Effective communication is the ultimate, but often daunting, purpose of any piece of medical research. Medical Writing: A Prescription for Clarity provides practical information enabling first drafts to be turned into clear, simple, unambiguous text, without loss of individuality. Written by a medical consultant and an experienced medical editor, it is sympathetic to the problems and needs of medical writers. Like the preceding two editions, this expanded third edition deals with the basic craft of writing for publication, from spelling and grammar to choosing the best word or phrase. Whether writing a simple clinical report or thesis, wanting to supervise others, or wanting just to develop greater skill in effective writing, this book is the ideal guide and reference. Clear, simple and precise, and illustrated with apt cartoons, this is an invaluable handbook.
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About the Author
The late Dr Martin B. Edwards was formerly Senior Research Fellow at the Royal College of Surgeons and a freelance medical editor.
Elise Langdon-Neuner is a freelance medical editor and editor emeritus of Medical Writing.
Dr Andy Black is a retired Senior Lecturer in Anaesthesia who formerly worked at the University of Bristol.
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Cambridge University Press
978-0-521-85857-1 - Medical Writing - A Prescription for Clarity - by Dr Nevillle W. Goodman, Dr Martin B. Edwards and Dr Andy Black
This book is about words: about the ways in which words are used by doctors, medical scientists and others who write on medical matters. These ways are mostly no different from the ways that words are used and misused in many other subjects. But, in our opinion, too many of the producers and consumers of academic medical English are tolerant of writing that is clumsy, inaccurate, obscure or just downright bad. The first section of this book examines the roots of that tolerance; the remainder and larger part deals with the nuts and bolts of writing, taking its numerous examples from the field of medicine.
Our approach is to encourage good writing by examining bad writing, because it is often easier to say what is bad about a piece of writing than what is good. This sentiment is shared by Bernard Dixon, who compiled a collection of unarguably well-written scientific articles from past and present. In his preface, he says of bad writing, ‘We can learn important lessons by inspecting such specimens, just as pathologists learn from even the most unattractive objects and tissues that arrive in their laboratories.’ This book contains collections of these specimens and a record of their dissections.
What constitutes good or bad writing is not easy to define. How to distinguish between good and bad without sounding didactic or arrogant is a challenge. Inapplying judgemental words – ‘good’, ‘bad’, ‘clumsy’, ‘pompous’ and others – to examples of writing, we accept that we are making value judgements. But we are actually more concerned with valid judgements and we leave it to readers to test the validity of our criticisms against their own values. Certainly no plea is made here that words have inviolable meanings and that we should all go back pedantically to their etymological roots to define meanings for evermore. For example, the original meaning of the word decimate was to put to death one in ten, but decimate has now come to mean to destroy a large proportion and the original meaning has been lost.
If any plea is entered it is on behalf of clear, simple, unambiguous writing. That whatever word is used should be, as far as possible, the correct word, chosen for its precise meaning that everyone understands. Words that are changing their meanings may mean different things to different people, and it is for this reason – not because they appreciate the finer points of etymology – that good writers will avoid them.
If there is a simple maxim for good medical writing, it is that almost always the better word is shorter and the better construction has fewer words.
The intent of this book is, then, largely practical. Some of the technical exercises involve that most practical of modern writing tools, the word processor. At the simplest level, the aim of the prescriptive lists in the book is to help writers to realize that it is easy to make a start at improvement. The lists are of suggested better words and better constructions, where better means clearer and more precise. If writers used the lists in this simple way, their writing would surely improve, but there is a more important reason for the book: to show that there is no difference between clear, precise thinking and clear, precise writing.
That much of medical writing is bad does not mean that the writers, particularly those with little experience, should bear all the blame. Bad writing is contagious if the reader has not received an adequately immunizing dose of good. The practical exercises in this book are intended to begin the process of acquiring resistance. Readers queuing for their first shot of vaccine but at this stage less concerned with the immunopathology of writing may choose to move directly to the next section – with both sleeves rolled up. Later, sustained by high titres of antijargon, we hope they will return to the more philosophical considerations of the next chapter.
The malaise of medical manuscripts
We think in words. We form our ideas in words. If doctors write descriptions of clinical trials that confuse readers assumed to be of equal knowledge and understanding, then that is the responsibility of the writers not the readers, who might justifiably wonder whether the conduct of the clinical trials had been similarly confused. (The difference between ‘responsibility’ and ‘fault’ serves a purpose here. We have already indicated that writers should not necessarily be blamed for their bad habits.)
Medicine is a practical subject so here is an example of confused writing, taken from a clinical report. The investigators were relating the rate of infusion of a drug to its concentration in the blood. They wrote,
The infusion rate was then increased and blood was taken 4, 8, 12, and 20 minutes after [our italics] the new target concentration had been achieved.
The meaning of this sentence is clear: they wanted there to be a higher concentration of drug, which would have a greater effect, and blood was taken to ascertain what happened after the new, desired concentration had been reached. This is a reasonable thing to want to know; after all, if the concentration varied, then the effect could be unpredictable.
The meaning is absolutely clear; but the trouble is that it is not what the investigators meant. They were interested in how quickly the concentration reached its new steady state after the rate of infusion had been increased; they took blood 4, 8, 12 and 20 minutes after taking the action that sought to produce a new target concentration, that is, after altering the rate of infusion. To do the experiment as described they would have needed to know the concentration at the time of sampling. This may be possible eventually, using quantitative methods in vivo, but these investigators did not know the concentration of the drug in the blood until after analysis some days later. What they should have written is, The infusion rate was then increased and blood was taken 4, 8, 12, and 20 minutes later, or (although it is implicit and not strictly necessary) . . . after the new target concentration had been set.
Science depends on clear thinking and accurate reporting. These investigators described the defining of a future event as the achievement of that event – they described aiming at the target as hitting the target. Is it unfair to wonder if their scientific method might have been similarly imprecise?
Sadly, an editorialist at the British Medical Journal was not being ironic when writing a comment on a doctor struck off the medical register for faking ethics committee approval for a research project, ‘The forgeries were described as “hopelessly inept”, containing grammatical errors and couched in language that was difficult to understand’. If the doctor had managed to do the research, such skill would have made the forged research pretty well undetectable.
The writer at bay
The first response of writers when their writing is criticized is likely to be one of indignation. This is not surprising. First, most people assume they can express themselves in their mother tongue. (It is unfair to be over-critical when writers are not writing in their first language.) Second, however unimportant the question, slovenly the method and inappropriate the conclusions may appear to the reader, a paper being prepared for a medical journal is the report of work that has taken time and effort. It is not easy to tell parents that their child is stupid.
Whatever the particular criticism, whether of incorrect use of a single word or of impenetrable paragraphs of ‘pseudo-scientific’ prose, there are five defences that authors commonly proffer.
- Everyday language is inappropriate and not precise enough to describe the results of a medical study.
- Long words are more scientific.
- Their writing style follows the convention for writing medical papers.
- However writers write, editors will alter the writing to suit themselves.
- Everyone has their own style, and to use this style is better than conforming to a supposedly correct set of rules.
There is some justification in the claim that everyday language is inappropriate, because sometimes it is. Colloquial expressions such as mum for mother, kid for child, and swig for drink would be out of place in formal writing, but that does not mean that all simple words are similarly condemned. There is no good reason for choosing maternal parent, paediatric patient and liquid imbibition: or for claiming that these longer substitutions are more precise. There is no more precise way of expressing the idea of a female parent than the word mother. To prefer liquid imbibition to drink (-ing) is a pompous inflation not often encountered. The paediatric patient is now a common visitor to medical texts and more problematic. Is he or she a child or an adolescent; is there a global standard age range for the paediatric category? (See p. 152.) It may be necessary to be more precise and use more words when a shorthand form, however familiar, is also ambiguous.
Precise, therefore, does not always mean short, although the more precise word of a pair is commonly the shorter one. Precise means accurately expressed. Something that is precise will be clear and unambiguous, which is what is needed in scientific or medical writing. We tend to avoid long words and complicated constructions in everyday speech with colleagues and patients, largely because these words and constructions are imprecise, inefficient and difficult to understand, and we should do the same in our writing. It is also nonsense, and arrogant, to claim that the words we use in medical articles and books should be different from everyday usage in case patients try to read them; that is going back to the Middle Ages, when to know the name of something was to have power over it.
There is a story, often quoted, about a child who was asked to describe a cow and wrote:
Somewhere between primary school and our postgraduate medical examinations something goes sadly wrong, because by then we may be capable of writing:
A cow is an animal with four legs, and horns on its head. Grass goes in at the head end and manure comes out at the tail end.
instead of We need to assess the efficiency and effectiveness of follow-up clinics, or We need to know whether follow-up clinics are efficient and effective or, what we really think, which is, ‘Are follow-up clinics worthwhile?’
Follow-up clinics should be subjected to critical analysis in terms of the efficiency and effectiveness of the care provided.
Long words and scientific conventions
Are longer words more scientific, a reason commonly given for their use? Roget's Thesaurus, in one of its lists of words with similar and allied meanings, has accurate, meticulous, delicate, undeviating and sensitive in the same section as scientific, but it does not have synonyms such as complicated, complex, contorted, or long winded. The COD defines scientific as ‘according to rules laid down in exact science for performing observations and testing soundness of conclusions, systematic, accurate’, and science is described as ‘systematic and formulated knowledge’.
Science can be very complicated, but there is nothing in its definition that implies it must be, or that requires descriptions of science to be written in any sort of special language that only scientists understand. (We consider the rhetorical aspects of scientific writing later (pp. 10 and 26).) The detail and implications of Einstein's theory of relativity may be beyond the understanding of many of us, but it can be described in simple language, which is what Einstein himself used in his own writing.
Complex language makes understanding even more difficult. There have been many developments in physics since Einstein, and there will be few clinicians who can grasp the intricacies of, say, the more recent theory of superstrings. This requires an understanding of a number of dimensions beyond the familiar three, and attempts to explain, in the same physical terms, time, mass, gravity and other phenomena. Complex the theory may be, but when an editorial appeared about it in the Lancet the writing was a model of clarity:
Since 1984, there has been an explosion of enthusiasm for superstring theory, motivated by indications that this theory will not only lead to a consistent understanding of quantum gravity but also necessarily unify all the fundamental particles and the physical forces. The basic principle is that the fundamental particles (e.g., the electron, the quarks, and other particles) are extended, string-like, objects rather
than the structureless point-like objects that appear in all previous quantum theories (e.g., those based on Maxwell's electromagnetism or Einstein's gravity). . .
The theory is mind-boggling; the idea of space–time fluctuation is certainly beyond easy comprehension. But the expression of these ideas could not be more clear, and it can be grasped readily at first reading. The clarity gives the subject immediacy and makes it interesting. It leaves the reader curious to know more. There is no reason at all why a medical paper should not read like a Lancet editorial.
. . .For general reasons, in a complete quantum theory that includes gravity along with the other forces, [the] familiar notion of space-time must be altered. . .[and]. . .can no longer be considered as a smooth collection of points but is continuously fluctuating in a manner that depends on the forces exerted by the particles that move through it.
Compare that passage with this next extract, which is about the control of breathing. All workers in medicine will have some idea of the physiology of breathing and so should have a grasp of the terminology (which we may lack in subatomic physics).
The writer has used the word coherent, which means, among other things, easily followed. Ironic, then, that the expression of these ideas, compared with the nominally more difficult ones from particle physics, could not be more opaque, and the ideas are impossible to grasp at first reading. The opacity makes the reader eager to skip the rest of the article. In fact, the extraordinarily contorted first sentence can be summed up quite simply:
A speculative proposal that the physiological explication of the control of pulmonary ventilation in the mammal is made coherent and consistent with most physiological observation if the control conceptualization is formulated around the notion that air flow is the real part of an analytic time varying signal. The instantaneous amplitude and phase of the signal correspond to depth and rate of breathing.
The original, though nearly impossible to understand, would probably be said by many to be more scientific.
All observations relating to the control of breathing in the mammal can be explained in terms of the instantaneous air flow.
There is a circular argument here: it is science that is reported in journals; journals contain heavy, polysyllabic, impressive-sounding prose; therefore, this style of writing is scientific. The inevitable conclusion is that this style must be used when writing medical and scientific papers.
Is scientific style just a matter of convention? Is it essential to follow that convention in order to communicate effectively? Clearly there are structures that contribute to making scientific communications ‘universally’ intelligible. An obvious example, above the level of sentences and their order, is the sequence of sections (Introduction, Materials and Methods, and so on) common to papers in many journals. However, down in the dirt among the words and punctuation there are other, less obvious but insidious, structures that have the guise of conventions but which all too easily produce stylistic obscurity. And these are certainly self-perpetuating. If papers in the journals are written badly, aspiring authors are likely to copy the style and write badly themselves. A convention that makes writing less clear cannot make for good science and, therefore, has no use. A convention that has no use should be abandoned.
Certain conventions in scientific writing endure for good reasons. For example, there is little place for style that imparts mood and emotion to the words; we are reporting facts, and stating opinions based on them and their relation to other facts. But even this requirement for ‘scientific objectivity’ may yield to literary analysis by detached observers. John Durant quotes from Alan Gross's The Rhetoric of Science: ‘The objectivity of scientific prose is a carefully crafted rhetorical invention, a nonrational appeal to the authority of reason.’ This is too large a subject to debate further here (see p. 20), but we suggest that clear and simple words can expose irrationality as powerfully as they can endorse objectivity. We may need to remember too that the Internet can give the so-called lay public far greater access than before to scientific pronouncements. These readers in cyberspace may prove to be harsh and demanding critics, with well-developed sensitivity to the ‘authority of reason’ and every justification for scepticism about scientism rather than science. The medical writer needs to think about this new audience.
Less controversially, there is more room for personal style in reviews and books. For reviewing, the style used for bare scientific reporting removes the whole purpose, which is to be critical. As Sam Shuster wrote in a book review, ‘In each of the three books mediocrity of approach showed itself in the fear of personal involvement and commitment and in the curious and almost reverential equality accorded to all published work.’
© Cambridge University Press
Table of ContentsForeword Tim Albert; Preface; Part I. Problem: The Illness: 1. Introduction; 2. The malaise of medical manuscripts; 3. The difficulties of English as an additional language (EAL); Part II. Solution: Symptomatic Relief: 4. Technology, changing language, and authority; 5. Guidelines to clearer writing; 6. Spelling; 7. Is there a better word?; 8. Superfluous words; 9. Imprecise words; 10. Superfluous phrases; 11. Trouble with short words; 12. Use of the passive voice; 13. Consistency: number and tenses; 14. Word order; 15. Punctuation; 16. Circumlocution; 17. Words and parts of speech for EAL writers; 18. Clichés and article titles; 19. Constructing sentences; 20. Further help with sentences for EAL writers; 21. Drawing clear graphs; 22. It can be done; Part III. Practice: Recuperation: 23. Exercises; Appendix: British-American English; References and further reading; Index.