editing process

Purposely, Purposefully

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These words sound similar, and over time their meanings have come to overlap somewhat. Generally, however, they are regarded as having different meanings and uses—although the differences are admittedly subtle—and in choosing between them, writers should carefully consider the message they wish to convey.

Purposely—meaning “with a deliberate or express purpose”1 or “intentionally”2—was first on the scene, entering usage in the late 1400s.2 A second meaning, “to good purpose; effectively,” came into use about 100 years later but is now considered obsolete.2

In contrast, purposefully—meaning “full of determination”1—was a relative latecomer, not coming into use until the mid 1800s,2 and is still used in those senses. Over time, though, purposefully also has come to be used interchangeably with purposely in the sense of “intentionally,”2 perhaps because something done with determination is also done intentionally. But of course the reverse is not necessarily true, which suggests that writers should use purposely when referring to intention alone.

To some ears, however, purposely sounds uneducated or incorrect, leading some writers to instead use purposefully in error; moreover, writers simply looking for a more impressive word will also sometimes instead use purposefully—again incorrectly.3 But even when purposefully is the correct choice, writers should take care that their intended meaning is not misconstrued. For example, the statement “On occasion, a clinician might purposely elicit pain” likely simply means that the clinician is intentionally eliciting pain (for the purpose of making a diagnosis). On the other hand, the statement “On occasion, a clinician might purposefully elicit pain” might imply that the clinician is determinedly eliciting pain (again—one can only hope—for the purpose of making a diagnosis). In both instances, careful handling of the context can make clear that the elicitation of pain is a necessary evil in service of a worthy end. For example, simply ending either of the above statements with “to help make a diagnosis” can go a long way toward ensuring that the clinician is not construed as something of a sadist.

The bottom line:

●Is “intentionally” the intended message? Use purposely.

●Is “full of determination” the intended message? Use purposefully.

●In both cases, however, take care to ensure that the context helps readers determine the intended meaning.—Phil Sefton, ELS

1. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003:1011.

2. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:1474.

3. Purposefully, purposely. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:376.

Jarring Jargon

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Theodore M. Bernstein, in The Careful Writer: A Modern Guide to English Usage, describes jargon as “meaningless, unintelligible speech,” which is how some people might describe their last conversation with their physician. In science and medicine, many barriers to clear communication exist, with jargon being one of them. In fact, it’s so difficult for physicians and patients to communicate clearly that a federal program has been created to promote simplified health-related language nationwide. The Health Literacy Action Plan is a “national action plan to improve health literacy.” The entire action plan is 73 pages (which is probably their first mistake) and it highlights the fact that we have a problem.

As editors, we know that jargon is to be avoided in medical literature. While jargon may evolve for the most innocuous of reasons, it is a vocabulary specific to a profession that sometimes is esoteric or pretentious and that can be confusing to those not familiar with it (sometimes to those familiar with it as well). “Inside talk” can be just that by design—it keeps outsiders out. Therein lies the source of the negative feelings about jargon.

In addition to being exclusive, some jargon is offensive and unprofessional. Have you ever seen an FLK? Probably. That’d be a funny-looking kid. “We bagged her in the ER” sounds ominous; what it means is that a patient was given ventilatory assistance with a bag-valve-mask prior to intubation in the emergency department. Hopefully the emergency department physician didn’t describe the patient as a GOMER. This means “get out of my emergency room” and could refer to, for instance, an elderly patient who is demented or unconscious and near death and who perhaps should die peacefully rather than occupy emergency department resources. In this example, jargon diminishes the complexity of a situation that should be dealt with in a more thoughtful way. As Bernstein writes, “All the words that describe the kinds of specialized language that fall within this classification [of inside talk] have connotations that range from faintly to strongly disparaging.”

Jargon also sometimes violates rules of grammar, eg, turning nouns into verbs, “The doctor scoped the patient,” or creating back-formations, like “The patient’s extremities were cyanosed,” instead of “The patient’s extremities showed signs of cyanosis.” Jargon can sometimes appear to depersonalize, by defining a person in terms of a disease. A “bypassed patient” may be one who has undergone coronary artery bypass graft surgery rather than one who has been overlooked. Sometimes, patients might be referred to by their organs, such as “the lung in room 502” instead of “the patient in room 502 with lung disease.”

The AMA Manual of Style lists examples of jargon to avoid in section 11.4, Jargon. Some other examples that we’ve collected over the years are listed here:

* Collodion baby is better phrased as collodion baby phenotype or “the infant had a collodion membrane at birth.”

* Surgeons perform operations or surgical procedures, not surgeries.

* Rather than say a patient has a complaint, describe the patient’s primary concern.

* Do not use shorthand (eg, exam for examination, preemie for premature infant, prepped for prepared).

* Euphemisms sometimes are not clear and should be avoided: “The patient died” is preferred to “The patient succumbed or expired”; the same holds true for killed vs sacrificed (in discussion of animal subjects).

* Patients aren’t “put on” medication, they’re treated with medication. Also, patients aren’t “placed on” ventilators, they’re given ventilatory assistance.

Certainly jargon does have its place. It is specialized, and those in the same field can use it to communicate precisely and quickly. However, when it comes to medical and scientific publications, jargon is best avoided. Bernstein ends his entry on “inside talk” with the following: “It must never be forgotten that the function of writing is communication.” Clear enough.—Lauren Fischer

Statistical Rounding and the (Mis)Leading Zero

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Sometimes editors (not you or I, of course) obey the rules of their institution’s preferred style manual without fully understanding, or really thinking about, why some of these rules exist. For example, some editors (not you or I, of course) automatically delete (or, if they’re lucky, their editing program deletes for them) the leading zero in a few statistics, but not all. They know exactly when and where to delete the leading zero, but not why. Or they round some statistics, but not all, assuming that all of this has something to do with saving space. It does, of course,1(p830) but this isn’t the only reason we do it.

The AMA Manual of Style defines a P value as “The probability of obtaining the observed data (or data that are more extreme) if the null hypothesis were exactly true.”1(p888) Per AMA style, P values greater than .01 are expressed to a maximum of 2 decimal places and those less than .01 are expressed to a maximum of 3 decimal places. I set out in search of the complicated statistical reason why we use this specific number of decimal places and found that, in addition to saving space, we do it for one simple reason: it’s all we need. Yep, that’s it. It’s all we need to know. P < .00000001 doesn’t tell us any more of value than P < .001. Both tell us that the probability is very low, and that’s good enough. Of course, if the author protests or rounding will make P appear nonsignificant, an exception is made (for example, if P = .046 and significance is set at P = .05).1(pp851-852) Also, studies such as genome-wide association studies report P values of P < .00001 or smaller, often in scientific notation, to address the issue of multiple comparisons; it is essential not to round these. So every rule has exceptions, I guess (remember Spanish class, anyone?).

Why then, you ask, do we not save ourselves the confusion and simply round P < .001 to P = .00? There’s a reason for that, too, and it’s the same reason we don’t use leading zeros with certain probability statistics (ah, you say, it all comes together). If probability is the chance that a given event will occur,2 and we have only surveyed a sample of a given population, probability cannot equal 1.0 or 0 because we can’t say absolutely that a null hypothesis will definitely or definitely not happen in that population.1(p889) And if P can’t equal 1.0 or 0, why include a zero that doesn’t tell us anything new? For this reason, we use P > .99 and P < .001 as the highest and lowest P values. For the same reason, and because they are used often, the leading zero rule applies to α and β probabilities as well. Why? To save space, of course.–Roya Khatiblou, MA

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

2. Merriam-Webster’s Collegiate Dictionary. 10th ed. Springfield, MA: Merriam-Webster Inc; 1997.

Abbreviation Nation

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Of the reference books I use while editing the Archives journals, my favorite by far is MEDical ABBREViations: 28,000 Conveniences at the Expense of Communication and Safety, 13th Edition, by Neil M. Davis. Not only does it have the most wonderfully snarky title I’ve ever seen on a reference book, but it is the Great Decoder, the book that allows me to make sense of the myriad abbreviations I run across in my daily work.

As much as we are a nation of people who speak largely in cliches and mixed metaphors (I will save my rant about the overused and incorrect “magic bullet” for another day), we are a nation of overabbreviators. The number of organizations that are known by their abbreviation are too many to quantify (NFL, AMA, NORAD). We put out APBs, send out CVs, take our OTC meds, surf our Macs and PCs, and occasionally go AWOL. But when you think about it, do these mean anything? A National Football League is a thing. An NFL is not. What about an AC? Is it an air conditioner? An alternating current? Atlantic City? Though sometimes context can tell us what an abbreviation means, just as often it cannot, and it’s my job to sort these out.

As someone who previously tried to argue that texting is a valid and efficient method of communicating, it may seem hypocritical for me to do a mental fist pump every time I read Mr Davis’ snappy title, but I do. It’s because for every abbreviation that I find easily in my AMA Manual of Style or my MED ABBREV, there are so many that I must ask authors about. This worries me, because I don’t think authors would put these in their articles if they weren’t  routinely used. And though they and their colleagues and most of the American medical community may know exactly what they mean, will readers in Zimbabwe, Thailand, or Argentina? Those readers may have their own set of metaphors, jargon, and abbreviations that makes perfect sense to them. Or they may be students who don’t come across them every day. What happens when we let them slide, or when a journal doesn’t have finicky, know-it-all editors to question them? I worry that it will make journals less accessible, and that it will make medical discourse less accessible. I hate the idea of a medical student somewhere in the world not being able to use one of our articles in his research because I didn’t feel like finding out what something means. And believe me, sometimes I don’t feel like it. But I know I must be persistent, as annoying as it feels to harass a busy professional about something that seems so trivial. And that medical student out there better appreciate it.—Roya Khatiblou, MA

Go, Embargo, Go

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So what’s an embargo, anyway? There’s the economic trade kind, but let’s stick to the news kind (much more relevant for AMA Style Insider readers). I spoke with Jann Ingmire, the JAMA and Archives Journals media relations guru, and she explained that embargoes exist primarily to give reporters the opportunity to cover a story in a more thorough way.

Here’s how they work: Embargoed material is released to members of the press prior to being released to the public, usually a few days early. This gives reporters time to do research, conduct interviews, and write a really great piece. When the embargo lifts, journalists are already prepared to report on newly published scientific studies.

Most of the time, the system works, but occasionally, an embargo is broken. Ms. Ingmire said she tries to give reporters the benefit of the doubt because, usually, it’s simple human error. Sometimes, though, the embargo break is flagrant. When this happens, reporters are sanctioned and stop receiving embargoed material.

Embargoes make it possible for everyone—from the independent blogger to the major media outlet—to have the same opportunity to gather a story. If you want to learn more, read embargowatch.wordpress.com, a blog that chronicles how embargoes affect news coverage.—Lauren Fischer

Dr Readability: Or How I Learned to Stop Worrying and Love the Pronoun

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In academic writing, the current modus operandi seems to be: the more words the better. Why say “children” when we can say “individuals of pediatric age”? Why “time” when “period of time” sounds so much more substantial? Strunk and White1 would surely disapprove. Extraneous verbiage may make one’s writing sound lofty and important, but it can muddle one’s message. Writers should not use circuitous, rhetorical language to persuade their readers. Strong, clear writing, without extra baggage, creates a confident tone and allows the reader to more easily understand a work’s significance.

Here are a few ways to clean up one’s writing for easier reading:

Use the pronoun. Use it.

Writers often repeat nouns instead of using pronouns, as writers fear that readers won’t understand what the writers are saying. Not horrible, but is there confusion over what they refers to in this revised sentence: “Writers often repeat nouns instead of using pronouns, as they fear that readers won’t understand what they are saying”? Repeating the same word or phrase creates reading fatigue, like listening to someone beat on a drum over and over. Trust that your reader has a longer attention span than the time it takes to read half a sentence and there will be no need to use the same nouns over and over and over…

Here’s an example: “Because many people use vitamin therapy, we must determine the efficacy of vitamin therapy compared with other treatments.”

How about this instead: “Because many people use vitamin therapy, we must determine its efficacy compared with that of other treatments.”

Use the verb.

Editors are in agreement that “to be” constructions are weak and should be replaced with the actual verb. I agree!

Substituting “to be” constructions with actual verbs makes writing stronger and more confident. Researchers often use the phrase, “Our findings are indicative of…” See the “to be” hidden in there? How about “Our findings indicate…”? Were “patients in receipt of the drug” or did they “receive the drug”? Were participants “in attendance” or did they “attend”? The meaning is the same, but the writing sounds a whole lot better with the true verb.

This goes hand in hand with the passive voice. We’re not saying that the passive voice is wrong necessarily, it’s just that it is believed by some people that it is not as strong as it could be. Rather, some people believe that the passive voice is weak. In general, the active voice should be used over the passive voice, especially in cases when the “actor” is present. For example, “Patients were monitored by resident physicians” should be changed to “Resident physicians monitored the patients.”

This is another way to say: Use the delete button.

Close your eyes. Pretend you have a word limit. Now, pretend you have to follow it. Would you rather cut 100 words from the “Results” section or 100 words throughout a manuscript that add nothing of substance substantial? See what I did there?

Here are a few substitutions that reduce wordiness:

–“combined with” instead of “in combination with”
–“important” instead of “of importance”
–“most” instead of “the majority of”
–“can” instead of “is able to”
–“affect” instead of “to have an effect on”

Eliminating exaggerations can also trim one’s writing. How often is quite, very, or rather necessary (or accurate)? Writers should also avoid superlatives like profoundly and significantly when describing a study’s results.

These tips will help eliminate excess verbiage and heighten readability while preserving meaning. What is there to be afraid of fear?—Laura Adamczyk

[author’s note: Some of these ideas came from lectures by Northwestern University professor Bill Savage, PhD.]
1. Strunk W Jr, White EB. The Elements of Style. 4th ed. New York, NY: Longman; 1999.

For Against As

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Since I have been copyediting at JAMA, I have been trying to reinvigorate the use of for as a coordinating conjunction when authors use the word as as demonstrated in the following construction.

There was no significant difference between the study population and the 60 participants who were excluded, as for they had inadequate sample volumes for the assay.

When the typescript came back, my for was deleted and replaced with because. Although I have no objection to because, I like for because it is clear, to the point, and efficient. Despite the continued rejection of my edits, I continue to advocate its use through the editing process, hoping it will take hold, hoping to change enough people’s minds that it will become so common that people will not regard it as “highfalutin” or “dated.”

Besides its efficiencies in language, its use has economic implications: it is shorter than because, for it saves ink and paper, which should please bottom-line conscious editors and publishers. Furthermore, it is grammatically correct and occupies the first place in the mnemonic FANBOYS, which can be found in writing guides to help students remember all of the coordinating conjunctions available to them. Why keep it in the writers’ reference manuals if no one uses it, I ask?

Finally, using as as a coordinating conjunction can be confusing and may steer readers in unintended directions. Coordinating conjunctions are used to show that the clauses of the compound sentence are equivalent. Subordinating conjunctions are designed to show that one idea is more important than another. Both as and because find themselves on the subordinating conjunction list. If they should head the second clause, they should stand alone without the aid of a comma, which when used with coordinating conjunctions announces the compound sentence. So as a copyeditor and a reader, when I see the comma preceding the as I think the author is presenting equivalent ideas rather than subordinating ideas, which is why I am compelled to change as to for. My point is that as when presented in a coordinating conjunction construction is ambiguous and can shift an author’s meaning despite his or her intent. For does not.—Beverly Stewart, MSJ

Quiz Bowl: Plurals

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It’s time for our second Quiz Bowl! This month’s quiz, which subscribers can find at http://www.amamanualofstyle.com/, examines the use of plurals. Test your knowledge by correcting the error in the following sample question based on your understanding of chapter 9 of the AMA Manual of Style.

Sera from 100 infants in the study were collected at birth.

Okay, time’s up. Did you identify the error? Here’s the answer (use your mouse to highlight the text box):

Serum samples from 100 infants in the study were collected at birth.

Beware of “pluralizing” nouns that cannot stand on their own as plurals (eg, use serum samples not sera and urine tests not urines) (§9.7, When Not to Use Plurals, p 369 in print).

If you want to learn more about how to edit plural words, subscribe to the AMA Manual of Style online and take the full quiz. Stay tuned next month for another edition of Quiz Bowl.—Laura King, MA, ELS

Say It Small

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“For sale: baby shoes, never worn.” This six-word story attributed to Ernest Hemingway is the subject of more contests and imitations than one can count. And there’s a reason for it. In just six words, the author manages to introduce the situation and characters, create conflict, and bring the story to its devastating conclusion. It’s this sort of economy of language that Hemingway is known for, and that many writers and editors, myself included, try to imitate.

I’m not suggesting we imitate Hemingway in only giving the reader an eighth of the story, of course. Clarity and directness are more important in scientific work than in fiction. But medical writing is dense, full of words and concepts one doesn’t always use in everyday speech (okay, maybe some physicians do). To have to wade through extra words and punctuation when already trying to concentrate on the subject at hand can be distracting, even exhausting.

Don’t get me wrong – I love words. I have an unnecessarily large Webster’s at home, though I can just as easily look up definitions online, and I will probably lug the thing from apartment to house to retirement home until my great-great-grandchildren finally use it for kindling after the Earth has run out of natural resources. But reading is not a passive activity. Our brains are working. And when there are more words than necessary, our brains must work an unnecessary amount. For the sake of the real economy, doesn’t economy of language make sense, to make readers and writers alike more productive, less taxed? If we all do our part to conserve language, we may even end up using less paper, and delaying my great-great-grandchildren’s postapocalyptic existence for a generation or two.

You want to talk more about Hemingway, you say? I’m happy to oblige.

Some say that Hemingway learned his succinct style through sending telegrams. As a reporter, he often had to get the gist of a situation across in 10 words or fewer; more than 10 would mean paying more for the telegram. He later used this as a device in his work. Jake’s telegram to Brett Ashley near the end of The Sun Also Rises tells the reader all they need to know when he goes over the ten-word limit so he can sign it, “Love.”

So what about text messages, e-mail, tweets? Some argue that these media are dulling the English language, making people lazy, unable to write in complete sentences. Maybe, maybe not. It could be that many people already couldn’t write well, and that these new media are simply putting their limitations on display. Perhaps it will prove beneficial to bring the subject out into the open.

If Hemingway became a master of brevity by sending telegrams, then why can’t we use these new modes of communication to become more effective writers? If we can no longer rely on context and nuance, we may be forced to actually say what we mean. In Jennifer Egan’s gorgeous and inventive new novel, A Visit From the Goon Squad, two characters find themselves exhausted during a conversation gone awry. The woman, Lulu, says in explanation, “…All we’ve got are metaphors, and they’re never exactly right. You can’t ever just Say. The. Thing.” She then asks, “Can I just T you?” and they continue the conversation, much more smoothly, via text message across the table from each other.

The brilliant thing is, Egan doesn’t seem to make much of a judgment about it; it’s simply the evolution of communication. Any linguistics class will teach you that language constantly evolves, and I’m happy to not be speaking Old English today, or sending telegrams for that matter. Nothing can ever replace true human connection and communication for many purposes, but perhaps through e-mails, texts, tweets, and their more sophisticated successors, language will evolve, and we will find new ways of telling each other what we really mean.—Roya Khatiblou, MA

Editors’ Eyes

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The dialog box in Word suggests unironically that I should consider changing antidiabetic to ant diabetic. Is there a hyperglycemic epidemic in the insect population that I missed hearing about?

Spell-check can be a useful tool that improves the quality and readability of content. But as editors and readers know all too well, spell-check can be dangerous if wielded indiscriminately. Instead of making the role of a human editor obsolete, spell-check has only underscored the need for such professionals.

Several papers submitted to JAMA recently proved this point. I usually run spell-check after I complete my editing in case I missed something. In addition to the diabetic ants, Word suggested the following: change metformin to motormen, pertussis to peruses, autonomously to gluttonously, and PDF to puff.

I politely declined all these fine suggestions but was grateful when Word spotted terible that should have been tertile. What a difference a word makes.

Over time spell-check has become more useful because I regularly add words to my locally stored dictionary (“Add to Dictionary” in the dialog box). In addition, Dorland’s offers a medical spell-checker that can be integrated directly into Word and Stedman’s offers a medical spell-checker as well

Despite these useful add-ons, I still like to read articles word-for-word, when time permits, and not rely solely on technology to prevent errors. The ants, I’m afraid, are beyond my expertise.—Stacy L. Christiansen, MA