Raising (Rearing?) Hell

Besides the dropping energy levels and unsightly wrinkles that daily remind me of my advancing age, I never expected an Associated Press style rule—beaten into me as a young reporter—to deliver the one-two punch that landed me squarely into the “old fogies” category.

I was editing a JAMA Viewpoint about a fairly modern question involving gender identity, hormone levels, and eligibility for women’s athletic events when my knee began to jerk at first sight of the descriptor “raised,” as it applies to how or where someone grew up.

As soon as I saw the word, I heard harsh tones in my head and felt the breeze of a wagging finger: “Corn and cattle are raised, people are reared!” So I dutifully changed “raised” to “reared” as the AP Stylebook commands. Soon, I sent the proof off for review by the senior editors and the authors.

As I had predicted, one of the medical editors deleted “reared” and inserted “raised.” I knew I was right about this! I was poised to cross off the edit when I thought, “Maybe I should look at a newer version of a stylebook, just to see if the rules have slackened over the decades.” (Our own AMA Manual of Style is silent on the matter.) My office was too cluttered to find the newest Associated Press Stylebook, so I turned to Google.

The first search result was titled “Grammar Gremlins: Is it ‘reared’ or ‘raised’?” I clicked—who says a pithy headline doesn’t draw in a reader?  Knoxville News Sentinel Columnist Don Ferguson, who by his photo looks older than me, offered his first sentence:

A recent Associated Press report about an accused terrorist said the man was “born and reared” in America.

He followed with,

Did this use of “reared” instead of “raised” say something about the age of the writer?

Oh my goodness! Who would have thought that old style rule would say more about me than my slowing gait? He noted that youngsters favor “raised.” He cited Garners Modern American Usage’s calculations that “born and raised” is used 8 times more often than “born and reared.”

As with most of often-confused words, he also noted that dictionaries say either is correct.

I dropped my pen and conceded the edit.—Beverly Stewart




Why Not Say It Clearly: The JAMA Network Editors on Correct Usage

The second edition of Why Not Say It Clearly? A Guide to Expository Writing by Lester S. King, MD, was published in 1991 (first edition in 1978).

Dr King was a charmingly irascible but fascinating and classically trained scholar who was a senior editor at JAMA for more than 25 years. A coauthor of the AMA Manual of Style (eighth edition), he was an accomplished raconteur and humorist as well as a prolific writer, particularly concerning language and usage.  He was professor of pathology and professorial lecturer of history of medicine at the University of Chicago.

Why Not Say It Clearly remains an enduring editorial classic on writing and usage and is the inspiration for this expansion of the AMA Style Insider:  The JAMA Network Editors on Correct Usage.  Feedback welcome!—Roxanne K. Young, ELS

Internet, Computer Terms, and References to Social Media

The JAMA Network editors prefer the following capitalization and punctuation styles for e- and i-entities, computer terms, and references to and in social media and networks.  Also check commercial websites for trademarked terms and conditions of their use.

app, application

cell phone

e-cigarette (E-cigarette at the beginning of a sentence or in a title, subtitle, or heading)

e-commerce (see e-cigarette)

e-learning (see e-cigarette)



e-terms (see e-cigarette)

email (Email at the beginning of a sentence or in a title, subtitle, or heading)

Follow (as on Facebook; also capitalize Junk folder, Option key, Edit menu, and other computer key and menu names)

Google (google as verb)



iPod, iPad, iPhone, etc (trademarks)




online (as both adjective and adverb)


Skype (skype as verb)


text, texted, texting

Tweet, Tweeting, Twitter, Twittering (despite the official logo being lowercase; a trademark)

webinar, website (World Wide Web, web-based literature search)

Wiki, Wikipedia

Quiz Yourself

Edit the following sentence to eliminate jargon:

A 78-year-old woman with a congenital heart and a history of high blood pressure and heart attack was admitted to the hospital and prepped for surgery.

Highlight for the answer:

A 78-year-old woman with congenital heart disease and a history of high blood pressure and myocardial infarction was admitted to the hospital and prepared for surgery.

Editor’s Note: A heart is not congenital; the preferred terminology is congenital heart disease or congenital cardiac anomaly. Myocardial infarction, not heart attack, is the preferred term. Patients are prepared, not prepped, for surgery (§11.4, Jargon, pp 408-410 in print). Some of these terms may be acceptable for certain types of writing; peer-reviewed medical journals generally avoid them.—Laura King, ELS

Questions From Users of the Manual

Q: I am putting together an annotated bibliography for a manuscript. What is the correct order recommended by the AMA Manual of Style for citing multiple articles by the same author? Is it by date of publication or article title?

A: The JAMA Network journals do not use a name-date style of reference citation. Instead they use a superscript reference citation system. If you look in the 10th edition of the Manual of Style, section 3.6 (Citation), you will see further information on this. So, it matters not the date of publication or the article title. What is key is the order in which the reference is cited in the paper, eg, the first reference to be cited would be reference 1, the second would be reference 2. (And if reference 1 is cited again later in the paper, it would still remain reference 1.)

Q: What do you tell authors who object to the house style your publications follow by saying that “Everybody does X [rather than what you recommend].”?

A: When people respond like this, I find that it’s helpful to look at what a few key style manuals or journals in the field (based on their Instructions for Authors) do in areas in which people have complaints or concerns. If you can put together a little chart (nothing fancy) showing that indeed maybe it is not EVERYBODY who does X, real data can sometimes calm the fevered brow. And sometimes you may find that indeed most others do have a different policy than what your house style recommends. Then it may be time to reconsider your policy. Sometimes this is how style policies change, and that can be a good thing. We learn from our authors just as we hope they learn from us.—Cheryl Iverson, MA

Reluctant, reticent

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

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.

Quiz Bowl: Radiology Terms

Do you know the difference between TE and TR? How about section and slice? And what exactly is an echo train? That’s right, this month we’re talking about radiology!

The AMA Manual of Style has a brief but informative section on radiology terms (§15.7.2). The section defines terms commonly used in radiology literature and offers instruction on how to use these terms correctly. Some of the terms addressed in the section are b value, k-space, echo time, and repetition time. The style quiz is a sample paragraph that contains commonly used radiology terms.

See if you can identify the problem(s) in the following sentences from this month’s quiz:

Twenty-four contiguous slices, each 2 mm thick, were acquired in an interleaved fashion. Radiologic slices were then examined for consistency of the hippocampal subfields from patient to patient.

Use your mouse to highlight the text box for the answer:

Twenty-four contiguous slices, each 2 mm thick, were acquired in an interleaved fashion. Radiologic sections were then examined for consistency of the hippocampal subfields from patient to patient.

The term section should be used to refer to a radiological image and slice to refer to a slice of tissue (eg, for histological examination).

That’s just a “slice” of what we have to offer in this month’s quiz. If you’re a subscriber, check out the complete quiz at www.amamanualofstyle.com.—Laura King, MA, ELS

Ex Libris: Grammar Girl’s 101 Words to Sound Smart

This column wraps up the reviews of Grammar Girl’s 101 words series with Grammar Girl’s 101 Words to Sound Smart. Just as our superhero Grammar Girl came to the rescue of high school graduates who want to appear educated and erudite with her book Grammar Girl’s 101 Words Every High School Graduate Needs to Know, so too does she come to the aid of general readers who want to appear smart. A daunting task to say the least, but our heroine Mignon Fogarty, disguised as her Grammar Girl alter ego, is up to the task. As she writes in her introduction, “It’s a presumptuous task to choose 101 words that ‘smart people’ use. Who says what’s smart?” But difficulty notwithstanding, Grammar Girl forges ahead and forms a list of 101 words to sound smart.

As with the other books in the series, 101 Words to Sound Smart is formatted as a glossary, with words arranged alphabetically and most entries only 1 page long. Each entry includes a quotation illustrating the correct usage of the word in question from authors, reporters, actors, and other notable sources. For example, in the entry on wane, Fogarty quotes the author Evelyn Waugh, “My unhealthy affection for my second daughter has waned. Now I despise all my seven children equally.”

Although 101 Words to Sound Smart is aimed at a general audience, it is a useful guide for editors and particularly writers. Although all these terms can be found in dictionaries, Grammar Girl presents the information more simply and clearly. In addition, her explanations provide a means to understand not only the definitions of terms but also their usage.

For example, one of the terms listed in 101 Words to Sound Smart is Occam’s razor (also spelled Ockham’s razor). Merriam-Webster’s Dictionary defines this term as “a scientific and philosophic rule that entities should not be multiplied unnecessarily which is interpreted as requiring that the simplest of competing theories be preferred to the more complex or that explanations of unknown phenomena be sought first in terms of known quantities.” Huh? Grammar Girl explains it as “a phrase that means the simplest solution is usually the right one.” Oh, now I get it. She then clarifies: “For example, if you find a basket of tomatoes outside your door, it’s conceivable that ninjas are trying to poison you because, although you don’t know it yet, you are essential for their enemy’s evil plan; but Occam’s razor suggests it’s more likely your neighbor who likes to garden, and gave you tomatoes last year, left them there.”

This book serves as a useful compilation of words most readers are generally familiar with but not deeply knowledgeable about. As Fogarty writes, “Many of the words that made the cut are at least familiar to most people, but convey an especially deep meaning when the reader has an understanding of history (Machiavellian, bowdlerize, Rubicon), different cultures (Talmudic, Sisyphean, maudlin), or philosophy (existential). The words are also general enough that most prolific writers could find a reason to use them on occasion.” A few of the entries I found most interesting were anodyne, atavistic, defenestrate, diaspora, ersatz, gestalt, hoi polloi, jejune, nascent, neologism, omertà, peripatetic, sui generis, and zeitgeist.

Overall, Grammar Girl’s 101 words series, including 101 Misused Words You’ll Never Confuse Again, 101 Words Every High School Graduate Needs to Know, 101 Troublesome Words You’ll Master in No Time, and 101 Words to Sound Smart, is a clever, easily readable, and immensely enjoyable quartet of books. Through this series, our superhero Grammar Girl succeeds is vanquishing her arch enemy “the evil Grammar Maven who inspires terror in the untrained and is neither friendly nor helpful” (http://grammar.quickanddirtytips.com/bio/) by offering an alternative to those murky, confusing grammar and usage books editors and writers have had to rely on for years.—Laura King, MA, ELS

Ex Libris: Grammar Girl’s 101 Troublesome Words You’ll Master in No Time

Of all the books in Grammar Girl’s 101 words series, 101 Troublesome Words You’ll Master in No Time is probably the most useful for editors. This books lists 101 words that, as author Mignon Fogarty puts it, “are only sort of wrong.” These words are particularly challenging for editors. Do we bow to convention and allow established usage to reign or do we forge new ground (as editors often do) by insisting on up-to-date usage? With this book, Grammar Girl guides the way.

Each entry in 101 Troublesome Words You’ll Master in No Time begins with a response to the question, “What’s the trouble?” In her response, Fogarty points out why the designated word is troublesome. For example, in the entry on healthy, she writes, “Some people insist that carrots aren’t healthy; they’re healthful because only healthful can mean ‘conducive to health.’” After outlining the trouble, Fogarty details the history of the problem. For healthy, she writes, “Healthy has long been used to describe things that improve your constitution. Healthful gained ground against healthy starting in the late 1880s, but healthy fought back and now, although healthful isn’t wrong, healthy is the dominant Standard English word we use when describing fruits, vegetables, exercise, and other things we hope will make us live longer.” Finally, Fogarty answers the question all editors ask themselves, “What should you do?” In the case of “healthy,” she states, “Ignore anyone who says you have to use healthful instead of healthy (unless you’re trying to feign an ‘old-timey’ air).” Fogarty concludes each entry with 1 to 2 quotations from pop culture sources (as she does throughout the 101 words series).

There are numerous entries in 101 Troublesome Words You’ll Master in No Time that are applicable to the medical editor and that support (and occasionally refute) information found in the AMA Manual of Style. The following is a table of terms commonly found in medical editing and an explanation of how the AMA and Grammar Girl handle each term.

Term AMA Grammar Girl
African American “For terms such as white, black, and African American, manuscripts editors should follow author usage. … In the United States, the term African American may be preferred to black (not, however, that this term should be allowed only for US citizens of African descent).” “For Americans of African descent, use African American or black. If the person you are describing is from another country, use another appropriate term, such as Caribbean American.”
Aggravate “When an existing condition is made worse, more serious, or more severe, it is aggravated (also, exacerbated), not irritated.” “In formal situations or if you’re feeling especially sticklerish, avoid using aggravate to mean ‘irritate.’”
Billion “The word million signifies the quantity 106, while billion signifies the quantity 109. Although billion has traditionally signified 1012 (1 million million) in Britain, many British medical journals now use billion to indicate the quantity 109. A number may be expressed in million rather than billion if the latter term could create ambiguity. In that case, the decimal should be moved 3 places to the right. Trillion should be used to denote the quantity 1012.” “Today you can safely use billion to mean 1,000,000,000.” When you are reading old or translated documents, however, be aware of their country of origin and remember that the meaning of billion could be 1,000,000,000,000.”
Data “…retain the use of the plural verb with data in all situations.” “In general writing, if information won’t work because you’re using data as a mass noun to mean ‘information collected in a scientific way,’ data can be singular; however, in scientific writing, always treat data as plural.”
Gender Sex is defined as the classification of living things as male or female according to their reproductive organs and functions assigned by chromosomal complement. Gender refers to a person’s self-representation as man or woman or how that person is responded to be social institutions on the basis of the person’s gender presentation.” “Gender is a social construct, so when you ask someone’s gender, you’re asking whether a person wants to be perceived as what society calls males or society calls female. … If your readers are likely to be extremely squeamish about sex, it’s OK to use gender as a replacement for sex, but if not, try to keep the distinction between the two words.”
Media “In the sense of laboratory culture or contrast media, medium should be used for the singular and media for the plural.” “When media is used as a collective noun, it’s fine to use a singular verb.”
Over Time: Over may mean either more than or during (for a period of). In cases in which ambiguity might arise, over should be avoided and more than used. … Age: When referring to age groups, over and under should be replaced by the more precise older than and younger than. “Unless you work for a publication that follows AP style, freely use over to mean more than if it works better in your sentence.”
Percent “The term percent derives from the Latin per centum, meaning by the hundred, or in, to, or for every hundred. The term percent and the symbol % should be used with specific numbers. Percentage is a more general term for any number or amount that can be stated as a percent. Percentile is defined as the value on a scale of 100 that indicates the percentage of the distribution that is equal to or below it.” “When you are writing about increases or decreases in measurements that are themselves percents, it’s often important to be painfully clear whether you changes are percent changes or percentage point changes.  For example, if 6 percent of students attended swim meets last year, and 8 percent of students attended swim meets this year, that’s a 33 percent increase in attendance, but an increase of only 2 percentage points.”
Preventive “As adjectives, preventive and its derivative preventative are equal in meaning. JAMA and the Archives Journals prefer preventive. “You may certainly choose to use the sleeker preventive, but don’t chide people who prefer the longer form.”
Since Since should be avoided when it could be construed to mean ‘from the time of’ or ‘from the time that.’” “Don’t be afraid to use since as a synonym for because. Just be sure you aren’t creating ambiguous sentences.”
Unique “An adjective denoting an absolute or extreme state or quality does not logically admit of quantification or comparison. Thus, we do not, or should not, say deadest, more perfect, or somewhat unique. It is generally acceptable, however, to modify adjectives of this kind with adverbs such as almost, apparently, fortunately, nearly, probably, and regrettably. … [Unique] should not be used with a comparative (more, less), superlative (most, least), or quantifying (quite, slightly, very) modifier.” Unique is an absolute term, but it’s common to hear people modify it, saying such things a very unique. Grammarians call adjectives such as unique, dead, and impossible ‘ungradable.’ It means they can’t be more of what they already are. … Unique means ‘one of a kind’ or ‘having no equal,’ and things can’t become more unique. … Gradable terms can be modified down, however. For example, almost unique is fine. … Reserve unique for things that are truly one of a kind.”
Utilize Use is almost always preferable to utilize, which has the specific meaning ‘to find a profitable or practical use for,’ suggesting the discovery of a new use for something. However, even where this meaning is intended, use would be acceptable.” “Often, you can replace utilize with use and your sentence will mean the same thing and sound less stuffy. Utilize does have its uses, though. It conveys more of a sense of using something specifically for a purpose or for profit than use does. … Don’t use utilize just because it sounds like a fancy word. When in doubt, choose use. On the other hand, don’t be afraid to use utilize when you’re confident that it’s the right word.”

The above table is meant as a guide for the editor. As always, usage depends on whom you’re writing for and what you’re writing. However, before editors can make decisions on usage, they need to know the options and the reasoning behind them. Both the AMA Manual of Style and Grammar Girl’s 101 Troublesome Words You’ll Master in No Time provide useful guidance on how to handle some of the trickier terms encountered while editing.—Laura King, MA, ELS

Significant and Significance

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