editing process

AMA Style in the Wild

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For many years, my best friend Conchita (not her real name—but she’ll appreciate this reference) and I lived accidentally parallel lives. We were band geeks together, shined in the back row of the chorus during high school musicals, and scrambled to compose an extremely derivative opera (a recording of which I’m pretty sure still exists, unfortunately) to satisfy a creative writing assignment in physics class. But whereas I dreaded said physics class with the fire of a thousand burning suns, Connie excelled in all things scientific. It was no surprise to me when she earned her Masters in Public Health, but it was a surprise when we both ended up in careers relating to the medical field. What was especially enjoyable was that the idle chit-chat usually reserved for whichever high school classmate had just had a baby could now be applied to hyperspecific work-related things, including our beloved AMA style.

Although initially I seized on our collective use of AMA style to complain about authors who had only used abbreviations 4 times, I became interested in learning how she used it in her corner, as I had previously assumed that AMA style was the domain of journal manuscript editors. So I gathered some questions together and polled both Connie and Edgar (name also changed), a former colleague of my fellow blogger Iris, to ask how they used AMA style in different areas of medical communications.

Edgar is an editor for a global advertising company whose clients provide products such as pharmaceuticals, medical devices, and guides relating to health and wellness. The writers and account managers creating their copy are required to be familiar with AMA style, and the style guide for each account has a template of “[X drug] uses AMA style with the following exceptions.” These exceptions usually come in the form of client preferences for the text and layout, which leaves Edgar with the challenge of how to be the resident style stickler while keeping the client’s dictates in mind. Ultimately, while a client’s spatial limitations may not allow for the correct number of thin spaces between P values, “no client style guide can match the AMA for depth and breadth” and it is an important organizing tool.   The final product represents a mix of both AMA style and client preferences, but, as Edgar puts it, “One veteran editor told me years ago, rather cheekily, ‘Not even AMA uses AMA style.’ … What he was getting at was that it’s a great tool to be adapted rather than followed in strict orthodoxy.”

In Connie’s previous role in the editorial services group of a medical communications agency, “The AMA Manual of Style was THE BIBLE. Past colleagues achieved mythical status for their ability to recall which section of the AMA manual housed the elusive answer to the day’s grammatical conundrum.” (As you can see, Connie also excelled in English class.) She now works for a pharmaceutical company in their labeling and product packaging divisions, which comes with its own set of complicated rules. The documents she works on (such as a product insert for a specific drug) are not organized with any one editorial style in mind, but rather in terms of their audience (eg, patients vs prescribers). Because these documents are written by multiple authors and pass through many hands before Connie sees them, the text can sometimes represent a hodgepodge of styles. However, because the text is also regulated by the FDA and any changes beyond simple typos would be subject to review by medical, legal, and regulatory teams, these inconsistencies often remain intact. In the rare opportunity when Connie is allowed to make edits on small items, she uses AMA style as a guide on things like italicization, reference lists, and capitalization to make her process more straightforward and efficient.

So my takeaway from these conversations is that while nobody will probably ever apply AMA style as strictly as manuscript editors do (and if we’re honest with ourselves, we probably take some proud satisfaction in that!), AMA style is a useful and important fall-back in other areas of medical communications because of its consistency, specificity, and efficiency. But for your sake, I promise that Connie and I won’t compose an opera about it.—Amanda Ehrhardt

Stranger Than Fiction

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Like many others working at JAMA Network, I’m a writer as well as an editor—and not just of blog posts! I’ve written the script for a graphic novel, Mooncakes, that will be published in 2019, and my first short story was published last year. I’ve been writing science fiction and fantasy for a long time now, but I only started working as a manuscript editor for the JAMA Network 3 years ago. Since I’ve started working here, a question I get asked frequently is: how has editing medical articles and working with AMA style affected your writing?

The short and simple answer is: not much. Science fiction writing and medical writing are such vastly different spheres that it’s pretty easy for me to ignore my medical editing brain when writing, or when I’m editing my fellow writers’ stories.

However, the long answer is a bit more complicated. I can ignore my medical editing instincts, but I can’t ever fully turn them off—I have to restrain myself from changing “though” to “although,” or “compared to” to “compared with,” if making that kind of a change would interfere with the author’s or character’s voice.

Other times, though (see what I did there?), I’ve found that listening to my AMA-editor voice has made me a better writer. For one thing, it’s encouraged me to be more succinct. My colleague Iris Lo wrote a post about removing redundancies in a manuscript, and I’ve found that this is an important guiding principle in all genres of writing. It’s especially useful when writing short stories—I have a tendency to be overly verbose in my writing, but in a tale of 4000 words or less, every word needs to matter. When I look back at my writing from 3 years ago and compare it to my writing now, I’ve found that my prose is sharper, and I’m enjoying my first publication success as a result. Most of that is just the natural shape of writing progression, but I’d be remiss if I didn’t attribute a part of it to my work here at the AMA.

And, every so often, I’ll have a character say “compared with” instead of “compared to.” Because grammar sticklers exist in every universe!—Suzanne Walker

 

 

Check It Twice

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Of all the magic a word processor can perform, I find spell-check to be the most useful, especially while editing dense medical copy. But I’m not too proud to admit that it’s not even the most sinisterly complicated words that my spell-check corrects most often. While I’m focusing on making sure “dysosteogenesis” or “hemocytopoiesis” are spelled correctly, I tend to gloss over the more commonplace language. Sometimes I’ll invert letters (“otolaryngoolgy”) or repeat articles (“the the procedure”) and, thank goodness, spell-check will catch it.

But spell-check is not without its shortcomings. It’s still just a computer program, and it isn’t tuned to the nuances of language with the same attention as a human brain. Spell-check will miss that I meant “through” when I’ve typed “though,” and of course there’s a long list of homophones that spell-check will inevitably ignore (ie, “knew/new,” “waist/waste,” “aisle/isle”). The bottom line is that reading back through your work and not relying solely on spell-check (or any automated process) to do the thinking for you could save you (and has certainly saved me!) a lot embarrassment. For example…

 

 

Spell-check couldn’t have saved those eager tweeters from themselves before they released their thoughts on followers, friends, and family. But a little more attention to detail could have. Tools like spell-check are helpful, but they’re still only tools. When it comes to writing, editing, and engaging in any form of written communication, nothing will serve you better than your own brain— and one more read-through.—Sam Wilder

Advice for the AMA Style Newbie

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After several years of working as an editor using the Chicago Manual of Style almost exclusively, I found myself interviewing for a job at JAMA Network. Naturally, I wanted to prepare by learning as much as I could about AMA style. Google searches such as “Chicago vs AMA style” produced little in the way of useful information. Luckily, the AMA Manual of Style offers a free trial subscription option. Poking around here and there, I was able to glean some similarities and differences. But much of what I really needed to know I learned once I started my new job. What follows are some of my thoughts on making the switch from “Chicago style” to AMA.

First, the good news: we’re a lot more alike than we are different! All the wonderful stuff you know and love from CMOS or other guides about matters like subject-verb agreement, parallel construction, misplaced modifiers, and the like are just the same in AMA. Even our much-beloved serial comma retains its place of honor. We’re literally all speaking the same language!

Of course, there are also differences. Many of them are relatively minor, but they take a while to get used to. For example, unlike CMOS, AMA almost never uses periods after abbreviations. “Dr” still looks underdressed to me, even after several months. In a similar vein, while Chicago style advises spelling out numbers 1 to 100 (while acknowledging the alternative rule of spelling out 1-10 and using numerals for anything larger), AMA prefers the use of numerals in nearly every context, the main exception being the beginning of a sentence (CMOS concurs on this point). One habit I’ve had to break is using an en-dash to express ranges of numbers, whereas AMA prefers a hyphen or the word “to,” depending on the context (hyphens are for ranges in tables or in parenthetical expressions). While I generally do prefer a word over a symbol in formal writing, I miss seeing the en-dash around. It’s also strange not to see commas separating the digits of larger numbers—instead AMA keeps 4-digit numbers closed up, and for larger numbers opts for a thin space, a character Chicago rarely uses.

The formatting of references is an obvious point of difference, especially for a journal copyeditor like myself. In my job at JAMA Network, I get to use software with a reference editing component. If you’ve ever spent hours hand-styling journal references, you know what an exciting development this is. Chicago offers 2 systems of source citation, notes and bibliography and author-date references. In AMA style, references are cited in-text with superscript numerals corresponding to a reference list at the end of the article. The style of reference items is generally sparer than in Chicago, with initials for authors’ given names, lowercased article titles, and parsimonious use of punctuation and spacing. It’s a clean style that delivers the necessary information in the most efficient way possible.

My absolute favorite thing about working in AMA style is having a resource developed specifically for the type of content I’m editing. Anyone who’s ever tried to apply the more general Chicago style to a technical or scientific discipline knows that it leaves many questions unanswered. Often these topics will be covered in a house stylebook, but these aren’t always kept current and may not always have the information you’re looking for. Like CMOS, AMA has a guide to correct and preferred usage. But in addition to old standbys like effect vs affect, you’ll also find explanations of why cases are “managed” but patients are “treated.” In my experience, the discipline-specific language of medical editing and the structure of articles have been the 2 major lessons. Luckily, the AMA Manual of Style has you covered on both counts.

If you’re just starting out in the world of AMA style, there are some helpful resources you may want to check out. The quiz section of the style guide’s website has quizzes on a wide range of topics. You can test your acumen (or if you don’t mind spoilers, page through the answers in order to discern major points of the style). If you’re interested in more guided instruction, a medical editing class may be worth looking into. However you go about it, enjoy the learning process, and when in doubt, look it up!—Heather Green

Dial “A” for Author

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

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

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

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

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

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

Get to the Point!

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

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

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

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

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

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

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

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

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

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

 

 

 

Discard the Rest

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

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

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

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

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

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

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

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

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

People-First Language

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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

The Use of Cause-and-Effect Language in the JAMA Network Journals

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As a manuscript editor and freelance manuscript editing coordinator for the JAMA Network specialty journals, I am constantly having to edit out cause-and-effect language from observational studies that are not randomized clinical trials. According to the AMA Manual of Style, the word effect, as a verb, means to bring about a change; as a noun, it means result.

A randomized clinical trial is one of the few types of studies that are designed to assess the efficacy of a treatment or intervention (and thus allowed to use cause-and-effect language) because the participants are treated in controlled, standardized, and highly monitored settings.

Whenever I come across a study in which the authors are trying to determine, for example, whether the use of a certain type of drug will reduce the risk of some complication following a certain type of surgery, I need to verify whether the study is a randomized clinical trial or a report of a controlled laboratory experiment. If it isn’t, and is a report of an observational study (such as a cohort, cross-sectional, case-control, or case series study, or a meta-analysis), then all cause-and-effect language must be replaced. But by what?

Generally, association may be a useful replacement for effect. The AMA Manual of Style defines association as a “statistically significant relationship between 2 variables in which one does not necessarily cause the other. When 2 variables are measured simultaneously, association rather than causation generally is all that can be assessed.” So instead of saying the “effect of this on that,” rephrase as the “association of this with that” or the “association between this and that.”

Sometimes, however, the authors don’t agree and want me to change it back, in which case I calmly let the authors know that it is AMA style to allow cause-and-effect language only for randomized clinical trials and controlled laboratory experiments and that, perhaps in the “Discussion” section of their manuscript, they can try to make arguments to support that the association might be causal. However, to quote from one of our scientific editors, “the expression and ultimate interpretation of the findings can’t be causal.”

The use of cause-and-effect language is quite common in everyday speech, and so it is easy for most people to assume that if one event comes before another, then the first is the cause of the second. In the JAMA Network journals, findings that rely on this type of logic had to have been rigorously tested in a randomized clinical trial.—Paul Ruich

 

Readability

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A common assumption about those of us who copy edit science papers is that we have a science background. Some of us do, but by no means all. After [mumble-number] years in the medical publishing field, I might feel like I “practically” went to medical school, but I did not. I could probably take out your gallbladder, though. Want to let me try?

Anyway, as long as you are a good reader, writer, thinker, and editor, and know your way around IMRAD, it is possible to edit a manuscript on a wholly unfamiliar topic. The authors are the content experts; the paper has (probably) been through peer review; and the copy editors have skills, coffee, and Google.

When a paper is excruciatingly hard to edit, it’s not usually because of the science but because of the writing. Some authors pile up jargon like hoarders collect cans of beans, as protection against the deadly apocalypse of someone being able to read their article without feeling squashed by the weight of all those words. Why settle for a teeny nothing word like “use” when “utilize” sounds so much more important? Why give us actual data when you can just talk about “trends” and “robustness”? Make sure you add a lot of “it has been shown that” and “the fact that.” And make sure you start every sentence in the Discussion section with “furthermore” or “moreover”!

Real talk from Nature: “You can always look up jargon, but with a poorly constructed sentence you’re on your own.” The best-case scenario between author and manuscript editor is a partnership—we don’t want to be on our own! We want to help explain complicated things in a simple way, and that often starts with authors picking the most direct words available.—Brenda Gregoline, ELS