usage

Minority Report

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Risk factors included racial/ethnic minority status, male sex, higher hemoglobin A1c level, use of insulin, longer duration of diabetes, and higher systolic blood pressure.—From This Week in JAMA, August 11, 2010.

The meaning of the adjective minority in this statement may appear to be clear to the reader. However, what constitutes minority status for race/ethnicity? In which country, population, or time? And in this context—risk factors for diabetic retinopathy—why would minority status per se (as opposed to a specific genetic background, or perhaps lower socioeconomic status and resulting lack of access to health care) be a risk factor? This usage points to a common but probably outdated use of the term minority to refer to a population of people. Why is this term to be avoided in this context?

Merriam-Webster’s Collegiate Dictionary1 defines minority as “a part of a population differing from others in some characteristics and often subjected to differential treatment; … a member of a minority group (an effort to hire more minorities)” and The American Heritage Dictionary of the English Language2 states, “A racial, religious, political, national, or other group regarded as different from the larger group.” These definitions evolved from the more basic meaning of minority. Insofar as usage and equity are concerned, however, historian Amoja Three Rivers stated emphatically 20 years ago that “at least four-fifths of the world’s population consists of people of color. Therefore, it is statistically incorrect as well as ethnocentric to refer to [them] as minorities. The term ‘minority’ is used to reinforce the idea of people of color as ‘other.’”3 The white race is becoming a “minority” in many countries where that had previously not been the case, including the United States. Nor are women to be considered minorities simply by their numbers (as an example of this, in the United States in the academic year 2008–2009, among first-year enrollees in medical school, there were 9619 men and 8889 women, compared with 10 576 men and 6205 women in 1988–19894).

When used as a noun to describe and thus label and marginalize a racial/ethnic, gender-specific, physically disabled, or other group of persons with a common trait, minority (and minorities) is an exclusive term that should be avoided.

Note: Minority (and majority) is appropriate to use when describing, for example, the count (number) in an election, an opinion of a nation’s high court, or in common usage to mean less than half (or more than half) of a given sample.—Roxanne K. Young, ELS, with thanks to Margaret A. Winker, MD

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

2. The American Heritage Dictionary of the English Language. 3rd ed. Boston, MA: Houghton-Mifflin Co; 1992.

3. Maggio R. Talking About People: A Guide to Fair and Accurate Language. Phoenix, AZ: Oryx Press; 1997:273.

4. Barzansky B, Etzel SI. Medical schools in the United States, 2008–2009. JAMA. 2009;302(12):1353(appendix I, table 2).

Criterion Standard

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The expression criterion standard, according to the AMA Manual of Style, represents the “diagnostic standard for a particular disease or condition, used as a basis of comparison for other (usually noninvasive) tests. Ideally, the sensitivity and specificity of the criterion standard for the disease should be 100%.” This definition on its face seems a fairly straightforward way to identify the best method for making a diagnosis or the best treatment plan for a given disease.

A controversy, however, emerges in a parenthetical phrase that suggests the alternate expression gold standard be avoided because it “is considered jargon by some.” This assertion is supported by a reference to A Dictionary of Epidemiology, third edition, by John M. Last, published in 1995. Treating it as slang, his entry not only presents gold standard in quotes but, to be sure the reader understands his meaning, follows it with the word “jargon” in parentheses before defining it. Last provides no alternate expression and does not include criterion standard in his dictionary. He does, however, include criterion, which he defines as “[a] principle or standard by which something is judged. See also STANDARD.” And that is defined as “[s]omething that serves as a basis for comparison.”

In his fourth edition, however, Last does not include a gold standard entry. His definitions for both criterion and standard remain the same, and because they have nearly identical definitions could account for his not including an entry for criterion standard.

The gold standard entry returns in the fifth edition, edited by Miquel Porta. It is again presented in quotes but omits the parenthetical naming of it as jargon and defines it as “[a] method, procedure, or measurement that is widely accepted as being the best available. Often used to compare with new methods of unknown effectiveness (e.g., a potential new diagnostic test is assessed against the best available diagnostic test).”

Looking at another source, Annals of Internal Medicine Editor Hal Sox in his book Medical Decision Making never mentions the expression criterion standard. He does, however, talk about gold standard, which he takes out of the realm of epidemiology and into clinical practice by defining the gold standard test as “[t]he procedure that is used to define the true state of the patient.”

Although the “when” of its adoption as the preferred expression for JAMA and the Archives Journals seems to have escaped memory, the “why” remains among most of the medical editors. Some suggest avoidance of gold standard because it crosses disciplines from economics to medicine. As an economic term, it had served as the basic support of paper money. Another consideration, offered by former JAMA Deputy Editor Richard Glass, is that “gold standard …implies more of a sense of permanence than is appropriate for scientific topics.” With new knowledge, he reasons, comes new standards.

Practice, however, defies style preference. A search of JAMA articles in 1998 shows that criterion standard was used 7 times while gold standard was used 42 times. Jumping ahead 10 years, the trend holds: criterion standard was used 9 times; gold standard, 35 times.

Yet the practice of using gold standard over the style recommendation may all boil down to what JAMA Deputy Editor Drummond Rennie wrote in an e-mail. “If we are prepared to consider using ‘criterion standard,’ we should really prefer ‘criterion criterion’ (though ‘standard standard’ sounds a tad less pompous, even if just as meaningless). We all know what ‘gold standard’ means. It has the merit of being customary, memorable, understandable.”

And isn’t that the job of editors? — 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

Questions From Users of the Manual

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Q:    If a person has multiple advanced degrees, should the medical degree always be listed first, eg, MD, PhD?

A:   We would advise following the author’s preference as far as the order in which degrees are listed.

Q:   I know that journal names are typically italicized in their expanded form, eg, Journal of the American Medical Association. Should the abbreviation also be italic, eg, JAMA?

A:   Yes. The same policy applies to book titles and their expansions. See, for example, International Classification of Diseases, Ninth Revision and ICD-9 in the list in 14.11.

Q:   On page 500, in the list of journal abbreviations, is there a reason that the journal Transplantation is spelled out in full as Transplantation and yet other journals whose titles include that word abbreviate it as Transplant?

A:    Yes, there is a reason. See the sentence on page 479 advising that “Single-word journal titles are not abbreviated.”

Q:    The AMA Manual of Style says that tables should be able to stand independently and not require explanation from the text. Could you clarify “stand independently”? Our publication has taken this rule to an extreme, often adding lengthy definitions of terms already provided in the text. One recent example added 15 footnotes to a single table!

A:   As with so many things editorial, this requires judgment.  We were thinking about things like this:

  • Expansion of any abbreviations, given in the text, provided again in a single footnote to the table.
  • Explanation of things that might not be apparent from the tables (eg, what the various groups are if they are only identified as “group 1, group 2, etc” in the table).
  • Explanation of how to convert units from conventional to SI (or the reverse), if this is important in your publication/to your audience.
  • Explanation of some statistical method that would likely not be familiar to your readers without some information—the bare bones, not a lengthy explanation. If a lengthy explanation is necesssary, simply refer the reader to the relevant section or subsection of the text.
  • Explanation of a phrase used for shorthand in a table stub or column head that might not be clear if all you were looking at was the table (eg, if a column head is “Unstable Vital Signs,” explain in a footnote the specific items and values that this refers to).

It truly is a question of judgment and I suspect that 15 footnotes in a single table is taking it too far.—Cheryl Iverson, MA

How Am I? I’m Good. Um, I’m Well … No, Wait: I Feel Good. I’m Doing Well.

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The Oxford English Dictionary (second edition, 1989) devotes a remarkable 7 and 9 pages, respectively, to good and well (in a mixture of 7- and 9-point type). Good and well are not synonyms, but their myriad meanings, interpretations, combinations, and usages are often similar, and thus each has the potential to be used incorrectly, if inadvertently. This post addresses good and well when describing the state of being of something or someone.

In this context, good is an adjective (modifies only nouns):

The researcher has a good idea [modifies a noun].

Her idea is good [modifies a noun and uses a linking verb that expresses a state of being, eg, to be, to seem, to appear].

Well is an adverb (can modify verbs, adjectives, or other adverbs). As an adjective, well can also be used as an adjective to mean “in good health.”

The patient did well [scored well, performed well] on the Mini-Mental State Examination.

The patient spoke well of her physician.

The patient articulated her concerns well.

The patient does not feel well.

Well may also be used to mean good health in its combined form: a well-baby checkup.

But: A usage note in Webster’s1 points out that “An old notion that it is wrong to say ‘I feel good’ in reference to health still occas. [occasionally] appears in print. The origins of this notion are obscure, but they seem to combine someone’s idea that good should be reserved to describe virtue and uncertainty about whether an adverb or an adjective should follow feel. Today nearly everyone agrees that both good and well can be predicate adjectives after feel. Both are used to express good health, but good may connote good spirits in addition to good health.” Moreover, Webster’s reports, “Adverbial good is primarily a spoken form; in writing it occurs in reported and fictional speech and in generally familiar or informal contexts.”

As a general rule of thumb: Things are good. One does things well.

Be well. And be good. —Roxanne K. Young, ELS

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

Questions From Users of the Manual

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Q:    When a bulleted list is introduced by a brief comment, eg, “The principal signs and symptoms of rheumatoid arthritis are as follows,” and all of the items in the bulleted list are from the same source, does a citation need to be placed at the end of each bulleted item or is it sufficient to place the citation at the end of the brief introductory comment?

A:    We would recommend placing the citation within the text that introduces the bulleted list if all the items in the list came from the same source.  If the items came from multiple sources, then placing the appropriate citation at the end of each item would be necessary.

Q:    In this example, would you hyphenate “well child”?

  • He was taken for a well-child [or well child] checkup.

A:    Yes, we would hyphenate in this case.

Q:    The Manual says nothing about how to treat reference citations in the abstract.  Should such citations simply be deleted from the abstract and from the reference list or should complete bibliographic details about the reference be inserted in the abstract parenthetically?

A:    You are quite right that the Manual does not mention how to treat references in the abstract as we never include reference citations (either as superscript numbers or within parentheses in the text) in the abstract (see 2.3, fourth bullet, re not citing references in an abstract).  If an author has included references in an abstract, it doesn’t seem advisable to delete the references altogether.  Discuss with the author trying to include the references early on in the manuscript itself.  It seems unlikely that an author would consider a reference important enough to include in the abstract and then not cite it in the text.

Q:   I don’t see anything in the Manual about how to style “e-mail,” ie, with or without a hyphen.  Help, please.

A:   Although the Manual doesn’t specifically address this point, it does include guidance on capping (see 10.7) and, in that section, it’s clear that the Manual recommends a hyphen in “e-mail.”  If you use the Manual online, for questions like this the “quick search” box is invaluable.  Just type the term you are looking for into the search box and the results should guide you.  If you had begun with “email,” you would have gotten no results, which would—I hope—have tipped you off to try “e-mail,” which produces 3 pages of results.—Cheryl Iverson, MA

Discomfit, Discomfort, Disconcert

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These words are commonly confused, perhaps because they begin with the same four letters and sound similar to boot. Moreover, they now have similar meanings thematically related to the original meaning of discomfit. How necessary is it to distinguish between them?

Discomfit was first on the scene (early 1200s1) and originally was used in the sense of “to defeat in battle.”2 The related form discomfiture, meaning “complete disconcertment or putting to confusion”1—a sense clearly related thematically to the original sense—appeared little more than a century later.

Discomfort also appeared slightly later (late 1300s1) and originally was used in the sense of “Undoing or a loss of courage; discouragement, disheartening.” In a related vein, discomfort also was used at roughly the same time to indicate “Absence or deprivation of comfort or gladness, desolation, distress, grief, sorrow, annoyance.”1 Both of these uses are now largely obsolete, although the word is still often used in a somewhat weaker sense to indicate one’s feeling mildly uncomfortable, either physically or emotionally.1,2

Disconcert was the late bloomer, not bandied about until the late 1600s,1 when it was used in the sense of “To throw into confusion, disarrange, derange, spoil, frustrate”1—again, a meaning clearly thematically linked to defeat in battle. The word is still often used, albeit in a weaker sense, ie, “to disturb the composure of.”2

The upshot? Purists will advocate maintaining the distinction between discomfit and discomfort, using the former only in its original sense of indicating defeat in battle.3 However, as is so often the case, usage is becoming more permissive, and while purists certainly will cringe at the thought, the interchangeable use of these words is gaining increased acceptance. Nevertheless, a few distinctions are worth preserving:

● Discomfit, while occasionally still used in the sense of “to frustrate or thwart,” is currently most often used to indicate mental, rather than physical, states, specifically in the sense of one’s being perplexed or embarrassed—ie, disconcerted. However, its use as either a verb or an adjective now seems stilted or pretentious. For example, Edmund Crispin’s “Widger was not wholly without Schadenfreude at seeing his informative colleague discomfited for once”4 conjures images of Niles and Frasier Crane slouching about in Harris Tweed, sipping sherry and exchanging witty asides. Most speakers will use disconcerted or, finding even disconcerted a tad too uppity, will simply use embarrassed.

● Discomfort is most often used to indicate one’s feeling physically or emotionally uncomfortable, resulting either from the efforts of others or from personal excess: “The excitement produced by the cigar is followed by a feeling of discomfort.”1

● Disconcert, indicating perplexity or disturbed composure, is still occasionally used as a verb but currently is used much more frequently as an adjective, eg, “I find all this very disconcerting.”—Phil Sefton, ELS

1. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:443.

2. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003:356.

3. The pedant: comfit and cloy. The Times Web site. http://women.timesonline.co.uk/tol/life_and_style/women/the_way_we_live/article6953527.ece. December 12, 2009. Accessed May 12, 2011.

4. Discomfit. Answers.com Web site. http://www.answers.com/topic/discomfit. Accessed May 12, 2011.

Quiz Bowl: Units of Measure

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Welcome, participants, to the AMA Manual of Style Quiz Bowl. Every month at http://www.amamanualofstyle.com/, we offer subscribers a quiz on different aspects of the manual that help participants master AMA style and improve their editing skills. Previous quizzes have covered topics as varied as correct and preferred usage, genetics, tables, figures, and ethics, as well as numerous other subjects. In this blog, we will offer a sample question from each month’s quiz to whet your appetite. This month’s quiz is on Units of Measure: Format, Style, and Punctuation. So, here goes.

Edit the following sentence based on your understanding of section 18.3 of the AMA Manual of Style.

A total of 50 mg of etanercept were administered subcutaneously twice weekly for 12 weeks.

Well, how did you do? Did you identify the problem? Here’s the answer (use your mouse to highlight the text box):

A total of 50 mg of etanercept was administered subcutaneously twice weekly for 12 weeks.

Units of measure are treated as collective singular (not plural) nouns and require a singular verb (§18.3.3, Subject-Verb Agreement, p 791 in print).

So, did you enjoy this tidbit? If you are not sated, subscribe to the AMA Manual of Style online and take the full quiz.—Laura King, MA, ELS

Are You Nauseous or Nauseated?

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Writers and editors rushing to meet deadlines know the feeling. The effects of stress, a few too many cups of coffee, and perhaps a candy bar or bag of chips in place of a meal can conspire to make the most steely-nerved wordsmith feel a tad nauseated. Or is it nauseous? And what of that stress, that coffee, that ill-chosen meal replacement—are its effects nauseating or nauseous?

Grammarians with more prescriptive leanings (ie, those concerned with language as it “should” be used, which presumably would include most writers and editors) would say that a person feels nauseated and that which has made him or her feel that way is nauseous. Those with more descriptive leanings (those concerned with language as it is actually used, which includes professional linguists as well as armchair observers of language) are eager to point out that while nauseated is still more often used to mean feeling the effects of nausea, the use of nauseous in that subjective sense is rapidly gaining acceptance. Similarly, while nauseous is still more often used to mean causing nausea, the use of nauseating in that causative sense will soon be more prevalent, if it is not already. Debates on the merits of prescriptive vs descriptive use of these terms can be quite heated, and current dictionaries and usage guides often attempt to walk a line between the two camps—which, considering the potential for rancor, is probably not a bad idea, particularly taking into account the ever-evolving nature of language as well as the history of these terms.

So first, a little history. Despite the pronouncements of some prescriptive grammarians promoting the idea that nauseous, when used to mean “feeling the effects of nausea,” is yet another example of a weed newly sprung up in the garden of educated usage, it appears that the term was used in that sense as early as 1604. What is more, it was likely not used to mean “causing nausea” until 1612 or later. At some point, the rule was set forth dictating that nauseous should be used to indicate causing nausea and nauseated to indicate the subjective feeling of nausea—a rule that for the most part held sway until the mid-20th century, when nauseous once again began to be used by persons describing how they feel.

Nauseous, then, when used to describe the feeling of nausea, is something of a grammatical atavism, a throwback to an earlier usage that seems to have fallen into disfavor in the intervening centuries. The term has regained its original meaning in a few generations, a resurrection only accelerated by today’s fast-paced media mix. For example, when comedian Mike Myers’ Saturday Night Live character, Linda Richman, claimed that something “makes me nauseous” (always pronounced as two syllables, with the slightest of pauses when pronouncing the first: “naaw′ shus”), the use of the term in that sense gathered steam in short order, gaining an ever-widening circulation as viewers of the program used it in conversation and e-mails; it likely now lives a healthy and happy life in the various social networking media. Other related terms from the 17th century—nauseation, nauseative, nauseity, nausity—are now obsolete or used very rarely, but for now nauseous as used to describe the subjective state of nausea seems here to stay.

So how does all of this pan out for the person seeking guidance on the use of nauseous, nauseated, and nauseating? As is often the case, an answer—very seldom is there such a thing as the answer—lies in the ever-shifting borders between the spoken and the written word. Whereas the use of nauseous in the subjective sense when speaking now seems a given, nauseated is still holding its own in text. Conversely, the use of nauseous to indicate the cause of nausea is rapidly falling into disuse in spoken conversation (and when it is used, it is sometimes confused with noxious), whereas it maintains only a rapidly diminishing tenuous lead over nauseating in text.

Accordingly, JAMA and the Archives Journals very seldom use nauseous in the causative sense and not at all in the subjective sense (unless part of quoted material); nauseating is used for the former and nauseated for the latter, at least until the dust has settled on another generation or two of language evolution. In the meantime, writers and editors rushing to meet deadlines are encouraged to take steps to eliminate or reduce stress, consume coffee in moderation, and make prudent dietary choices if skipping meals. — Phil Sefton, ELS

Aggravate, Irritate

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Students are commonly taught that these words should be distinguished from one another, with aggravate used to mean “to make worse, more serious, or more severe”1(p24) and irritate to mean “to provoke impatience, anger, or displeasure in.”1(p663) However, aggravate has been used to mean irritate since at least 1611 (in a dictionary, no less: Randle Cotrave’s A Dictionairie of the French and English Tongues)2 and moreover has been used in that sense by such writers as Cheever, Cowper, Dickens, Melville, and Styron.3

Despite that sterling track record, by 1870 the use of aggravate to mean irritate had for some reason begun to provoke finger-wagging,1(p24) and currently such use is more acceptable in conversation and casual writing. (Perfectly understandable, really: who has time to stop and ponder which is correct, when one’s meaning seems clear enough using either word?) On the other hand, more formal writing—perhaps because the reader has the benefit of neither nonverbal cues nor personal acquaintance with the writer—often calls for more precision, and published writing commonly preserves the distinction between these words.1(p24) Hence, many guides to written English continue to maintain that aggravate should never be used to mean irritate; for example, regarding such usage, Bernstein pointedly maintains that “neither the commonness nor the long history of misuse makes it any better than inept.”4

However, even writers who freely use aggravate in place of irritate do so only when describing a mental state—specifically, when someone or something is getting on one’s last nerve. Descriptions of physical states are another matter: while aggravate was used at least as early as the 1800s to indicate physical irritation (“With stinging wood smoke aggravating the eyes”),2 precision mandates that that the distinction between the words be preserved in such contexts. For example, a patient with conjunctivitis does not have an “aggravation of the conjunctiva”; irritation, or a reaction to a stimulus, is the finding here, although the patient might be advised that environmental irritants such as smoke can further aggravate the irritation already present (see §11.1, Current and Preferred Usage of Common Words and Phrases, in the AMA Manual of Style, pp 381-405 in print).

The bottom line:

●Describing a physical finding or state? In casual as well as formal contexts, current usage calls for irritate, with aggravate used only to describe the worsening of the irritation.

●Describing the effects of irksome behavior or circumstances? The use of aggravate to mean irritate is usually acceptable in casual communications and is rapidly gaining acceptance in more formal contexts as well, but persons writing for publication might be wise to use aggravate only to refer to a worsening of one’s irritation. On this point, Bernstein again: “[t]hose who say they are aggravated are, most likely, the same persons who say that in the hospital they were diagnosed.”4—Phil Sefton, ELS

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

2. Aggravate. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:28.

3. Aggravate. Merriam-Webster’s Dictionary of English Usage. Springfield, MA: Merriam-Webster Inc; 1994:49.

4. Aggravate. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:30.