usage

People-First Language

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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

Weeds and Words

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Here at AMA Manual of Style headquarters, there is snow on the ground and all the weeds are mostly dead. However, that doesn’t mean we don’t “get into the weeds” on a near-daily basis, particularly during style manual committee meetings. Here’s a post from The Word Detective that explores, but does not solve, the mysteries of that phrase’s origin. —Brenda Gregoline, ELS

Reluctant, reticent

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These 2 terms are not interchangeable, although reticent is occasionally seen in informal usage as an imprecise synonym for reluctant.

Reluctant refers to someone who feels or shows doubt about doing something, not willing or eager, or feeling or showing aversion.  Synonyms are disinclined, dubious, hesitant, loath.

Dr Smythe was reluctant to share his preliminary, non–peer-reviewed research with the news media.

Reticent refers to someone who does not reveal his or her thoughts or feelings readily and is restrained in expression, presentation, or appearance.  Synonyms are reserved, withdrawn, introverted, inhibited, diffident, shy, uncommunicative.

 Professor Harrington has been described by colleagues and friends as “shy and reticent” but is also well known for his poise and calm demeanor during a medical emergency.

—Roxanne K. Young, ELS

 

Intention, Intent

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These words are used interchangeably in many contexts, and such usage is often perfectly acceptable. In some contexts, however, they do have slightly different meanings.1

Although both words connote an attitude of resolve toward a contemplated action, intention is the weaker term, often suggesting “little more than what one has in mind to do or to bring about”2 and sometimes also further signaling that the action was not or will not be acted on. If, for example, a speaker begins a sentence by saying “I had every intention of….” the listener knows very well the gist of what’s coming next, regardless of the words that actually follow.

Intent, on the other hand, is all business, suggesting a concentration of will and the active application of reason in making a contemplated action come to pass1: “They were rushing upon the old peasant with no very merciful intent.”3Intent often further signals that a contemplated action actually has been or will be carried out—which perhaps leads to its use in sentences such as “He who wounds with intent to kill…. shall be tried as if he had succeeded.”3 Perhaps for these reasons, intent is now most often encountered in legal communication,1,3 and its connotations in such contexts are well understood. Imagine, for example, that NBC’s Law & Order: Criminal Intent had instead been titled Law & Order: Criminal Intentions. Loses something, does it not?

Another difference between the words is that intention is a countable noun, whereas intent is an uncountable noun.4 So, whereas a person might have a veritable laundry list of intentions related to a contemplated action (one might, for example, speak of one’s intentions for the coming weekend), one typically has only a single state of mind—an intent—related to that action. In short, intention often suggests mere ambition to achieve something, whereas intent often suggests the application of reason to actually achieve it. A clue to the distinction is that the words usually take different prepositions: intention takes to (think “to-do list”) or of, whereas intent takes on or upon.5

Intent and intention can sometimes apply in the same instance. A person might, for example, have every intention of never gambling again, even while heading to the track intent on making a killing.

In medical contexts, the words appear in the constructions “intent-to-treat analysis” and “intention-to-treat analysis”— ie, analyses “based on the treatment group to which [study participants] were randomized, rather than on which treatment they actually received and whether they completed the study.”6 Although both constructions are used, in light of the negative connotations of intent, “intention-to-treat” might be preferable.

The bottom line:

● Intention and intent are often used interchangeably, and in many cases such usage is acceptable.

● However, although intention and intent both connote an attitude of resolve toward a contemplated action, intention is the weaker term, often suggesting mere ambition. Intent, on the other hand, suggests deliberate planning or the active application of the will to make an action come to pass.

● Although in medical contexts “intent-to-treat analysis” and “intention-to-treat analysis” are used interchangeably, given the negative connotations associated with intent, “intention-to-treat” might be preferable.—Phil Sefton, ELS

 

 

1. Ask the Editor: “Intent” and “Intention.” Merriam-Webster Learner’s Dictionary website. http://www.learnersdictionary.com/blog.php?action=ViewBlogArticle&ba_id=78. Accessed September 10, 2013.

2. Intention, intent. Merriam-Webster’s Dictionary of Synonyms. Springfield, MA; Merriam-Webster Inc; 1984:458.

3. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:861.

4. Intention or intent? Glossophilia website. http://www.glossophilia.org/?p=416. Accessed September 10, 2013.

5. Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:240.

6. 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; 2007:873.

Significant and Significance

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If there is any doubt about whether significant/significance refers to statistical significance, clinical significance, or simply something “important” or “noteworthy,” choose another word or include a modifier that removes any ambiguity for the reader.

The AMA Manual of Style (§20.9, Glossary of Statistical Terms, pp 893-894 in print) includes definitions for statistical significance (the testing of the null hypothesis of no difference between groups; a significant result rejects the null hypothesis) and clinical significance (involves a judgment as to whether the risk factor or intervention studied would affect a patient’s outcome enough to make a difference for the patient; may be used interchangeably with clinical importance). Significant and significance also are used in more general contexts to describe worthiness or importance.

Often the context in which the word appears will make the meaning clear:

▪ Statistical Significance:

• Exposure to the health care system was a significant protective factor for exclusive throat carriage of Staphylococcus aureus (odds ratio, 0.67; P = .001).

• Most associations remained statistically significant at the adjusted significance level (P < .125).

▪ Clinical Significance:

• Low creatinine values in patients with connective tissue diseases were found to be clinically significant.

• The combination of erythromycin and carbamazepine represents a clinically significant drug interaction and should be avoided when possible.

▪ Worthy/Important:

• His appointment as chair of the department was a significant victory for those who appreciated his skill in teaching.

• A journal’s 100th anniversary is significant and should be celebrated.

Sometimes, however, the context does not clarify the meaning and ambiguity results.

▪ The one truly significant adverse effect that has caused carbon dioxide resurfacing to lose favor is hypopigmentation, which can be unpredictable and resistant to treatment.

To avoid the possibility of ambiguity, some have recommended confining the word to only one of its meanings. However, why cheat a word of one of its legitimate meanings when there are ways to retain its richness and yet not confuse the reader?—Cheryl Iverson, MA

Option, Alternative, Alternate

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Alternate means “one after the other,” whereas alternative means “one instead of the other”1—and option and alternative are essentially the same thing. Easy peasy, no?

Well, no. At least not quite.

Although few writers would incorrectly use alternative in place of alternate in the sense of “one after the other,” there are subtle differences between these words—and between option and alternative, as well—when they are used in other senses. The potential for confusion is readily apparent when one considers, for example, that option has been defined as “something that may be chosen”2(p871); alternative as “one of two or more things, courses, or propositions to be chosen”2(p37); and alternate as “one that substitutes for or alternates with another”.2(p37) And that’s considering only the use of these words as nouns. As an adjective, alternative has been defined as “offering or expressing a choice” and alternate as “constituting an alternative.”2(p37)

So—is there a way through this thicket?

Option and choice are usually considered interchangeable, but an alternative is an option or choice that stands “instead of the other.”1 Thus, a person faced with numerous options (choices) will always have one more option than alternatives.3 (Some authorities have proposed that alternative should be used only when no more than 2 choices are available. However, few writers observe this distinction.3,4) For example, a diner presented with a dessert menu that lists 4 desserts will—assuming a 1-dessert limit—have 4 options (ie, choices) but only 3 alternatives. Furthermore, it is usually assumed that one of the options will be the original or preferred one, to which the others are alternatives. For example, on that dessert menu, the red velvet cake, tiramisu, and crème brûlée might be alternatives to that triple fudge ganache lava brownie that one has been ogling, in the event that the server comes back with the sad news that the brownie has apparently been everyone else’s first choice as well.

But things get a bit fuzzy when it comes to the choice between alternative and alternate. As suggested above, these words have acquired meanings that are quite close. When a distinction is made, it would seem to hinge on whether a degree of compulsion is in play, with alternative preferred when such compulsion is not present. For example, a person selected to serve as an alternate juror has little choice in the matter; similarly, whereas a person planning a trip might well map out several alternative routes, the same person faced with an unexpected road closure is forced to take an alternate route.5 And, although option and choice can be used interchangeably, alternative has a bit more nuance than choice, suggesting “adequacy for some purpose.”4 Alternative also can suggest a “compulsion to choose”4—although in this case the compulsion is to choose between alternatives (eg, “The alternatives are liberty and death,”4) rather than, as is the case with alternate, a compulsion or duty to serve in place of another (eg, alternate juror, alternate batter).

In practice, although some authorities still advocate maintaining the traditional distinctions between alternative and alternate, actual usage is changing rapidly, and alternative is now often used when a noun is called for and alternate when an adjective is called for.6 However, a big nota bene for medical writers: alternative is used as an adjective in medical contexts when referring to nonallopathic medicine, treatments, or therapies, such as acupuncture, homeopathy, etc. So, the adjective alternate is certainly preferred when referring, for example, to different allopathic treatment choices available to a patient (eg, “the consulting physician recommended surgery but also proposed 3 alternate approaches”).

The bottom line:

● Looking for a word that indicates “one after the other”?1 Use alternate (eg, “Alternate smiles and frowns, both insincere.”7)

● An alternative is by definition an alternative to something else—usually a preferred choice or original plan of action—so one will always have 1 more option than alternatives.

● Although some authorities still maintain the traditional distinctions between alternative and alternate, usage is changing rapidly, and alternative is now often used when a noun is called for and alternate when an adjective is called for—but in medical contexts, the adjective alternative is often used in reference to nonallopathic medicine, treatments, or therapies.—Phil Sefton, ELS

1. Alternate/Alternative. In: O’Conner PT. Woe Is I: The Grammarphobe’s Guide to Better English in Plain English. 3rd ed. New York, NY: Riverhead Books; 2009:88.

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

3. Fogarty M. Quick and Dirty Tips: “Alternate” Versus “Alternative.” Grammar Girl website. http://grammar.quickanddirtytips.com/alternate-versus-alternative.aspx. Accessed January 16, 2013.

4. Alternate; alternative. In: Garner BA. The Oxford Dictionary of American Usage and Style. New York, NY: Oxford University Press; 2000:18.

5. Alternate vs. alternative. Grammarist website. http://www.grammarist.com/usage/alternate-alternative/. Accessed March 27, 2013.

6. Alternate, alternative. English Forums website. http://www.englishforums.com/English/AlternateVsAlternative?bzxvg/post.htm. Accessed January 16, 2013.

7. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:41.

Aegis

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“Recognizing that the genetic contribution to health disparities is likely to be relatively limited is not the only reason to question the wisdom of promoting genetic research under the aegis of health disparities.”1

“In several examples published under the aegis of the [Agency for Healthcare Research and Quality], the benefit side rests on the data from randomized controlled trials….”2

“[T]his definition and associated regulations have become de facto rules for US academic and other research institutions and are applied to any work done by their employees or under their aegis regardless of the source of funding.”3

While somewhat infrequently encountered in medical writing, aegis is occasionally used in content related to health policy, institutional oversight, or the conduct of research. It also is occasionally used to refer to a journal’s vouching for the validity of data or other findings published in its pages; when such validity is called into question, a journal may issue a full retraction or simply “withdraw aegis,” ie, issue a statement to the effect that the journal is no longer responsible for the data.4

In its original sense, aegis (Greek aigis [goatskin]) referred to the shield or protective cloak worn by Zeus or Athena in the myths of ancient Greece.5 In the centuries since, the word has by association come to be used idiomatically to indicate defense (“Feeling is the aegis of enthusiasts and fools.”6) or guidance or influence (“They made their valuable individual contributions, but under the Ellington aegis they found themselves constantly enriched musically.”6). Similarly, the word is perhaps most often used in the construction “under the aegis of” to express patronage or sponsorship (“under the aegis of the museum”) and, especially, protection (“a child whose welfare is now under the aegis of the courts”).5

All of which is perfectly comforting. However, the classical roots of the word are far less benign. Whereas aegis-like shields appear in Egyptian, Nubian, and Norse mythology and art,7,8 the most elaborate account of the origins and attributes of the aegis comes, as suggested above, from the narratives of ancient Greek mythology and literature, in which it is consistently depicted as an object possessing fearsome supernatural power.

In one such narrative, the goat deity Amaltheia suckles the infant Zeus, who then—in the curiously detached manner so frequently encountered in mythological accounts—breaks off her horns and flays her hide. From one of her horns Zeus fashions the cornucopia, or horn of plenty; from her hide, he fashions the shield or cloak that would come to be called the aegis, which he then wears, on the counsel of an oracle, into battle against the marauding Titans.9 However, in the hands of Zeus, king of the gods, the aegis is more than a protective device; when in his wrath he shakes the aegis from his perch atop Mount Olympus, thunder crashes, bolts of lightning slash the sky, and fierce storms devastate the land.10 Moreover, in the Iliad, Homer describes the device as the “tempestuous terrible aegis, shaggy [and] conspicuous… given to Zeus to the terror of mortals.”11

But the aegis is associated with deities other than Zeus. In the Iliad, for example, Zeus lends the aegis to Apollo, who wields it to push his enemies back to their ships12; in other accounts, Zeus lends the aegis to his daughter, Athena, goddess of war,12 or presents it to Athena after his conquest of the Titans.9 In the most colorful account, Zeus swallows his wife, Metis, whole—after which Athena is born from Zeus’ head, emerging fully formed and bearing the aegis and other weapons of war.13 Regardless of how Athena comes to possess the aegis, however, in her hands it becomes more formidable still. For example, in the Iliad Homer reverently describes the aegis as no mere goatskin but rather as “ageless and immortal,” worn by “bright-eyed Athene” and adorned with tassels of the purest gold12; moreover, elsewhere in the Iliad he describes the aegis as a dramatic golden cloak fashioned by Hephaistos, god of fire and metalwork,14 to resemble a scaly skin like that of a snake, linked and fringed with writhing serpents, and bearing in its center the severed head of the Gorgon Medusa, eyes rolling and scalp also bristling with serpents.11

Charming as this may be, given the provenance of the word and the fell associations that come with it, how did aegis, apart from its military associations, come to be used to express defense or protection? Perhaps more puzzling, how did it come to be used to express benevolent guidance, influence, or patronage? A possible clue is that whereas early accounts often depict Athena as cultivated, civilized, urbane, and wise, the economy of ancient Greece was bolstered by military pursuits, and in short order Athena came to be depicted as the goddess of war—although, importantly, her military might was tempered by the cultivation and divine wisdom earlier attributed to her.15 Thus, Athena is sometimes viewed as having 2 sides. The first is characterized as wrathful, tempestuous, and destructive; however, the other is characterized as divinely beneficent and endowed with the inclination and ability to grant the gifts of aid, wisdom, and protection to favored mortals.16 The power of both sides is wielded through the supernatural power of the aegis—hence Homer’s description of the device in the Iliad and its depiction in visual art as inky black or brilliant gold.11,12,16

Interestingly, however, while Athena extends divine beneficence and protection—backed by the wrathfulness also attributed to her—she does not authorize those mortals fortunate enough to come under her favor to act on her behalf. Thus, whereas in current usage aegis is correctly used to express defense, protection, guidance, influence, patronage, or sponsorship, its use to indicate “under the jurisdiction of” is considered incorrect.17 —Phil Sefton, ELS

1. Sankar P, Cho MK, Condit CM, et al. Genetic research and health disparities. JAMA. 2004;291(24):2985-2989.

2. Vandenbroucke JP, Psaty BM. Benefits and risks of drug treatments: how to combine the best evidence on benefits with the best data about adverse effects. JAMA. 2008;300(2):2417-2419.

3. 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; 2007:157.

4. Hammerschmidt DE, Franklin M. The limits and power of peer review. Minn Med.

http://www.minnesotamedicine.com/PastIssues/PastIssues2006/June2006/CommentaryHammerschmidtJune2006/tabid/2527/Default.aspx. June 2006. Accessed February 13, 2013.

5. Aegis. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003:19.

6. Aegis. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:22.

7. Aegis: in Egyptian and Nubian mythology. Museum of Learning Web site.

http://www.museumstuff.com/learn/topics/aegis::sub::In_Egyptian_And_Nubian_Mythology. Accessed February 15, 2011. 8. Aegis: in Norse mythology. Museum of Learning Web site. http://www.museumstuff.com/learn/topics/aegis::sub::In_Norse_Mythology. Accessed February 15, 2011.

9. Amaltheia. Theoi Project Web site. http://www.theoi.com/Ther/AixAmaltheia.html. Accessed February 13, 2013.

10. Zeus. Theoi Project website. http://www.theoi.com/Olympios/Zeus.html. Accessed February 13, 2013.

11. Hephaistos Works 2. Theoi Greek Mythology Web site. http://www.theoi.com/Olympios/HephaistosWorks2.html. Accessed February 13, 2013.

12. Teleporter: aegis mound. Entropia Planets Web site. http://www.entropiaplanets.com/wiki/Teleporter:Aegis_Mound. Accessed February 13, 2013.

13. Athena. Theoi Project Web site. http://www.theoi.com/Olympios/Athena.html. Accessed February 13, 2013.

14. Hephaistos. Theoi Project Web site. http://www.theoi.com/Olympios/Hephaistos.html. Accessed February 13, 2013.

15. Athena. Encyclopedia Britannica Online. http://www.britannica.com/EBchecked/topic/40681/Athena?anchor+ref85160. Accessed February 13, 2013.

16. Deacy S, Villing A. What was the colour of Athena’s aegis? J Hellenic Stud. 2009;129:111-129. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=6779888. Accessed February 13, 2013.

17. Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:29.

Emergency, Emergent, Urgent

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As I was editing a manuscript on patients undergoing surgery for brain tumors, I came across the sentence, “Patients who required emergency care were admitted to the hospital and classified as needing emergent or urgent surgery.” As I reread the sentence, the terms emergency, emergent, and urgent started to swim before my eyes, each backstroking to take the place of the other. Soon I was reading, “Patients who required urgent care were admitted to the hospital and classified as needing emergency or emergent surgery.” And then, “Patients who required emergent care were admitted to the hospital and classified as needing emergency or urgent surgery.” What was going on? Was my late-night habit of perusing stylebooks and usage guides before bedtime starting to produce side effects (oops, I mean adverse effects)? Was I no longer able to delineate the difference between commonly used medical terms? I had to take action.

Diligent medical copy editor that I am, I turned to my bookshelf, which is chock full of dictionaries and grammar, usage, and editing books. Now I would be able to solve this conundrum. I would take this problem step by step, or rather word by word, and find the resolution. Here’s what I found:

Emergency

Stedman’s Medical Dictionary1 defines emergency as “an unexpected development or happening; a sudden need for action.”

Dorland’s Illustrated Medical Dictionary2 defines emergency as “an unlooked for or sudden occurrence, often dangerous, such as an accident or an urgent or pressing need.”

Merriam-Webster’s Collegiate Dictionary3 defines emergency as “an unforeseen combination of circumstances or the resulting state that calls for immediate action.”

Consensus! There’s nothing a copy editor likes better.

Resolution: An emergency is basically an unexpected event that requires immediate action.

Emergent

Dorland’s defines emergent first as “pertaining to an emergency” and second as “coming into being through consecutive stages of development, as in emergent evolution.”

Stedman’s omits the definition stemming from the term emergency and defines emergent first as “arising suddenly and unexpectedly, calling for quick judgment and prompt action” and second as “coming out; leaving a cavity or other part.”

Merriam-Webster’s defines emergent as “arising unexpectedly” or “calling for prompt action.”

This one’s a little trickier. Dorland’s relates the term emergent to emergency and Stedman’s and Webster’s simply define emergent as the adjectival form of the noun emergency. So, is there a difference between these 2 words or are they synonymous? It was time to reach deeper into my bookshelf.

I first turned to the classic text A Dictionary of Modern English Usage by H. W. Fowler.4 I knew Fowler wouldn’t let me down. Fowler’s entry on emergence and emergency reads as follows, “The two are now completely differentiated, -ce meaning emerging or coming into notice, and -cy meaning a juncture that has arisen, especially one that calls for prompt measures.”

After some additional research, I found this entry in Common Errors in English Usage by Paul Brians5: “The error of considering ‘emergent’ to be the adjectival form of ‘emergency’ is common only in medical writing, but it is becoming widespread. ‘Emergent’ properly means ‘emerging’ and normally refers to events that are just beginning—barely noticeable rather than catastrophic. ‘Emergency’ is an adjective as well as a noun, so rather than writing ‘emergent care,’ use the homely ‘emergency care.’”

Eureka! Emergent means beginning to arise and emergency means arising unexpectedly.

Resolution: Use emergent to mean emerging (as in Dorland’s section definition of “coming into being through consecutive stages of development, as in emergent evolution”) and emergency to mean an unexpected event that calls for immediate attention.

But then what about urgent?

Urgent

Neither Dorland’s nor Stedman’s defines the term urgent.

Merriam-Webster’s Collegiate Dictionary defines urgent as “calling for immediate action.”

So, can urgent and emergency be used interchangeably? The Children’s Hospital of Wisconsin website provides a list of surgery types. It groups urgent or emergency surgery and defines it as surgery “done in response to an urgent medical need, such as the correction of a life-threatening congenital heart malformation or the repair of injured internal organs after an automobile accident.”6 However, the website Trivology.com states, “There is major difference between elective, urgent, emergency surgery. In urgent surgery we can wait until the patient’s health is unwavering but it has to be performed in 1-2 days. But emergency surgery needs to be performed without any impediment otherwise there will be colossal risk to patient’s life.”7

Therefore, in medical editing, be careful of changing emergency to urgent because emergency means immediate attention is required and urgent indicates quick but not immediate action is required. There is no such thing as emergent surgery unless you mean surgery that is just beginning.

Resolution: Although emergent and urgent both indicate calls for swift action, urgent is more, well, urgent.

Well, there you have it. I guess that original sentence I was editing makes sense after all. “Patients who required emergency surgery [immediate surgery because of the unforeseen nature of the incident] were admitted to the hospital and classified as needing emergent [with a few hours] or urgent [within 24 hours] care.”— Laura King, MA, ELS (January 2013)

1. Stedman’s Medical Dictionary. 26th ed. Baltimore, MD: Williams & Wilkins; 1995.

2. Dorland’s Illustrated Medical Dictionary. 32nd ed. Philadelphia, PA: Elsevier Saunders; 2012.

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

4. Fowler HW. A Dictionary of Modern English Usage. 2nd ed. Oxford, England: Oxford University Press; 1965.

5. Brians P. Common Errors in English Usage. 2nd ed. Sherwood, OR: Williams James & Co; 2008.

6. The Children’s Hospital of Wisconsin website. Types of Surgery. http://www.chw.org/display/PPF/DocID/22082/router.asp. Accessed January 10, 2013.

7. Trivology.com. http://www.trivology.com/articles/209/what-is-elective-surgery.html. Accessed January 10, 2013.

Top 10 Mistakes Authors Make

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Publishing a style manual, particularly a lengthy, detailed manual that covers a ridiculous amount of technical material (Hello, AMA Manual of Style!), is a grueling process. In our case, it involved 10 people meeting for at least an hour every week for more than a year, where we tried not to get into arguments about grammar, usage, and the presentation of scientific data. After the meetings there would usually be flurries of e-mails about grammar, usage, and the presentation of scientific data. Then we’d all go home and dream about grammar, usage, and the presentation of scientific data. You get the picture.

My point is that the writers of style manuals are often a little, shall we say, too close to the material. In the case of the AMA Manual of Style, we are all editors as well—and it can be hard for us not to roll our eyes when we run into the same problems on manuscript after manuscript. Come on, authors: there’s a whole book on this stuff!

Which, of course, is precisely the problem. There is a whole THOUSAND-PAGE book that tries to encompass all aspects of medical editing. It’s impossible to expect authors to absorb all the information–they’re just trying to get published, and it’s our job to help them. Here, in classic top-10-list reverse order, are the top 10 editorial problems we see in our submitted and accepted manuscripts, compiled by committee and editorialized upon by me. If any authors happen to read this, maybe it will help them avoid the most common errors; if any journal website–design people read it, maybe they can grab some ideas for more explicit user interface; and if any copy editors read it, maybe they can enjoy shaking their heads in wry commiseration.

10. Missing or incomplete author forms. Most journals require authors to fill out some forms, usually involving things like copyright transfer, an assertion of responsibility for authorship, and so on. These forms are often filled out incorrectly or incompletely. Following a form’s instructions as to signatures and boxes to check can save significant amounts of time in the publication process.

9. Not explaining “behind the scenes” stuff. Values in a table don’t add up—oh, it’s because of rounding. The curve in this figure doesn’t connect the values listed in the “Results” section—oh, we used data smoothing. This kind of thing can be easily explained in a footnote, but many authors forget to do so because it seems so obvious to them.

8. Making life difficult for the copy editor. Authors and editors have the same goal: a polished, published, accurate manuscript. Sure-fire ways authors can ruin what should be a pleasant working relationship are to suggest that the copy editor is making changes in the manuscript for no reason; calling the copy editor to discuss changes without having read the edited manuscript first (this wastes oodles of time); and not reading the cover letter that comes with the edited manuscript. This last is particularly charming when the author then calls the copy editor to ask all the questions that are very nicely answered in said cover letter.

7. Common punctuation and style mistakes (not an exhaustive list). Most frequently we see authors fail to expand abbreviations; use different abbreviations for the same term throughout a manuscript; use commas like seasoning instead of like punctuation marks with actual rules of deployment; and overuse the em dash. However, I’d like to tell any authors reading this not to fret, because that’s the kind of stuff we’re paid to fix. Plus I can’t really throw stones—being a fan of the em dash myself.

6. Errors of grandiosity. Sometimes a perfectly nice and valid study will go hog-wild in the conclusion, claiming to be changing the future of scientific inquiry or heralding a sea-change in the treatment of patients everywhere. Or authors will selectively interpret results, focusing on the positive and ignoring the negative or neutral. It’s natural to want to write an elegant conclusion—it’s one of the few places in a scientific manuscript where one can really let loose with the prose—but it’s always better to err on the side of caution.

5. Wacky references. All journals have a reference citation policy, and across scientific journals it is fairly standard to give reference numbers at the point of citation, cite references in numerical order in the text (as opposed to only in tables or figures), and retain a unique number for each reference no matter how many times it’s cited. However, we still get papers with references handled in all kinds of odd ways (alphabetical, chronological, or seemingly inspired by the full moon). References that include URLs can mean big problems. Often the URL doesn’t work or the site is password-protected, subscription-only, or otherwise useless to the reader. Also aggravating: references that are just the result of the search string for the article and not the URL for the article itself.

4. Duplicate submission. In scientific publication, it is not acceptable to submit a report of original research to multiple journals at the same time. Journal editors are likely to be more disturbed by this if it looks deliberate rather than like a simple mistake (not realizing that a foreign-language journal “counts,” for example) or if the case is debatable (a small section of results was published in another paper, but the new paper adds tons of new material). Remember those forms from the 10th most common mistake? One of them asks about previous submission or publication. We need authors to be up-front about any other articles in the pipeline, even if (especially if) they’re not sure if they might constitute duplicate publication.

3. Failing to protect patient identity. Yup, there’s a form for this too! Any time a patient is identifiable, in a photograph or even in text (as in a case report), authors must have the patient’s consent. (Contrary to popular belief, the gossip-mag-style “black bars” over the eyes are not sufficient to conceal identity.) Usually we hear complaints about this, because studies are written long after patients are treated and it can be hard to track people down, but them’s the breaks. If it’s really impossible to obtain after-the-fact patient consent, editors will work with authors to crop photos, take out details, or whatever it takes to “de-identify” patients.

2. Not matching up all the data “bits.” In the abstract, 76 patients were randomized to receive the intervention, but it’s 77 in Table 1. There was a 44.5% reduction in symptoms in the medicated group in the text, but later it’s 44.7%. Sometimes this is because the abstract is written first from the overall results, while the data in a table are more precisely calculated by a statistician; or maybe the number of patients changed along the way and no one went back to revise the earlier data. Either way, it drives copy editors crazy.

1. Not reading a journal’s Instructions for Authors. These days almost all scientific journals have online submission, and almost always there is a link to something called “Information for Authors,” “Guidelines for Manuscript Submission,” or something similar. Judging by the kinds of questions editorial offices receive almost daily, authors rarely read these—but the publication process would often go so much more smoothly if they would.

We are proud of our style manual, although we realize it isn’t the last word in scientific style and format. There can never really be a “last word” because some editor will always want to have it! Anyway, without authors there wouldn’t be anything to edit, so we would never hold any “mistakes” against them. No matter how grievous a manuscript’s misstep, an editor will be there to correct it, because it’s our job. (But mostly because we can’t stop ourselves.)—Brenda Gregoline, ELS

 

Going the Distance: Further or Farther?

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A medical editor who in a manuscript meeting asks, “Should we take this manuscript farther?” sparks the idea for this discussion on the grounds that farther suggests distance and further, “quantity or degree.”1

 
Once decided, the examples of variant use jump unexpectedly forward without my having to crack a book:

• Jack Shephard, spinal surgeon and Lost castaway, pauses amid the lush tropical foliage to ask his guide to Jacob’s lighthouse, “How much further, Hurley?”2 He’s a spine surgeon, not a brain surgeon, I think smugly, feeling confirmed in my theory that fictional characters are only as smart as the people who create them.
• The writer of a blurb on the Adventure Cycle Association itinerary3 for a guided bicycle trip in the Blue Ridge Mountains gets it right when describing what’s in store for riders after they reach Mabry Mill: “Approximately five miles farther down the road, you might want to take a detour of less than a mile off the parkway for a tour and a taste at the popular Chateau Morrisette winery.”
• I am sitting at an Italian restaurant celebrating the birthdays of 2 manuscript editors. Talking about my running schedule, I say that my weekly distance “will extend further.” I pause. “That would be farther.” I smile, lift my brows, and announce that I have selected further and farther for my blog entry.

But once I crack the dictionary and English-language usage books, my smugness at knowing the difference between the two dissolves, for the words “have been used more or less interchangeably throughout most of their history,” says the 11th edition of Merriam-Webster’s Collegiate Dictionary, which allots 11 lines to a discussion of their usage differences, adding that they “are showing signs of diverging.” First, noting that they are not used differently as adverbs “whenever spatial, temporal, or metaphorical distance is involved,” the entry says they “diverge” when the meaning is not conveying distance. In that case, “further is used.” Furthermore, when used as a transitional adverb announcing that the sentence aims to advance a point, the entry says further is used, but farther is not. (However, further is usually changed to furthermore in JAMA in such instances.) Adjectivally, the usage entry continues, “Farther is taking over the meaning of distance.”

 
To put it in perspective, Webster’s Dictionary of English Usage devotes 3 columns to the discussion that begins, “About every usage commentator in the 20th century … has had something to say about farther and further… as to how they should be used or how they seem to be used.”1 This explanation comes after first noting that few of the commentators have ventured little beyond a 1906 “pronouncement”:

Farther should be used to designate longitudinal distance; further to signify quantity or degree.

Webster’s says that farther and further “are historically the same word” and concludes that their interchangeable use is after all “not surprising.” To buttress the claim that they have the same origin and that they did not stem from the word far, the Webster’s entry reports that, of the two, further is older and “appears to have originated as the comparative form of a Germanic ancestor of the English forth,” whereas “farther originated in Middle English as a variant of further that was influenced by the comparative (spelled ferre) of far (then spelled fer) which it (and further) eventually replaced.”

 
The rest of the entry provides examples of usage, noting when grammatical usage for one eclipses the use by the other. In modern English, Webster’s says that further “used in the sense ‘additional’ … has taken over…” But farther is more frequently used adjectivally when “literal or figurative distance is involved.”

 
The Chicago Manual of Style4 and The Associated Press Stylebook and Libel Manual5 echo the 1906 pronouncement and distinguish the two by distance and degree. However, swerving slightly, the seventh edition of Scientific Style and Format6 suggests that the use of farther as an adverb works for physical or nonphysical distance and suggests that further be reserved for use as a transitive verb: “His theory did little to further our knowledge of the oldest galaxies.”

 
After examining the language usage explanations of the 2 words, perhaps the commentators who have not ventured further than the 1906 pronouncement offer the best understood explanation. I could go farther, but I won’t. —Beverly Stewart, MSJ

1. Webster’s Dictionary of English Usage. Springfield, MA: Merriam-Webster Inc; 1989.
2. Lighthouse. Lost. ABC television. February 23, 2010.
3. Adventure Cycling Association. Blue Ridge Bliss: tour itinerary. http://www.adventurecycling.org/tours/tourdetail.cfm?id=175&t=EV10&p=3. Accessed September 25, 2012.
4. The Chicago Manual of Style: The Essential Guide for Writers, Editors, and Publishers. 15th ed. Chicago, IL: University of Chicago Press; 2003.
5. Goldstein N, ed. The Associated Press Stylebook and Briefing on Media Law. New York, NY: Basic Books; 2007.
6. Council of Science Editors. Scientific Style and Format: The CSE Manual for Authors, Editors, and Publishers. 7th ed. Reston, VA: Council of Science Editors in cooperation with Rockefeller University Press; 2006.