Discard the Rest

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For several years, I have had a healthy curiosity with minimalism. I’ve listened to TED talks and watched documentaries about the topic and pared down my items accordingly. Last year, I read The Life-Changing Magic of Tidying Up: The Japanese Art of Decluttering and Organizing by Marie Kondo. The author describes a process in which you go through every item you own, keep only what sparks joy or is necessary, and discard the rest. Once you have tidied up your belongings, your mind is free to tackle other issues. This process resonated with me, perhaps because it seemed quite similar to my approach to medical editing.

Part of our job as editors is to remove redundancy in manuscripts—to tidy it up, if you will. We go through a manuscript word for word and carefully discard what phrases or words that do not serve the science (with the author’s approval, of course). Omitting unnecessary words can improve readability. In making an author’s work clearer and more concise, readers are able to tackle other issues, such as responding to the research or designing their own studies. Moreover, scientific writing should be as precise as possible to avoid misinterpretation. Below are some tips, adapted from AMA Manual of Style 11.1.

Some common redundancies that can typically be avoided (redundant words are italicized):

first initiated
skin rash
herein we describe
past history
period of time, time period, point in time
whether or not [unless the intent is to give equal emphasis to the alternative]
younger [older] than 50 years of age

Here are some common words and phrases that can usually be omitted without affecting meaning:

as already stated
it goes without saying
it is important [interesting] to note
it was demonstrated that
take steps to

And here are some expressions to avoid and what to use instead:

Avoid	Better
in terms of	in, of, for
an increased [decreased] number of	more [fewer]
as the result of	because of
during the time that	while
in close proximity to	near
in regard to, with regard to	about, regarding
the majority of	most
have an effect [impact] on	affect

When editing and reducing redundancy, a balance must be struck. Deleting or rewriting too much may lead to accidentally altering the author’s intended meaning, which could adversely affect the author-editor relationship or perhaps even result in a correction after publication. I have been tempted to rewrite sentences, but I have to remind myself that this is the author’s work, not mine. Our responsibility as manuscript editors is to make a research paper as readable as possible so the science is the main focus.—Iris Y. Lo

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

The Use of Cause-and-Effect Language in the JAMA Network Journals

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As a manuscript editor and freelance manuscript editing coordinator for the JAMA Network specialty journals, I am constantly having to edit out cause-and-effect language from observational studies that are not randomized clinical trials. According to the AMA Manual of Style, the word effect, as a verb, means to bring about a change; as a noun, it means result.

A randomized clinical trial is one of the few types of studies that are designed to assess the efficacy of a treatment or intervention (and thus allowed to use cause-and-effect language) because the participants are treated in controlled, standardized, and highly monitored settings.

Whenever I come across a study in which the authors are trying to determine, for example, whether the use of a certain type of drug will reduce the risk of some complication following a certain type of surgery, I need to verify whether the study is a randomized clinical trial or a report of a controlled laboratory experiment. If it isn’t, and is a report of an observational study (such as a cohort, cross-sectional, case-control, or case series study, or a meta-analysis), then all cause-and-effect language must be replaced. But by what?

Generally, association may be a useful replacement for effect. The AMA Manual of Style defines association as a “statistically significant relationship between 2 variables in which one does not necessarily cause the other. When 2 variables are measured simultaneously, association rather than causation generally is all that can be assessed.” So instead of saying the “effect of this on that,” rephrase as the “association of this with that” or the “association between this and that.”

Sometimes, however, the authors don’t agree and want me to change it back, in which case I calmly let the authors know that it is AMA style to allow cause-and-effect language only for randomized clinical trials and controlled laboratory experiments and that, perhaps in the “Discussion” section of their manuscript, they can try to make arguments to support that the association might be causal. However, to quote from one of our scientific editors, “the expression and ultimate interpretation of the findings can’t be causal.”

The use of cause-and-effect language is quite common in everyday speech, and so it is easy for most people to assume that if one event comes before another, then the first is the cause of the second. In the JAMA Network journals, findings that rely on this type of logic had to have been rigorously tested in a randomized clinical trial.—Paul Ruich

Raising (Rearing?) Hell

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Besides the dropping energy levels and unsightly wrinkles that daily remind me of my advancing age, I never expected an Associated Press style rule—beaten into me as a young reporter—to deliver the one-two punch that landed me squarely into the “old fogies” category.

I was editing a JAMA Viewpoint about a fairly modern question involving gender identity, hormone levels, and eligibility for women’s athletic events when my knee began to jerk at first sight of the descriptor “raised,” as it applies to how or where someone grew up.

As soon as I saw the word, I heard harsh tones in my head and felt the breeze of a wagging finger: “Corn and cattle are raised, people are reared!” So I dutifully changed “raised” to “reared” as the AP Stylebook commands. Soon, I sent the proof off for review by the senior editors and the authors.

As I had predicted, one of the medical editors deleted “reared” and inserted “raised.” I knew I was right about this! I was poised to cross off the edit when I thought, “Maybe I should look at a newer version of a stylebook, just to see if the rules have slackened over the decades.” (Our own AMA Manual of Style is silent on the matter.) My office was too cluttered to find the newest Associated Press Stylebook, so I turned to Google.

The first search result was titled “Grammar Gremlins: Is it ‘reared’ or ‘raised’?” I clicked—who says a pithy headline doesn’t draw in a reader? Knoxville News Sentinel Columnist Don Ferguson, who by his photo looks older than me, offered his first sentence:

A recent Associated Press report about an accused terrorist said the man was “born and reared” in America.

He followed with,

Did this use of “reared” instead of “raised” say something about the age of the writer?

Oh my goodness! Who would have thought that old style rule would say more about me than my slowing gait? He noted that youngsters favor “raised.” He cited Garners Modern American Usage’s calculations that “born and raised” is used 8 times more often than “born and reared.”

As with most of often-confused words, he also noted that dictionaries say either is correct.

I dropped my pen and conceded the edit.—Beverly Stewart

Why Not Say It Clearly: The JAMA Network Editors on Correct Usage

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The second edition of Why Not Say It Clearly? A Guide to Expository Writing by Lester S. King, MD, was published in 1991 (first edition in 1978).

Dr King was a charmingly irascible but fascinating and classically trained scholar who was a senior editor at JAMA for more than 25 years. A coauthor of the AMA Manual of Style (eighth edition), he was an accomplished raconteur and humorist as well as a prolific writer, particularly concerning language and usage. He was professor of pathology and professorial lecturer of history of medicine at the University of Chicago.

Why Not Say It Clearly remains an enduring editorial classic on writing and usage and is the inspiration for this expansion of the AMA Style Insider: The JAMA Network Editors on Correct Usage. Feedback welcome!—Roxanne K. Young, ELS

Internet, Computer Terms, and References to Social Media

The JAMA Network editors prefer the following capitalization and punctuation styles for e- and i-entities, computer terms, and references to and in social media and networks. Also check commercial websites for trademarked terms and conditions of their use.

app, application

cell phone

e-cigarette (E-cigarette at the beginning of a sentence or in a title, subtitle, or heading)

e-commerce (see e-cigarette)

e-learning (see e-cigarette)

e-print

e-publication

e-terms (see e-cigarette)

email (Email at the beginning of a sentence or in a title, subtitle, or heading)

Follow (as on Facebook; also capitalize Junk folder, Option key, Edit menu, and other computer key and menu names)

Google (google as verb)

Instagram

Internet

iPod, iPad, iPhone, etc (trademarks)

MEDLINE, MeSH, PubMed

offline

online (as both adjective and adverb)

podcast

Skype (skype as verb)

smartphone

text, texted, texting

Tweet, Tweeting, Twitter, Twittering (despite the official logo being lowercase; a trademark)

webinar, website (World Wide Web, web-based literature search)

Wiki, Wikipedia

Quiz Yourself

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Edit the following sentence to eliminate jargon:

A 78-year-old woman with a congenital heart and a history of high blood pressure and heart attack was admitted to the hospital and prepped for surgery.

Highlight for the answer:

A 78-year-old woman with congenital heart disease and a history of high blood pressure and myocardial infarction was admitted to the hospital and prepared for surgery.

Editor’s Note: A heart is not congenital; the preferred terminology is congenital heart disease or congenital cardiac anomaly. Myocardial infarction, not heart attack, is the preferred term. Patients are prepared, not prepped, for surgery (§11.4, Jargon, pp 408-410 in print). Some of these terms may be acceptable for certain types of writing; peer-reviewed medical journals generally avoid them.—Laura King, ELS

Questions From Users of the Manual

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Q: I am putting together an annotated bibliography for a manuscript. What is the correct order recommended by the AMA Manual of Style for citing multiple articles by the same author? Is it by date of publication or article title?

A: The JAMA Network journals do not use a name-date style of reference citation. Instead they use a superscript reference citation system. If you look in the 10th edition of the Manual of Style, section 3.6 (Citation), you will see further information on this. So, it matters not the date of publication or the article title. What is key is the order in which the reference is cited in the paper, eg, the first reference to be cited would be reference 1, the second would be reference 2. (And if reference 1 is cited again later in the paper, it would still remain reference 1.)

Q: What do you tell authors who object to the house style your publications follow by saying that “Everybody does X [rather than what you recommend].”?

A: When people respond like this, I find that it’s helpful to look at what a few key style manuals or journals in the field (based on their Instructions for Authors) do in areas in which people have complaints or concerns. If you can put together a little chart (nothing fancy) showing that indeed maybe it is not EVERYBODY who does X, real data can sometimes calm the fevered brow. And sometimes you may find that indeed most others do have a different policy than what your house style recommends. Then it may be time to reconsider your policy. Sometimes this is how style policies change, and that can be a good thing. We learn from our authors just as we hope they learn from us.—Cheryl Iverson, MA

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.

Quiz Bowl: Radiology Terms

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Do you know the difference between TE and TR? How about section and slice? And what exactly is an echo train? That’s right, this month we’re talking about radiology!

The AMA Manual of Style has a brief but informative section on radiology terms (§15.7.2). The section defines terms commonly used in radiology literature and offers instruction on how to use these terms correctly. Some of the terms addressed in the section are b value, k-space, echo time, and repetition time. The style quiz is a sample paragraph that contains commonly used radiology terms.

See if you can identify the problem(s) in the following sentences from this month’s quiz:

Twenty-four contiguous slices, each 2 mm thick, were acquired in an interleaved fashion. Radiologic slices were then examined for consistency of the hippocampal subfields from patient to patient.

Use your mouse to highlight the text box for the answer:

Twenty-four contiguous slices, each 2 mm thick, were acquired in an interleaved fashion. Radiologic sections were then examined for consistency of the hippocampal subfields from patient to patient.

The term section should be used to refer to a radiological image and slice to refer to a slice of tissue (eg, for histological examination).

That’s just a “slice” of what we have to offer in this month’s quiz. If you’re a subscriber, check out the complete quiz at www.amamanualofstyle.com.—Laura King, MA, ELS