usage

The Proliferation of Wellness

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My interest was piqued by this post on Language Log exploring the ubiquity of the word wellness. It’s a trend I might never have noticed, but now that it’s been brought to my attention I have to admit that wellness is everywhere.

For many, wellness connotes a certain touchy-feeliness that health doesn’t, in particular the integration of mental, emotional, and even social well-being into the concept of health. In this sense it’s very much a word for our times, as science explores the physiological effects of practices like meditation and mental health is discussed more openly. A New York Times article from 2010 referenced in the blog post gives some of the background on the burgeoning popularity of wellness over the years. The author notes that the word has become more popular as society expands its notion of what it means to be healthy. The article traces the origins of this mindset back to the mid twentieth century, quoting from the preamble to the World Health Organization’s 1948 constitution: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” On the flip side, to some wellness has a whiff of the unscientific; one of the commenters on the blog post recalls seeing the word used extensively in sales pitches for alternative medicine.

What makes wellness such a hot property? As Mark Liberman of Language Log points out, wellness has a ring of positivity to it that health doesn’t: “My impression is that ‘health’ has become too much about negatively associated things like doctors, hospitals, insurance companies, and giant pharmaceutical firms—and it was never rigorously positive enough anyhow, since you can have good health or bad health. There’s no such thing as bad wellness.”—Heather Green

 

 

Medical Literature and “Forbidden Words”

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On December 15, 2017, reports emerged that staff at the Centers for Disease Control and Prevention (CDC) were presented with a list of 7 forbidden words or phrases (ie, diversity, transgender, vulnerable, fetus, entitlement, evidence-based, and science-based) when writing budget appropriation requests. Since then, officials from the Department of Health and Human Services clarified the situation, saying that these words should be avoided but were not necessarily prohibited. Regardless, physicians, researchers, marginalized people and their allies, and others have spoken out against this. What is the importance of these words in a medical research context, and what does the AMA Manual of Style say about usage?

Diversity

Including men and women of different races/ethnicities is imperative to research, particularly for understanding drug outcomes. For example, male and female bodies metabolize drugs at different rates. Because women wake faster from sedation with anesthetics, they recover at a slower rate and report more pain events than men. Not including both male and female participants in a study could lead to incomplete results. Race and ethnicity are also important to incorporate in medical research because specific diseases or disorders may be more pertinent in certain groups, such as chronic hepatitis B in Asians and Pacific Islanders or Tay-Sachs disease in the Ashkenazi Jewish population.

Transgender

Transgender refers to people whose gender identity differs from the sex they were assigned at birth. Transgender health care is unique and differs from cisgender health care. Besides gender reassignment surgery, transgender patients may also require special care concerning mental health or substance dependence.

Vulnerable

Clinically vulnerable populations may include persons with Medicaid, no health insurance, low educational attainment, limited English proficiency, and members of racial/ethnic minority groups.

Fetus

A fetus is the unborn offspring in the postembryonic period, after major structures have been outlined. Per AMA style, neonates or newborns are persons from birth to 1 month of age, and infants are children aged 1 month to 1 year. There is a clear difference between a fetus and a newborn or infant. Fetus is a medical term and is not open to political or social interpretation.

Entitlement

Government programs that give assistance to anyone who qualifies are called entitlements. For example, Medicaid, the Children’s Medical Security Plan, and the Vaccines for Children Program are entitlement programs. These types of programs are important for those who may not have easy access to health care.

Evidence-based and science-based

According to some reports, these phrases should be replaced with “CDC bases its recommendations on science in consideration with community standards and wishes.” Evidence-based medicine applies the best evidence from rigorous studies (eg, randomized clinical trials) to clinical decision making, and hopefully, to policies. Without evidence-based medicine, clinicians may not be using the best knowledge base when treating patients.

Even if these words are actually banned from use in CDC budget requests, it is important to note that medical journals with true editorial freedom would theoretically never fall into a similar situation. Editors and publishers/owners must guard against the influence of external commercial and political interests (as well as personal self-interest) on editorial decisions. Editors of such journals should not comply with external pressure from any party that may compromise their autonomy or of their journal’s integrity. The AMA Manual of Style notes these examples, among many others, of inappropriate pressure:

  • Pressure from an owner or a politically powerful or motivated individual or group on the editor to avoid publishing certain types of articles or to publish a specific article
  • Compliance with governmental or other external policy to not consider manuscripts from authors based on their nationality, ethnicity, race, political beliefs, or religion

Read more about editorial freedom and integrity of medical journals in AMA 5.10.—Iris Lo

A Dirty Look at the AMA Manual of Style

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Remember how much fun you had reading The Elements of Style? How about the times you yukked it up over the ambiguity examples in Warriner’s English Grammar and Composition? Here is a classic to jog your memory:

As soon as the students had left the classrooms, the custodians cleaned them.

That’s entertainment!

You can revisit those days of abandon in the quest for clear writing, even if no one seems to chuckle when they consult the AMA Manual of Style. Maybe this owes to its being a behemoth. If you wish to consult the manual with a smile instead of grim determination, the opportunities are there.

Every so often, a nonassociation style guide becomes a bestseller. Such a chartbuster assumes that usage matters, and that correct usage rules and examples entertain and inform. Authors have climbed the list with pragmatism (thanks, Susan Thurman), charm (hi, Mary Norris), innuendo (I’m talking to you, Lynne Truss), or light-heartedness (howdy, Bill Bryson).

Some even go dirty, quick and dirty, as in Mignon Fogarty’s amazing Grammar Girl. I understand this. A down and dirty read (a basic, practical review and not a backstreet editing assignation) is often called for when deadlines loom.

But pragmatic or dirty, these bestsellers put their readers in good hands. That they entertain and inform offers a springboard for a quick dive into the ways that the style manual, in addition to assuring you that you’re in good hands, can entertain as it informs. Here is a representative down and dirty look at a portion of the manual.

If you hand out Halloween candy, you have seen the proverbial “fun size,” a bite that only leaves you wanting more unless it is a Butterfinger. My idea of fun size would be a candy bar as big as my arm. However, any amount of candy is fun (except a Butterfinger), so in that spirit, small can be fun size. By my original standard, the 1010-page Manual of Style is already fun size, but chapter 11 offers the overlooked qualities of being thought-provoking and entertaining. (So do chapters 7-10, 12, and 13, but that is another post.)

The online manual can take you right to 11 without the papercuts, but the idea is to look at its alignment with the tone of popular usage books. From a certain vantage, this chapter could stand as a compact usage book alongside other usage books that sell well. A fun size AMA style guide!

The “Correct and Preferred Usage” chapter starts with 2 fun quotations, one with empathy for proofreaders and another that mentions a porcupine. The entries begin with word choice examples aplenty (similar to Bryson’s look at troublesome words), with italicized labels and directives that establish a hierarchy (Incorrect, Correct, Also Correct, Avoid, Preferred, Also, and the apotheosis of middle ground, Acceptable).

Sometimes a truth plainly spoken is in itself amusing, and that truth can orient you toward correcting descriptive language. The entry “abnormal, normal, negative, positive” indicates “Examinations and laboratory tests and studies are not in themselves abnormal, normal, negative, or positive.” If you have gone around allowing authors to describe tests as negative, it can be bracing to see such clear direction.

The entry for Jargon offers a similar plain-spokenness. “….[D]rugs are usually neither systemic nor local but are given for systemic or local effect.” Parallelism can sharpen a keen awareness of specificity.

Because redundant words are always funny according to natural law, section 11.2, with its eye-opening list of redundancies, expendable words, and incomparable phrases, can supply abundant levity. You will also encounter a well-known quotation from Yogi Berra.

The legal profession once advocated plain language (ha ha!). Everyone talks about jargon, but the AMA Manual of Style does something about it. Granted, you can violate the manual’s jargon directives and still be allowed to walk around freely, vote, and drive a car, but if you see what Morris Fishbein wrote on page 408, you will never want to use jargon again. Even by accident or in an emergency.

Chapter 11 contains scores of other usage grace notes. Shakespeare’s Polonius says, “brevity is the soul of wit,” and you can verify that by looking up “describe, report” for an example. Even one of the longer entries (“because of, caused by, due to, owing to”) ends with a lovely Clue to usage (a one-off category) that brings it all home in 3 lines.

One-off labels nod toward the gray areas of usage, which are usually skillfully handled in style guides. The manual may be a behemoth, and another one-off category, Possible exception, under “adherence, compliance,” may help explain why. This example shows its accommodation of nuance. Nuance can take space.

Across its chapters, the manual draws from literature (Alexander Pope, Samuel Johnson, Mark Twain, Toni Morrison) for contextual quotations. Medical editing embraces the humanities in its quest for clarity.

For a good time, read chapter 11 of the AMA Manual of Style.  It shares some of the endearing qualities of the bestselling usage guides (except, I think, innuendo). Review the material when you aren’t searching for an answer. It’s not just for reference anymore.—Timothy Gray

 

Quoth the Raven

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The word impact as a verb comes up pretty often in the course of my work. I am not a fan (and neither is the AMA Manual of Style). I prefer to use affect instead, and when it comes to nouns I like effect better than impact, but I always had to stop and think about it and be sure that I was correctly using these words. I just could not remember. Then, a few weeks ago, I was poking around the internet and came across this useful mnemonic device, RAVEN.

“Remember: Affect is a Verb and Effect is a Noun.”

It’s not a new thing, but I hadn’t heard it before. It stuck in my mind because crows and ravens, those smart, handsome birds, are very interesting to me. Since then, I’ve noticed that the phrase popped into my head right away when I was confronted with the effect/affect question.

Happy Halloween!—Karen Boyd

 

 

People-First Language

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In the new Netflix series Atypical, a father attends a support group meeting for parents of children with autism. As he begins to describe how well his son has been doing lately as an “autistic person,” he is gently interrupted by the support group leader.  She stresses the importance of him using “people-first” language, that his son is not an autistic person, but rather a person with autism. When she intercedes again to remind him that his son can’t get “better” from autism, he stares at her blankly while his wife (who is more well-versed in the appropriate vocabulary) interjects with an explanation of their son’s recent progress using replacement behaviors.

The scene is played to parodic effect—the support group leader comes across as a pretentious pedant who pays more sensitivity to correct language use than to an exasperated father who is struggling to connect with his son. The insistence on using people-first language is seen as a distraction from what is really being communicated, and I couldn’t help but be reminded of similar reactions from authors over this same issue. How many times as a manuscript editor have I rolled my eyes when I’ve seen the phrase “the patient was diagnosed with” and known I’d have to significantly restructure the sentence? How many authors have been annoyed with the sea of red strikethroughs they encounter because their article is filled with “autistic patients” or “diabetics ” or “the disabled”?

But yet, whenever I explain to authors that AMA style is strict about not defining patients by their illnesses or survivors by their experiences, they get it. “Oh yeah,” they say, “that makes sense.” They understand that it’s important for patients to have autonomy and a sense of personhood, that it’s important to recognize that behind the data are human beings who trying to live their lives while facing all sorts of experiences, of which illness may only be one.

There has been considerable pushback from politicians, corporate leaders, and even comedians against what is seen as a culture of “political correctness,” with people bemoaning that there is a social imperative to use what they see as arbitrary substitutions for words that are considered insensitive or offensive. But what good word nerds know (and manuscript editors take that title with pride) is that words and the way we choose to use them are symbolic and communicate more than their definitions.  And that is why AMA style is committed to using its reputation as an industry standard to set a tone of inclusion and sensitivity for medical discourse, a tone that states that these values are not only accepted but required.—Amanda Ehrhardt

Weeds and Words

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

Reluctant, reticent

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

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

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

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

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

—Roxanne K. Young, ELS

 

Intention, Intent

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

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

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

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

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

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

The bottom line:

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

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

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

 

 

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

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

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

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

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

6. Iverson C, Christiansen S, Flanagin A, et al. AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007:873.

Significant and Significance

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

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

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

▪ Statistical Significance:

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

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

▪ Clinical Significance:

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

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

▪ Worthy/Important:

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

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

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

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

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

Option, Alternative, Alternate

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

Well, no. At least not quite.

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

So—is there a way through this thicket?

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

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

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

The bottom line:

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

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

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

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

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

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

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

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

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

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