Middle Low German words pick and pike, according to Random House. As a noun it has several meanings, some of which point to the top of a mountain, ridge, or summit. It can also be used to describe a “projecting part of a garment,” as in the bill of a hat. Nautically, it means the “upper most corner of a fore-and-aft sail” or the “narrow part of a ship’s bow.” As an intransitive verb, it means reaching “maximum capacity, value, or activity,” as in “My running pace peaked at 10 minutes per mile.” Similarly, as an adjective, reaching peak levels demonstrates that one has maxed out.

In a less common usage, those who grow sick or thin are sometimes spoken of as having peaked or “dwindled away” or, as an adjective, being peaked (2 syllables), “being pale and wan or emaciated: sickly.”

Emotion rules pique. It stems from the Vulgar Latin verb piccare, “to pick,” and its usage in English is traced to 1525-1535. It is menacingly linked with pickax and pike. As a noun, it is defined as “a transient feeling of wounded vanity.” Or, as one might say of a woman scorned, “She’s in a fit of pique.” But a woman moves quickly on, pique being a transient emotion. As a verb it means that someone has been “aroused” to “anger or resentment.” Or, as I like to use it, aroused to the state of curiosity.

Although they sound alike and to an extent they look alike, the piques are as different as … Has your interest peaked? (Begs for a pun, doesn’t it?)—Beverly Stewart, MSJ

Around, About, Approximately

Although each of these words is used to refer to a value that is estimated and therefore imprecise, whether it is acceptable to use them interchangeably depends in part on context and the level of accuracy being implied.

Some speakers and writers will use approximately before turning to the other two—not surprising, because people faced with a choice between words will often choose the most impressive-sounding one. And sometimes that choice happens to be correct. On the other hand, people will often, especially in casual communications, use around or about as a sort of verbal shorthand. And again, sometimes that choice happens to be correct.

So, what’s the scoop? To sort this out, it helps to recognize that authorities for the most part agree that around, about, and approximately lie on a scale from casual to formal. As it happens, around is also thought of as the most imprecise and approximately the most precise, with about falling somewhere in between. It further helps to note that around, meaning merely “with some approach to exactness,”1(p68) is not widely considered an adequate replacement for either about or approximately and thus is often accepted only in casual conversation.2 Hence, in conversation between friends, for example, many speakers will toss off a “See ya around three,” whereas in written communications, as Bernstein maintains, “‘about three o’clock’ is preferable to ‘around three o’clock.’”2

Things get a bit more complicated as one moves along the scale: not only does the choice of word depend in part on the closeness to accuracy required by different types of communication, but the differences between the implied degrees of closeness can be subtle. For example, Merriam-Webster’s defines about as “reasonably close to”1(p4) and approximately as “nearly correct or exact.”1(p61) However, it is safe to say that in nontechnical communications (which presumably often place less emphasis on precision), the use of about is not only accepted but is perhaps preferred. As Garner maintains, “When possible, use about instead of approximately, a formal word”3(p5)—where a “formal” word is defined simply as one “occupying an elevated level of diction.”3(pp153-154) On the other hand, as suggested by the above definitions, about does not emphasize a closeness to accuracy as strongly as approximately does—which helps explain why about seems fine when used to refer to estimated values that have been rounded to multiples of 5 or 10 but can seem strange when used to refer to unrounded values.4 Moreover, around and about each have multiple meanings and can be used in other senses, whereas approximately is used in a single sense only, leading some authorities to maintain that the latter is a better choice for technical communications.5

The bottom line:

● Referring to an inexact value in casual conversation? Around, about, and approximately are all acceptable, but approximately can sound a bit pretentious.

● Referring to an inexact value in nontechnical writing? About is perhaps the best choice, around being too informal and approximately being a tad too formal.

● Referring to an inexact value in medical or other technical writing? Although about may very occasionally be used if one carefully assesses the context, approximately is nearly always the best choice.—Phil Sefton, ELS

1. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003.

2. Around. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:44-45.

3. Garner BA. The Oxford Dictionary of American Usage and Style. New York, NY: Oxford University Press; 2000.

4. Yateendra J. About and Around and Approximately: Shades of Difference? Editage website. http://blog.editage.com/about-and-around-and-approximately-shades-of-difference. Accessed August 1, 2012.

5. Scientific English as a Foreign Language: Around, About, Approximately. Worcester Polytechnic Institute website. http://users.wpi.edu/~nab/sci_eng/97_Jun_20.html. 1997. Accessed August 1, 2012.

Questions From Users of the Manual

Q: How can a user of your online manual tell if use of a particular word (such as namely) is discouraged?

A:  The first place to look might be chapter 11, Correct and Preferred Usage. But the word you used as an example is not included therein. Or you could try a search in the online manual for the word in question. But that too produces nothing helpful, most likely because we have no “official” policy on this word. Next you might consult a good usage book or the usage notes in the American Heritage Dictionary. Finding nothing anywhere, you could decide on a policy for your publication or the document you are working on, if this seems appropriate or desirable.

Q:  Several questions about the citation of abstracts in a reference list.

  • Section 3.11.9 (Abstracts and Other Material Taken From Another Source) states on page 50 that for abstracts published in the society proceedings of a journal, “the name of the society before which the paper was read need not be included” and that “if a[n abstract] number is included, it is placed in brackets along with the ‘abstract’ designation.” What is not made clear is whether including an “abstract” designation is mandatory or voluntary.   

Should an “abstract” designation be included in the citation to an abstract published in the society proceedings of a journal if neither the society’s name nor an abstract number is being provided? In other words, using example 3 of the book as a base, which of the following would be correct?  

  •  . . . Lemli-Opitz syndrome. Invest Ophthalmol Vis Sci. 2001;42(suppl):S627.  (the reference is not identified as being an abstract)


  • . . . Lemli-Opitz syndrome [abstract]. Invest Ophthalmol Vis Sci. 2001;42(suppl):S627.  (the reference is identified as being an abstract)

If the “[abstract]” designation is not mandatory, is it AMA style to delete it when an author includes it (without an accompanying society name or abstract number) in such a reference?

Also, if an abstract is given an abstract number in the place where it is published, is it considered mandatory or voluntary for its number to be included in the reference citation? The text in the manual says “if a number is included” but the meaning of this is possibly ambiguous (included by the journal in which it was published; or voluntarily included by the author who submits the manuscript as a matter of the submitting author’s preference? It seems most likely that it is the latter, but I’m not certain). 

A:  In order:

  • The if  is meant to signify that the designation as an abstract should be included if it is provided.
  • The second version you provided would be preferred. It’s a nice service to readers to let them know that what is referenced is an abstract.
  • Absolutely not. We would never delete it. It too provides a service to readers, helping them to find the abstract referred to, should they be so inclined.
  • You interpreted the manual correctly—the latter is what is intended.—Cheryl Iverson, MA

Anticipate, Expect

Although the use of anticipate and expect as synonyms is now largely accepted,1 at least in casual communications, the careful writer will do well to note that some authorities still hold that there is a subtle difference between them.1-3

Although both words refer to a person’s attitude toward a future event, they differ in what they convey about that attitude. For example, some observers hold that the difference between the words relates to the level of certainty toward the future event (ie, anticipate implies that a person is certain that the event will take place, whereas expect implies only that a person predicts that the event will take place3). However, this weak distinction is easily blurred, and in practice it seems that it is not often upheld. A stronger and more often upheld distinction maintains that anticipate is the stronger of the two words, connoting that some action has been taken to prepare for the foreseen event.2,3 This sense possibly arose from an early (late 1500s) use, “To seize or take possession of beforehand.”4 Although that use is now obsolete, by the early 1600s anticipate was being used to suggest simply “to take action beforehand,” a meaning still current.4 Bernstein points out that such action “Need not be taken so literally as to mean the performance of an overt act; it may simply connote an advance accommodation of the mind or the senses, even involuntarily, to the coming event.”2

In any case, if anticipate suggests the taking of some sort of action to prepare for an expected event, it seems clear that one should perhaps not use it when wishing to convey only simple expectation. Interestingly enough, even those who consider anticipate and expect synonyms do not extend the same acceptance to the synonymous use of unanticipated and unexpected.1

The misuse of anticipate in place of expect likely arose from the tendency common among writers and speakers to use larger words.5(pp22-23) It also is an example of what Garner terms “slipshod extension”5(pp22-23)—“the mistaken stretching of a word beyond its accepted meanings, the mistake lying in a misunderstanding of the true sense.”5(pp307-308) Garner further maintains that the use of anticipate in the sense of “to await eagerly” is also incorrect and points out that such use is also likely the result of slipshod extension.5(pp22-23)

The bottom line:

● Referring to a person’s attitude toward a future event? Using anticipate and expect interchangeably is likely acceptable in casual communications, but in more formal contexts one should take care to observe the subtle differences between them.

● Referring to the simple expectation of a foreseen event? Use expect.

● Referring to a state of taking action—whether that action be either concrete, mental, or emotional—in preparation for a foreseen event? Use anticipate.—Phil Sefton, ELS

1. Anticipate. The Free Dictionary website. http://www.thefreedictionary.com/p/anticipate. Accessed June 8, 2012.

2. Anticipate, expect. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:44-45.

3. Anticipate or Expect: What’s Next? Grammatically Correct website. http://www.uhv.edu/ac/newsletters/writing/grammartip2008.05.28.htm. Accessed June 8, 2012.

4. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991: 58.

5. Anticipate. In: Garner BA. The Oxford Dictionary of American Usage and Style. New York, NY: Oxford University Press; 2000.

Right, Almost Right, and Just Plain Wrong: Spelling (and Spacing) Variations

It is now the work of years for children to learn to spell; and after all, the business is rarely accomplished. A few men, who are bred to some business that requires constant exercise in writing, finally learn to spell most words without hesitation; but most people remain, all their lives, imperfect masters of spelling, and liable to make mistakes, whenever they take up a pen to write a short note. Nay, many people, even of education and fashion, never attempt to write a letter, without frequently consulting a dictionary.—Noah Webster1

The primary nonmedical/nonscientific dictionary used at JAMA and the Archives Journals is Merriam-Webster’s Collegiate Dictionary, and the medical/scientific dictionary of record is Dorland’s Illustrated Medical Dictionary. In the list given below, we show the preferred spelling of frequently misspelled scientific and nonscientific words as indicated by Webster’s and Dorland’s.

Whereas Webster’s shows equal or secondary variants in the entry “head,” Dorland’s uses a single term for the entry head but lists cross-references for variant spellings at the end of the entry for the preferred term. But note that Webster’s also often includes variant spellings in its entries (eg, aesthetic and esthetic). These “equal variants” are indicated by or. If they are given in alphabetical order, “they occur with equal or nearly equal frequency.” If they are given out of alphabetical order, but still joined by or, the first is slightly more common than the second. If they are joined by also, the word given second “occurs appreciably less often” than the first and is considered a “secondary variant.”

The front matter of Webster’s also notes: “Other spelling variants may be flagged with var with some further brief explanation, for example, metre … chiefly Brit var of meter.” Exception: Variant spellings that appear in direct, written (eg, published) quotations should not be changed to US variants.

To maintain consistency within their journals, the editors of JAMA and the Archives Journals prefer the first spelling of the entry of any given word.

Right and Almost Right

acknowledgment (equal variant, out of alphabetical order: acknowledgement)

aesthetic (secondary variant: esthetic)

breastfeeding (Webster’s: breast-feeding)

cutoff (as noun or adjective)

cut off (as verb)

distention (as given in Dorland’s; equal variant in Webster’s: distension)

judgment (equal variant, out of alphabetical order: judgement)

phosphorus (as noun)

phosphorous (as adjective)

sulfur (secondary variant: sulphur)

supersede (secondary variant: supercede)

Just Plain Wrong

accommodate (not accomodate)

ancillary (not ancilary)

arrhythmia (not arhythmia)

brussels sprouts (not brussel sprouts)

cholecystectomy (not cholecysectomy)

consensus (not concensus)

cribriform (not cribiform)

desiccate (not dessicate)

diphtheria (not diptheria)

dyspnea (not dysnea)

embarrass (not embarass)

erythematosus (not erythematosis)

Escherichia (not Echerichia)

fluorescent (not florescent)

fluorouracil (not flourouracil)

Haemophilus (not Hemophilus)

harass (not harrass)

hematopoietic (not hematopoetic)

Legionella pneumophila (not Legionella pneumophilia)

levothyroxine (not levothyroxin)

millennium (not millenium)

minuscule (not miniscule)

Neisseria gonorrhoeae (not Neisseria gonorrhea)

ophthalmology (not opthalmology)

Papanicolaou (not Papanicolou)

pertussis (not pertussus)

pruritus (not pruritis)

sagittal (not saggital)

sinusitis (not sinusitus)

sphygmomanometer (not sphygomamometer)

sulfide (not sulphide)

syphilis (not syphillis)

unwieldy (not unwieldly)

Now, this is nice and neat. But what if the 2 principal dictionaries (medical and nonmedical) differ on the preferred spelling of a word? Which to follow? We make such decisions on a case-by-case basis. For example, anti-inflammatory in Webster’s was chosen instead of antiinflammatory in Dorland’s because the former was considered to be expressed more clearly with a hyphen between the 2 i’s. Similarly, workup (as a noun, meaning a thorough evaluation to arrive at a diagnosis) was chosen over work-up. (But: Use work up as a verb!)

Spacing and punctuation (to hyphenate or not to hyphenate) add further questions of variation. These too are decided on a case-by-case basis. Below is a small sample of some of these decisions.

cost-effective, cost-effectiveness (not cost effective, cost effectiveness)

end point (not endpoint)

health care (not healthcare)

policy maker (not policymaker)

under way (not underway)

A final word to the wise: Until spell-checkers include a read-my-mind function, do not rely on them for solving spelling problems!—Roxanne K. Young, ELS

1. Webster N. An essay on the necessity, advantages, and practicality of reforming the mode of spelling and of rendering the orthography of words correspondent to pronunciation. In: Dissertations on the English Language: With Notes, Historical and Critical, to Which Is Added, by Way of Appendix, an Essay on a Reformed Mode of Spelling, With Dr. Franklin’s Arguments on That Subject. Boston, MA: 1789.

Apt, Liable, Likely

Although these words are sometimes used interchangeably, particularly in infinitive constructions (apt to fall, liable to fall, likely to fall),1,2 using them interchangeably obscures subtle yet important distinctions between them.

Of the three, it seems that apt is the one most often used in its proper sense—perhaps because, unlike liable and likely, which both stress a potential consequence and thus are often confused, apt simply stresses inherent tendency (eg, “Elmer is apt to be a bit unsteady on his feet”).3 Also, whereas liable and likely refer to consequences and thus most commonly to conditions that will become manifest in the future, apt usually refers to conditions manifest in the past or present.1 In addition, some authorities hold that apt is perhaps most commonly used when referring to persons, although it can refer to nonhuman or inanimate subjects as well.1

So far so good—but, as alluded to above, tossing liable and likely into the mix can muddy the waters a bit. Both stress degrees of potential, but liable is the weaker of the two, used to stress possibility (eg, “Because Elmer is apt to be a bit unsteady on his feet, he’s liable to fall”) rather than outright probability.1 It has sometimes been held that liable should be used only when the subject of the sentence would face unpleasant consequences from the action expressed by the verb (“Because Elmer is apt to be a bit unsteady on his feet, he’s liable to fall and break a hip”).2 Certainly, of the three words under discussion, liable is the one most often taken as indicating that a consequence might be unpleasant or disadvantageous.3

Compared with liable, likely is a stronger term, used to stress probability (eg, “Because Elmer is apt to be a bit unsteady on his feet, he’ll likely fall if the steps are icy”) rather than mere possibility.1 However, unlike apt, likely used alone stresses no particular tendency in the subject that would enhance the probability of the outcome; moreover, unlike liable, it need not suggest the potential for an unpleasant consequence (eg, “Although Elmer is apt to be a bit unsteady on his feet, he’ll likely not fall, even if the steps are icy”).2

The bottom line:

● Looking for a word that stresses inherent tendency, particularly in a person? Use apt.

● Looking for a word that stresses possibility (as opposed to probability)—especially the possibility of some unpleasant consequence? Use liable.

● Looking for a word that stresses probability (as opposed to possibility), whether the perceived consequences be good or ill? Use likely.—Phil Sefton, ELS

1. Apt, liable, likely. Merriam-Webster’s Dictionary of Synonyms. Springfield, MA; Merriam-Webster Inc; 1984:56.

2. Liable. TheFreeDictionary.com website. http://www.thefreedictionary.com/p/liable. Accessed March 8, 2012.

3. Apt, liable, likely. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:48.

Ambiguous, Equivocal

These words often are taken to mean the same thing—which in some contexts they indeed do. When used to refer to test results or experimental findings, for example, both words are properly used to indicate uncertainty, ie, that the findings can be understood in more than one way.

However, a distinction comes to bear when one is referring to statements, either written or oral. Although both words also can properly be used when referring to a statement subject to more than one interpretation, accepted usage holds that ambiguous is the proper choice if the resulting uncertainty seems unintentional1(p39) and that equivocal is the way to go if the uncertainty seems to have been intentionally introduced to confuse or deceive.1(p423) The deceptive intent is key, and it is worth noting that whereas the verb equivocate is an accepted word, ambiguate is not.

Deceptive intent might be inferred from the immediate context of surrounding statements. Often, however, intent is inferred from the larger context, ie, the history of the issue under discussion or the (perceived) character of the person making the statement. Given the latter means of inference, it is not surprising that the use of equivocal to refer to deceptive statements has been accepted since the late 1700s—about the time that the word also came to be commonly used to describe persons believed “[d]oubtful in character or reputation; liable to unfavorable comment or description; questionable; suspicious.”2(p527) Equivocal is still occasionally used when referring to such persons, but current usage, particularly in the social media, tends to favor terms somewhat more colorful.

Equivocal also can imply that a person has used ambiguous language in a qualifying way to avoid personal commitment to the statement made.1(p423) This meaning, however, although a bit more neutral than the meaning already noted, still hints at something less than savory. In short, although using ambiguous and equivocal interchangeably to describe a statement will be correct in some instances, writers tempted to use equivocal in place of ambiguous would do well to remember that the former has additional connotations often freighted with “nasty overtones.”3

Perhaps because clarity and certainty are seldom used for deceptive purposes, matters are less complicated in negative constructions: unambiguous and unequivocal both indicate that a test result or a statement has only one interpretation. However, because equivocal carries negative connotations, unequivocal is often used to emphasize a lack of deceptive intent.

As a side note, another word, unequivocable, has been used interchangeably with unequivocal since the early 1900s.2(p2166) How this monster came to be is a matter of some conjecture, but it likely arose either from innocent confusion over the proper spelling and pronunciation of equivocal or from a desire to use a loftier-sounding word (although it is difficult to imagine an instance in which unequivocal would not be lofty enough). In any case, unequivocable and its variants are often considered nonstandard.1(p1366)

The bottom line:

● Referring to test results or experimental findings having more than one interpretation? Ambiguous and equivocal are both correct, but it is worth noting that the latter can have negative overtones and is perhaps best avoided unless the reporting of results seems intentionally unclear.

● Referring to a statement having more than one interpretation? Remember that all equivocal statements are ambiguous, but not all ambiguous statements are equivocal. If the statement seems intentionally unclear with the goal of distancing or deceiving, use equivocal.

Unambiguous and unequivocal both indicate that something has only one interpretation, although when describing a statement unequivocal is sometimes used to emphasize an absence of deceptive intent.

Unequivocable, while found in some dictionaries, is often considered nonstandard and should probably be avoided.—Phil Sefton, ELS

1. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003.

2. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991.

3. Ambiguous, equivocal. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:38.

A Few Thoughts on Fewer and Less

All of the usual English-language usage books seem so sure that they give little more than a compound sentence to explain that fewer should be used when referencing things that can be counted and less when referencing quantity or things that can be measured.

The AMA Manual of Style1 points out that the 2 words “are not interchangeable.” Then explains the difference by advising readers to “[use] fewer for number (individual persons or things) and less for volume or mass (indicating degree or value).” It offers the following examples: “Fewer interventions may not always mean less care” and “The authors evaluated fewer than 100 studies yet still reported more support for the conventionally prescribed therapy.” The entry is followed by a note that provides 2 more examples including parenthetical explanations:

spent less than $1000 (not: spent fewer than $1000)

reported fewer data (not: reported less data)

The Associated Press Stylebook2 entry says, “In general, use fewer for individual items, less for bulk or quantity” and provides the following examples, or should I say commands:

Wrong: The trend is toward more machines and less people. (People in this sense refers to individuals.)

Wrong: She was fewer than 60 years old. (Years in this sense refers to a period of time, not individual years.)

Right: Fewer than 10 applicants called. (Individuals.)

Right: I had less than $50 in my pocket. (An amount.) but: I had fewer than 50 $1 bills in my pocket. (Individual items.)

The Elements of Style3 elliptically warns, “Less should not be misused for fewer” with the following explanation. “Less refers to quantity, fewer to number. ‘His troubles are less than mine’ means ‘His troubles are not so great as mine.’ ‘His troubles are fewer than mine’ means ‘His troubles are not so numerous as mine.’”

A Writer’s Reference,4 a college handbook, is equally economical: “Fewer refers to items that can be counted; less refers to items that cannot be counted” followed by its example for usage: “Fewer people are living in the city” and “Please put less sugar in my tea.” (I’d rather that you didn’t put any sugar in my tea.)

But if the rule were so easy as these commonly used English-language usage references suggest, why are people confused?

If anything is certain about language, it is that nothing is certain: a truism that often frustrates my composition students, who simply want the answer when no one true answer exists. In the case of fewer and less, Webster’s Dictionary of English Usage5 and Fowler’s Modern English Usage6 support my position by telling an entirely different story about how to use less and fewer, with Webster’s devoting 3 and a third columns to it and Fowler’s devoting about 3 columns over 2 entries.

The former launches the alternate-usage discussion with a metaphoric clearing of its throat to suggest, however, that the general usage rule cited in most English-language reference texts “has only one fault–it is not accurate for all usage” and offers a rule amendment for using less:

less refers to quantity or amount among things that are measured and to number among things that are counted.

In other words, less can be used in both cases. Webster’s punctuates its point by saying the amended rule has actually reflected common usage for say “the past thousand years or so.” The general rule became established and embraced by most language scholars, so Webster’s theorized, from a 1770 comment about less made by Robert Baker in Reflections on the English Language. He wrote:

The word [less] is most commonly used in speaking of a Number; where I should think Fewer would do better. No fewer than a Hundred appears to me not only more elegant than No less than a Hundred, but more strictly proper.

Thus, a modest preference has become, as Webster’s points out, “elevated to an absolute status.” That transformation, the entry laments, may be due to the reluctance of “many pedagogues … to share the often complicated facts about English with their students.” In fact, Webster’s points to the Oxford English Dictionary as showing that “less has been used as countables since the time of King Alfred the Great.”

Although Fowler’s trends toward the generally accepted usage rule, it recognizes that perhaps the “complicated facts about English” should in fact be elucidated. As a means of clarification, it uses parts of speech to explain the usage differences. It says that “few and its comparative adj. fewer are used with countable nouns, i.e. with nouns that have both a singular and a plural form (book/books)…; or with collective nouns (fewer people…)” but, “[l]ess which is a comparative of little, is properly used with uncountable or mass nouns: in other words less refers to quantity and is the opposite of more (less affection, less power, less misery).” Furthermore, Fowler’s acknowledges when less can be used “idiomatically with plural nouns … esp. distances (it is less than seventy miles to London)” and the like.

In its final example in the few entry, Fowler’s notes the “regrettable” trend of “the use of less with an unprotected plural noun.”(That’s an expression that’s new to me.) One of the example sentences of that violation is

There will be less 100% loans about.

Don’t we all know that?—Beverly Stewart, MSJ

1. Iverson C, Christiansen S, Flanagin A, et al. AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007.

2. Goldstein N, ed. The Associated Press Stylebook and Briefing on Media Law. New York, NY: Basic Books; 2007.

3. Strunk W, White EB. Elements of Style. 4th ed. New York, NY: Longman; 2000.

4. Hacker D. A Writer’s Reference. 6th ed. Boston, MA: Bedford/St Martin’s; 2009.

5. Webster’s Dictionary of English Usage. Springfield, MA: Merriam-Webster Inc; 1989.

6. Burchfield RW. Fowler’s Modern English Usage. 3rd rev ed. New York, NY: Oxford University Press; 2004.

Illicit, Elicit, Solicit

“I am the offspring of illicit love.”1(p814)

“Only suffering… can elicit the perfumes of the soul.”1(p503)

“Henry had been soliciting the pope for some time, in order to obtain a divorce from Catherine of Aragon, his queen.”1(p1822)

Illicit, elicit, solicit. The above examples make it abundantly clear that these words have distinctly different denotations; yet they are often confused or misused, even by careful writers. In medical contexts, it is especially important to preserve the distinctions between them.

Illicit, denoting simply “not permitted; unlawful”2(p618) (and sometimes used colloquially to indicate naughty, unseemly, or immoral), has limited use in medical writing. For example, written materials might convey the risks associated with use of illicit drugs, discuss illicit relationships between researchers and industry, or report on the illicit trade in human body parts. Beyond such instances, however, the word does not often come into play.

Elicit, however, is another story. Denoting “to call forth or draw out (as information or a response)” or “to draw forth or bring out (something latent or potential),”2(p404) the word occurs frequently in medical contexts. It might be used in both senses regarding a patient–physician encounter: for example, a physician evaluating a patient’s pain will ask questions to elicit information about the characteristics of the pain (eg, location, nature, duration, exacerbating factors). From the patient’s perspective, that is the easy part, and patients might well wish this were the end of the matter; however, having thus elicited mere information about the patient’s pain, the physician then embarks on maneuvers expressly designed to elicit the real thing. In written materials covering the basic sciences and their clinical applications, elicit is perhaps most frequently used in the second sense noted above. For example,a writer might report that a new vaccine elicits a given immune response, describe pathological mechanisms that elicit organ damage, or present a theory of how a treatment might elicit changes in gene expression.

Even accomplished writers sometimes confuse the homophones illicit and elicit. However, these terms are easily distinguished from each other: illicit is always an adjective, whereas elicit is—in current usage—always a verb. (It also can help to remember that illicit denotes illegal; for the temperance-minded, the illicit distillation of spirits might also come to mind.)

Troublesome as homophones can be, however, sometimes near-homophones can be more so, especially when they are similar in meaning. For example, elicit and solicit—the latter most frequently used in medical contexts in the sense of “to approach with a request or plea”2(p1187)—are often used interchangeably, with solicit perhaps more frequently used in place of elicit.3 However, such use obscures an important distinction. The Oxford Dictionary of American Usage and Style perhaps explains this distinction most succinctly: “To solicit a response is to request it. To elicit a response is to get it.”3 Thus, in the patient–physician encounter alluded to above, the physician solicits information regarding the patient’s pain and then performs a physical examination to elicit and evaluate actual pain. The Oxford resource also points out an ambiguity that can arise when elicit and solicit are confused: “‘Sentient representatives expect the core group to solicit [read elicit?] response from about 4,000 people.’”3 In other words, will the group solicit responses from 4000 persons, or will the group approach a larger number of persons to try and elicit 4000 responses, knowing that some persons approached might not reply? In medical contexts, the distinction has obvious implications for reports of survey studies and possibly for discussions of power calculations in reports of clinical trials.

Three quick tips:

* Looking for an adjective to describe something as immoral, forbidden, or illegal? Illicit (think illicit = illegal) might be the ticket.

* Looking for a verb to convey the requesting of information? Consider solicit.

* Looking for a verb to convey the obtaining of information or the drawing forth of a response or change? Consider elicit (think elicit = get).—Phil Sefton, ELS

1. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991.

2. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003.

3. Garner BA. The Oxford Dictionary of American Usage and Style. New York, NY: Oxford University Press; 2000:309.


In medical contexts, incidence is most often used in its epidemiologic sense, ie, the number of new cases of a disease occurring over a defined period among persons at risk for that disease. When thus used, incidence may be expressed as a percentage (new cases divided by number of persons at risk during the period) or as a rate (number of new cases divided by number of person-years at risk).

Reporting several incidence values in the same sentence can nearly always be accomplished using the singular form (eg, “the incidence of nonfatal myocardial infarction during follow-up was 10% at 6 months, 19% at 12 months, and 26% at 18 months” or “the incidence of clinical stroke decreased significantly, from 7.6 to 5.3 per 1000 person-years in men and from 6.2 to 5.1 per 1000 person-years in women). However, in rare instances, sentence construction may necessitate the use of the plural, which of course is… what, exactly? The understandable urge to simply add an “s” at the end of the word to form the plural results in incidences — a form not found in most dictionaries and a clunker of a word if ever there was one. Writers wishing for a more mellifluous plural sometimes use incidence rates, a valid term but one perhaps best reserved for reporting incidence values expressed as actual rates rather than simple percentages. Moreover, incidences is sometimes used when reporting values either as percentages or as rates, in the latter case missing a valuable opportunity to emphasize that rates rather than percentages are being reported.

Thus, it is perhaps best to use incidences, awkward as it may be, when reporting multiple incidence values as percentages and incidence rates when reporting such values as rates, eg, “at first follow-up, the incidences of falls resulting from frailty, neuromuscular disorders, or improper use of mobility devices were 15% (95% CI, 10%-20%), 12% (95% CI, 7%-17%), and 12% (5%-19%), respectively” or “the incidence rates for falls resulting from frailty, neuromuscular disorders, or improper use of mobility devices were 5.1, 6.3, and 4.6 per person-year, respectively.” Incidentally, these 2 examples report occurrences (falls) rather than diseases or conditions, and so represent 2 instances reporting the incidence of incidents.

To further muddy the waters, incidence is sometimes confused with prevalence, defined as the proportion of persons with a disease at any given time (ie, total number of cases divided by total population). Thus, whereas incidence describes how commonly cases are diagnosed, prevalence describes how widespread the disease already is; on a more personal level, incidence describes one’s risk of developing the disease, whereas prevalence describes the likelihood that one already has it. The confusion between the terms is perhaps attributable to the occasional use of prevalence in place of incidence in the study of rare, chronic diseases for which few newly diagnosed cases are available; however, this circumstance is unusual, and incidence and prevalence should always be distinguished from one another and used appropriately. (See also §20.9, Glossary of Statistical Terms, in the AMA Manual of Style, p 872 in print.)

Whereas prevalence is often used in general contexts to indicate predominance or general acceptance, the circumstances calling for the use of incidence in general contexts are quite few and become fewer still when one takes into account that incidence is often used when incidents (the simple plural of incident) or instance (again denoting an occurrence) would be the better choice. Perhaps incidents or instances was intended but never made it to the page — as is so often the case with homophones and near-homophones, even the careful writer who usually would not confuse incidence, incidents, and instance might one day look back over a hastily typed passage only to see that a wayward incidence has crept in; if the passage is hastily edited to boot, the error might well go unnoticed until the passage is in print and a discerning reader takes pains to point it out in a letter or e-mail. The plural form, incidences, has virtually no use outside of the epidemiologic discussed above, although it has been used to subtly disorienting effect by translators rendering the Kafkaesque works of Russian writer Daniil Kharms (1904-1942) into English, most notably when rendering the 1-word title of Incidences, Kharms’ 1934 collection of absurdist critiques on life in the Soviet Union under Stalin. However, writers who are not political dissidents aiming for absurdist effect — presumably all medical writers — would do well to proofread carefully and often. — Phil Sefton, ELS