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

Ding Dong: the Death Dagger Is Dead

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AMA Manual of Style, section 2.3.2, has an ominous subheading: “Death.” I’ve quoted it below:

Death. If an author of an article has died before the article goes to press or is posted online, a death dagger (†) should follow the author’s name in the byline, and one of the following footnotes should be inserted after the author affiliation footnote.

†Died November 17, 2005.

†Deceased.

Okay. That’s super-goth and all, but…why? Is that useful information for a reader? Does it serve any purpose other than a moment of recognition that life is fleeting, memento mori, etc?

Also, the life of a scholarly article is long—why single out the author who died during a relatively narrow window (from acceptance to publication)? We’re all going to die someday, including every byline author. (Sorry if you came to AMA Style Insider for happy feelings. Here is a picture of a puppy.)

At a recent stylebook committee meeting, we decided to kill the death dagger. (Get it?) If authors want to note that a coauthor is deceased, a note can be put into the acknowledgment section instead.

Interestingly, the dagger symbol is sometimes called an obelus. A variant on this symbol was probably used by Homeric scholar Zenodotus to critically mark lines in manuscripts that were of dubious attribution. The Oxford English Dictionary uses it to note that a word is obsolete. It seems a bit cruel to use the same typographical mark to denote a person as dead and to mark a word as obsolete—-but I suppose I can see the connection.—Brenda Gregoline, ELS

Raising (Rearing?) Hell

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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

Steal This Article

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Today we shine a light on a fascinating blog on plagiarism and scientific misconduct, Copy, Shake, and Paste (dig that serial comma!), written by Debora Weber-Wulff. Do any of you work with plagiarism-detecting software? Leave us a comment on your experiences.

Also check out her sadly hilarious entry about fake editorial board members. —Brenda Gregoline, ELS

Quiz Bowl: Editorial Processing and Assessment

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So, what happens to my manuscript once it has been submitted for publication? Who reads it? Who decides its fate? If it is accepted, what happens next? Help!

Many authors are perplexed by the editorial processing and assessment stages of the publication process. Sometimes it seems as if manuscripts are submitted for publication only to disappear into a sinkhole of unpublished data. Never fear, diligent authors. This month’s AMA Manual of Style quiz covers the procedures involved in editorial assessment and processing.

Here’s an example to test your knowledge of this often puzzling process.

Who on the editorial team makes decisions regarding rejection, revision, and acceptance of manuscripts?

editor

peer reviewer

both the editor and peer reviewer

So, what do you think? (Use your mouse to highlight the text box.)

editor

That one wasn’t too hard. The editor is the head honcho after all, although input from the peer reviewers is invaluable.

If you’re interested in learning more about how manuscripts are processed and assessed, check out this month’s quiz at www.amamanualofstyle.com.—Laura King, MA, ELS

Quiz Bowl: Author-Editor Relationship

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There have been some famous, even notorious, author-editor relationships: Charles Dickens and Edward Bulwer-Lytton, Ted Hughes and Sylvia Plath, Raymond Carver and Gordon Lish. This month’s quiz takes us on a tour of some of these fruitful and fractious relationships as a means of exploring effective ways for editors to handle issues with authors. The following is an example from this month’s quiz.

Vladimir Nabokov, author of Lolita, notoriously and wittily disdained editors. In a 1967 interview in The Paris Review, he said, “By ‘editor’ I suppose you mean proofreader. Among these I have known limpid creatures of limitless tact and tenderness who would discuss with me a semicolon as if it were a point of honor—which, indeed, a point of art often is. But I have also come across a few pompous avuncular brutes who would attempt to “make suggestions” which I countered with a thunderous ‘stet!’”¹

What is the best way for editors to communicate with authors who balk at the suggestions made to improve the manuscript?

a. E-mail the author to tell him/her that all the edits are based on the AMA Manual of Style and therefore not subject to change.

b. Telephone the author to discuss the edits, iterating the rationale and providing resource support for the changes.

c. Do not respond to the author.

d. Eliminate all the edits and publish the paper as the author originally submitted it.

What would you do? Here’s our advice (use your mouse to highlight the text box):

Telephone the author to discuss the edits, iterating the rationale and providing resource support for the changes.

Usually, an author’s insistence to overrule all editorial changes is a knee-jerk reaction to extensive editing. Most authors are aware of the editing process, although some need to be guided gently through it. Communicating with the author and explaining the reason for the changes (as well as providing resource support when necessary) can often defuse a volatile situation.—Laura King, MA, ELS

Gold H, interviewer. Vladimir Nabokov, The Art of Fiction No. 40. The Paris Review. http://www.theparisreview.org/interviews/4310/the-art-of-fiction-no-40-vladimir-nabokov. Accessed February 8, 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

The “Asterisk Solution,” or Group Authorship Is Still Authorship

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Authors may come alone or in pairs or trios. Or more. Today, more and more frequently, they come as part of a group. There is nothing wrong with group authorship—groups can accomplish great things. But if a group is named in the byline as sole author or in addition to individually named authors, all members of the group are still being presented as authors and all must meet authorship requirements.

This is a point of contention or difficulty for some authors (or some groups), who wish to have only the name of the group in the byline even if only a small number of the members of the group (eg, the Writing Committee) meet the standards of authorship set forth by the International Committee of Medical Journal Editors (ICMJE) and outlined on the authorship forms required by our journals.

What to do? The AMA Manual of Style lists an option to address both concerns: (1) authors who want only a group name to appear in the byline, even if all members of the group do not meet authorship criteria, and (2) journals that want to adhere to the criteria for authorship outlined by the ICMJE. Let’s call this the “asterisk solution.” An asterisk is placed after the group name in the byline, and this links to an asterisked footnote that indicates which members of the group met authorship criteria.

The asterisk solution often is a happy one for both authors and journal editors (and it allows readers to see who the true authors are). But sometimes even the asterisk is objected to. The editors of 3 ophthalmology journals (Archives of Ophthalmology, American Journal of Ophthalmology, and Ophthalmology) found strength in numbers. In August 2010, the 3 editors published a jointly written editorial in each of their journals, outlining the “asterisk solution” policy from the AMA Manual of Style and announcing that they planned to hold firm to this policy in their journals.

Being an author is a form of recognition and can add to one’s reputation. It also represents a responsibility. The asterisk solution bestows recognition and responsibility with a single character.—Cheryl Iverson, MA

Envy, Jealousy

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Words that convey similar meanings sometimes come to be used interchangeably. In the case of envy/envious and jealousy/jealous, though, the move seems to have been in one direction only; jealousy is often used in place of envy (“I’m so jealous of your new job”) but not vice-versa (one does not write, for example, “He was poisoned by his envious wife.”). Theodore Bernstein further points out that jealousy is sometimes used, not merely in place of envy, but as a stronger form: “‘There, within a stone’s throw of the sea, he makes his home, and his description of how he does this makes one move from envy to downright jealousy.’”¹ A human, and perhaps all-too-familiar, state of affairs—anyone who denies having experienced such a progression of emotion is either hopelessly out of touch with his or her feelings or a liar.

However, although jealous has been used in place of envious since the late 1300s² and using jealous as a more intense form of envious creates no confusion, it is often held that the words have distinct meanings and that this distinction should be maintained. Even authorities sometimes flounder around a bit when trying to nail the distinction,³ but in general envy is taken to convey a coveting of the wealth, possessions, or success of someone else,⁴ whereas jealousy is often taken to convey a state of “intolerance of a rival for the possession of a thing which one regards as peculiarly one’s own or for the winning of which one has set one’s heart….”⁴ Jealousy also can be used in a less grasping sense to indicate the understandable guarding of some possession or attribute, as in “new colonies were jealous of their new independence.”⁵ Both of the latter meanings highlight that jealousy concerns an attitude toward something that one has or believes one has. In this sense, envious and jealous are not interchangeable—one can jealously guard something, but one cannot enviously guard something.

However, jealous also often carries a frank note of hostility, “a strong implication of distrust, suspicion, enviousness, or sometimes anger.⁴ This might suggest why the person seeking a word with a bit more heft than envious will sometimes use jealous instead—quite simply, when casting about for a suitably malicious word in the heat of the moment, jealous is low-hanging fruit.

On the other hand, envy is not the innocuous little milquetoast that it at first seems. True, it can be used without malice; one can say, for example, “I don’t envy him his mother in law.” Equally true, it has in the past been used in a noble sense—Aristotle wrote of “good envy,” an admiration that drives one to emulate another³—although that usage has been rare since the 1600s and is now nearly obsolete.⁶ Certainly, envy carries less emotional charge than jealousy. But to assume that envy is simply a meek cousin of jealousy is to make a mistake.

If jealousy implies strong emotion that often is perhaps all too apparent to everyone involved, envy can imply something more clandestine; as Joseph Epstein puts it, “Malice that cannot speak its name, cold-blooded but secret hostility, impotent desire, hidden rancor, and spite all cluster at the center of envy.”³ Used in this sense, envy suddenly becomes a different animal altogether, and, as Epstein further points out, “The openness changes the nature of the game. Envy is almost never out in the open; it is secretive, plotting, behind the scenes.”³ Perhaps this is another reason that jealousy is often used, albeit subconsciously, in place of envy—after all, envy is one of the Seven Deadly Sins; jealousy is not.

In short, although envy and jealousy have long been used interchangeably and jealousy has come to be frequently used in place of envy, the words do denote different states, and the careful writer should take care to maintain the distinction between them. Both can be used in neutral ways (“She was jealous of her honor”; “I don’t envy him his workload”), but both also can carry weightier meanings; in choosing between them, one might keep in mind that “The real distinction is that one is jealous of what one has, envious of what other people have.”³

The bottom line:

● Looking for a word that expresses the coveting of what someone else has? Use envy.

● Looking for a word that expresses the guarding of what one has or believes one has? Use jealousy.

● Keep in mind that although jealousy is often used as a more intense form of envy, it might be better to use another word or to reword the sentence so as to retain envy.—Phil Sefton, ELS

1. Envy, jealousy. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:166-167.

2. Jealous. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:892.

3. Epstein J. The green-eyed monster: envy is nothing to be jealous of. Washington Monthly website. http://www.washingtonmonthly.com/features/2003/0307.epstein.html. July/August 2003. Accessed December 13, 2011.

4. Envious, jealous. Merriam-Webster’s Dictionary of Synonyms. Springfield, MA; Merriam-Webster Inc; 1984:295.

5. Jealous. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003:671.

6. Envy. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:523.