usage

Abbreviation Nation

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

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

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

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

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

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

Use the pronoun. Use it.

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

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

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

Use the verb.

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

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

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

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

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

Here are a few substitutions that reduce wordiness:

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

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

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

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

Ability, Capacity, Capability

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These near-synonyms actually mean slightly different things—but teasing out the subtleties requires a bit of hairsplitting.

To drive the first wedge, distinguish between ability and capacity. Ability denotes actual (as opposed to potential) skill that may be either native or acquired.1 On that point, Merriam-Webster’s Collegiate Dictionary cuts right to the pith, stating that ability is “natural aptitude or acquired proficiency.”2(p3) Capacity, on the other hand, denotes the potential to develop a skill, a native characteristic that one either does or does not have and that cannot be acquired or developed.3 (Language purists might maintain that capacity should be used only to refer to space or volume, but its use to refer to aptitude is well accepted.) Moreover, whereas ability and capacity can each refer to either physical or mental aptitude, capacity is more commonly used in connection with mental aptitude—in particular, to “mental or intellectual receiving power; ability to take in impressions, ideas, knowledge.”4

Persons attempting to keep these subtleties straight might, like William Caxton, well be inclined to exclaim, “My capacity is not sufficient for the proper handling… of such subjects”4—but things get more complicated yet. When differentiating ability from capacity, some language users distinguish between whether a sentence is referring to persons/animals or to things (with ability often used with persons and capacity most often used with either persons or things)1; however, this distinction is rapidly waning, and both words are commonly used to refer either to animate or to inanimate agents. For example, both words are commonly used when referring to inanimate agents such as physiological mechanisms (eg, “The ability/capacity of this pathway to promote….”) or anatomical structures (eg, “The ability/capacity of the liver to clear the body of these toxins….”).

Capability denotes “the quality or state of being capable”2(p182) as well as “a feature or faculty capable of development.”2(p182) Thus, capability comes closer to ability in meaning. However, capability further denotes a unique fitness for achieving a defined end,1 and this specificity makes capability a good choice in contexts requiring a greater degree of precision. So, while capability is all too often simply used as a pretentious substitute for ability—a 10-dollar word lobbed in when a 1-dollar word would have gotten the job done—capability might have been the better choice in the above examples (“The capability of this pathway to promote….”; “The capability of the liver to clear the body of these toxins….”). Furthermore, language users often use capability in place of capacity, likely led astray by the “cap” with which they both begin. However, whereas the use of capability in place of ability is becoming more accepted, particularly when referring to a unique aptitude to accomplish a particular end, the use of capability in place of capacity is usually incorrect.

The bottom line:

Ability = Actual skill, either mental or physical; native or acquired.

Capacity = Potential to develop a skill, usually mental; native, as opposed to acquired.

Capability = Unique fitness for a defined end; sometimes may be used in place of ability, but its use in place of capacity is incorrect.—Phil Sefton, ELS

1. Ability, capacity, capability. Merriam-Webster’s Dictionary of Synonyms. Springfield, MA; Merriam-Webster Inc; 1984:4.

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

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

4. Capacity. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:209.

For Against As

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

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

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

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

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

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

Say It Small

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

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

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

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

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

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

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

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

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.