usage

What’s in a (Drug) Name?

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I’ve recently joined the JAMA Network after a brief career in pharmaceutical editing, where I’ve read everything from the easy-to-digest pamphlets that come with your prescription to the headache-inducing instructions chemists follow when testing that a drug meets its quality compliance requirements.

One of these jobs required the terrifying task that editors, after editing an assignment, would sit together and read aloud entire monographs and articles to confirm all changes.

Real talk: I love editing because I get to read alone all day. I avoid public speaking whenever possible. Mustering the courage to read aloud in front of other people for hours on end—let alone pronounce words I’d never seen before—really revved the ol’ anxiety engine.

After countless sessions of tripping over impossible-to-say generic (or nonproprietary) drug names, I finally decided to do some research on my multisyllabic angst inducers.

Enter the United States Adopted Names (USAN) Council, a team composed of representatives from the American Medical Association, the United States Pharmacopeia, and the American Pharmacists Association, as well as a US Food and Drug Administration liaison and 1 member-at-large. This team “is responsible for selecting simple, informative, and unique nonproprietary (generic) drug names,” according to its website.

“Simple,” they say?

But, in fact, the names are not as daunting as I once thought and are often broken down into a general pattern. Again, from the USAN Council website:

Prefix: Means nothing; differentiates drug from others in class

(See? Nothing to be scared of here.)

Infix: Used occasionally; further subclassifies

Stem: Indicates place in nomenclature scheme; drugs with the same stem are related

(The stem is considered the pharmacologic family name and can be broken into further subgroups.)

 An example:

Cobimetinib

Prefix: co-

Infix: -bi-

Stem: -tinib (meaning: tyrosine kinase inhibitors [anticancer drug])

Stem subgroup: -metinib (meaning: MEK inhibitor [anticancer drug specifically to treat melanoma])

It also helps that the USAN Council strives to place any new drug into already existing families, so once you’ve seen several drugs in that family, pronouncing their siblings should be a breeze.

Next up for me: Conquering my Dorland’s Illustrated Medical Dictionary. Wish me luck!—Jamie Scott

 

 

Disability and Language

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I recently found myself in the middle of an intense inter-community debate regarding whether the term “disabled people” or “people with disabilities” should be used when speaking of people who have disabilities. I personally prefer to describe myself as a person with a disability (hard-of-hearing, to be exact), but there are many people within the disability community who object to the term and would describe themselves as disabled people. As that article highlights:

The description “disabled people” is preferred by people who follow the social model of disability, which prefers the term “impairment” to describe our conditions and argues that “disability” is caused by barriers put in place by society to prevent people with impairments accessing society “normally.’”

This is certainly true, but the barriers society has put in place regarding disability are often not fully realized by most people. I’ve lost count of how many times someone claims they “don’t need a microphone,” ignoring hard-of-hearing folks who won’t be able to hear without a microphone no matter how loudly the speaker projects. Unfortunately, society as a whole still views disability as a negative thing. The AMA Manual of Style combats such negativity by emphasizing “people-first” language. The style guide’s section on inclusive language advises writers to “avoid labeling (and thus equating) people with their disabilities or diseases (eg, the blind, schizophrenics, epileptics). Instead, put the person first.” In describing myself as a person with a disability, rather than a disabled person, I avoid defining myself solely by my hearing loss (not to mention the negative connotations that society has given the term “disabled”).  The same must be done when discussing patients or study participants. Avoid using phrases such as “confined to a wheelchair,” which implies that the person is somehow limited or by their wheelchair use. Instead, “uses a wheelchair” is preferable.

It is similarly important to avoid words or phrases that imply helplessness on the part of people who have experienced illness or trauma. For this reason, the style guide advises against using the term “victim”: instead of “victim of trauma” or “stroke victim,” use “survivor of trauma” or “person who has had a stroke.”

Use of people-first language and avoidance of emotion-laden terms such as “suffering” and “victim” offer patients autonomy and dignity even as they’re being written about anonymously in a journal publication that thousands of people read every day.—Suzanne Walker

 

 

 

Death Sentences

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Could it really be 15 years since we waited in this funeral home parking lot for a wake to begin? It seems only last week that we were here for her mother. Both women are now gone from our lives, too soon. We steel ourselves for a few moments more but exit the car when her grandmother arrives. I take the small woman’s frail arm, opposite the one holding a cane, and walk my mother-in-law into the building.

The funeral parlor hasn’t changed much. In place of easels with poster boards full of family photographs, a large-screen monitor at the back of the room runs a PowerPoint file chronicling my niece’s life. Friends and family watch and smile as they recognize themselves in photographs from happier days.

Funeral parlor conversations haven’t changed much either. She “passed away,” “is in a better place,” and “is at peace.” Most conversations are in those soft tones reserved for such occasions. Quiet laughter, though, is heard every so often as stories about fun times are retold.

Wikipedia includes a table of more than 131 expressions related to death categorized as slang, polite, formal, humorous, and so forth. In my work as a medical copy editor, we encounter expressions for death in many forms.

Large clinical trials may include a Kaplan-Meier graph illustrating mortality, with each treatment group represented by a curve that shows the percentage or proportion of patients still alive as follow-up progressed. The number of patients at risk at regular time intervals is provided in a table; the values dwindle as they advance in pace with the downward trajectory of their group’s curve. Text descriptions may list the different causes of death with a simple “(n = X)” after each one. “Seventy-two patients with visual impairment died during follow-up: myocardial infarction (n = 27), respiratory disease (n = 18), and renal disease (n = 12) were the causes most often listed for patients with this information.”

Case reports provide narratives of a single patient from presentation to the end of follow-up or death. In these manuscripts, I’m more likely to encounter euphemisms (taken from the Greek eu, “good,” and pheme, “voice”). The AMA Manual of Style describes euphemisms as “indirect terms used to express something unpleasant,” and states that “directness is better in scientific writing.” Part of my job, then, is to replace the euphemisms: patients died rather than succumbed or passed away.

Even reports of animal studies are not immune to the appearance of euphemisms. Such studies typically require the animal’s death to allow for dissection and subsequent measurement of bone, tissue, or ligament to assess outcomes. However, even in these manuscripts, I often replace sacrificed or euthanized with killed or humanely killed.

The Manual’s chapter on correct and preferred usage further states that “persons die of, not from, specific diseases or disorders.” An example of this usage could be the written as: “She died of complications of renal failure.”

Scientific reports may seem clinical and removed; patients may be grouped and their mortality is frequently categorized. Nevertheless, individual lives underlie advances in medical science. Although euphemisms seem called for when discussing the deaths of people we love, direct language, such as that used in our work, is no less respectful.—Connie Manno, ELS

 

Stranger Than Fiction

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

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

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

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

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

 

 

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 Due Diligence Excursion Into Nomenclature

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You might know the definition of the word “excursion” as it relates to leisure activity. You may also consider its technical definition, which is to do with the movement of something along a path. I recall an unexpected delight once while reading some Prescribing Information. A statement about drug storage and handling indicated that the drug can be stored for up to 4 months at 25°C (77°F). The kicker for me was “excursions permitted to 15-30°C (59-86°F).”

Excursion? Sounds like that drug is in for a treat.

My earliest excursion into professional proofreading and copyediting occurred at a law firm. The required confidentiality agreement lit a fire in me as an initiation into specialized knowledge.

Good, I will know something I am not allowed to talk about.

Flushed with triumph, I sat down to read contracts, deeds, torts, and trusts. Page by page, section by section, paragraph by paragraph, unwieldy sentence by unwieldy sentence, clause by clause, parenthetical phrase by parenthetical phrase.

Confidentiality agreement? A few months into the job revealed that agreement to be a formality. I couldn’t have blabbed about any deals had I wanted to (putting aside the question of who would want to be told any of what I was reading). The baroque legal prose lent itself to pattern recognition instead of language comprehension.

Particular phrasing has stayed with me. Pursuant to. Indemnify, defend, and hold harmless. Any and all claims that arise from or relate to. Including without limitation. As herein before stated. Some terminology has migrated into general use, as when you overhear someone say into a phone, “Do your due diligence, dude.” As a synonym for “preparation,” there are worse choices.

Performing due diligence is a vital component of processing articles for JAMA Network journals. In manuscript editing, the biggest confidentiality issue is the embargoed proof. Knowledge across the specialty journals is not meant to be confidential (after publication). The spread of knowledge requires fixed meanings—or at least is greatly helped by it.

Words slip out of professional and into general use, and from general into professional (although I don’t know the origin of “excursion” in Prescribing Information). A migrated term can lend a patina of mindfulness—“curate” is no longer a member of the clergy in an Anthony Trollope novel but a thing one does on behalf of one’s own “brand”—which once meant the maker of cereal you preferred to eat but now means something like the self you present to the world. Word migration can veer into pretension, depending on your personal threshold.

We routinely consult the AMA Manual of Style to solve usage issues in preparing an article for publication. Changes in usage can be exciting. The manual is too sophisticated to be merely proscriptive; if you admire change, you will find plentiful discussion. If, however, you find yourself wishing to sample a lexicon with a heritage of stability, the AMA Manual of Style is at your service.

Your well-thumbed manual may focus your attention on references, usage, conversion factors, and abbreviations. We all need reminders for those principles that don’t stay in our heads. That raises a question. What about what is not in in our heads to begin with?

You won’t know that you don’t know nomenclature unless you are exposed to what there is to know. Make an excursion into Chapter 15, Nomenclature, the single longest chapter in the manual (followed, in a bit of poetic juxtaposition, by what is likely the shortest, the 5-page treatise on Eponyms).

Why stroll through a 250-page chapter with 17 segments? You will encounter terms for Equipment, Devices, and Reagents, a lexicon of Immunology, and vernacular names for Organisms and Pathogens. One reason to move along this path is that, while editing, you may not realize that usage in your article is imprecise or incorrect. Maybe the author inadvertently mixed up 2 conventions in a single term. The term looks scientific and the author is both MD and PhD, so you might move along with your next task in mind. Perusing Chapter 15, though, can orient you toward terminology in a way that can help you know when to clean it up.

Even though the chapter is enormous, its rationale is simple: “to present style for terms and to explain terms in hopes that they are more easily dealt with.”

In my book, that’s grounds for an excursion.—Timothy Gray

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

 

Living With Style

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Did you know that the Chicago Museum of Science and Industry doesn’t follow AMA style? Here’s proof:

There are a few things I would change if I could edit that. Amanda, author of “People-First Language,” texted this to me and a few other JAMA Network editors a few weeks ago. It got me thinking about some stuff. Namely: am I becoming a style snob?

I know I’m not a grammar snob. I’m a lazy talker who don’t always speak good. No matter how many times I’m corrected, “my friends and I” never hang out, but “me and my friends” do. I don’t really care about parallel structure or flat adverbs when talking because—when it comes to speech—I think communication is more important than talking proper.

But that’s grammar. Like Amanda, I’m noticing style in everyday life, and I can’t not want to correct it. Whenever my girlfriend talks about side effects, I mutter “adverse” under my breath. I joke with a friend that she isn’t “suffering” through the day but simply “experiencing” it. I’m starting to change “compared to”s to “compared with”s on the fly when reading children’s books aloud. Seriously: I’m starting to change children’s books to style.

All of this is pretty harmless, and I’d imagine my manager is happy that some style changes are becoming automatic. But outside of work? I don’t want to be so automatic that I change, for example, “Alzheimer’s” to “Alzheimer,” shifting the focus of the conversation from illness to eponyms and the nonvirtue of ’s. I don’t want to derail trains of thought because I keep mumbling corrections when listening to people talk. I don’t want to be a style snob.

I’ve only been editing exclusively to AMA style for 2 years. For those with more time dedicated to one style guide: how bad have you gotten? Leave us a comment!—Kevin Brown

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