Writing the Biomedical Manuscript: Essentials of Good Writing

1. Writing the Biomedical Manuscript:Essentials of Good Writing Christopher Dant

2. A Recognized Problem “There is no form of prose more difficult to understand and more tedious to read than the average scientific paper!” -Dr. Francis Crick, 1994The Astonishing Hypothesis

3. An Editor’s Warning “Poor writing is likely to annoy reviewers and decrease the author’s chance of publication recommendation” Bordage, G: Peer Reviewer, University of Illinois at Chicago: Academic Med 76(9), 2001

4. An Author’s Warning “Some authors believe that they must impress the reader (and the editor) with mastery and erudation of multisyllabic words in order for their work to be given attention.” “Say what you mean, mean what you say, and don’t use big words” David Pierson, MD. Repiratory Care 49(10): 2004.

5. Methods are Critical: Editors’ Responses How frequently do Editors encounter manuscript problems? Poorly written, excessive jargon Inadequate/inappropriate presentation Poor description of design Excessive zeal and self promotion Rationale confused, contradictory Essential data omitted, ignored Boring Important work of others ignored Seldom Occasionally Frequently Byrne DW, Publishing Medical Research Papers, Williams and Wilkins, 1998

6. In 1953, Crick Writes: • We wish to suggest a structure for the salt of deoxyribose nucleic acid (DNA). This structure has novel features, which are of considerable biological interest. • A structure for nucleic acid has already been proposed by Pauling and Corey1. The model consists of three intertwined chains, with the phosphates near the fibre axis, and the bases on the outside. In our opinion, this structure is unsatisfactory for two reasons: • (1) We believe that the material which gives the x-ray diagrams is the salt, not the free acid. Without the acidic hydrogen atoms, it is not clear what forces would hold the structure together, especially as the negatively charged phosphates near the axis will repel each other. • (2) Some of the van der Waals distances appear to be too small.

7. In 2005, an Author Writes: In order to determine if the expertise in the attribution of emotion from basic facial expressions in high functioning individuals with autism spectrum disorder (ASD) is supported by the same reported brain regions of interest (ROI) as the regions supported by typically developing individuals, the present study employed functional MRI scanning technology acquired from 14 males and 32 females with the specified disorder while performing emotion-matched and emotional label linguistic and also control tasks. The accuracy, response time, and average activation was acquired and measured in the amygdala and other important ROIs.

8. In 2005, an Editor Rewrites: In this study, our goal was to determine which brain regions were active during emotion-based tasks in children with autism spectrum disorder (ASD) compared with typically developing children. Specifically, we used functional MRI in 14 boys and 32 girls with ASD aged 6 to 11, and compared them with a cohort of typically developing boys and girls while they reacted to basic facial expressions in the MRI. The children performed a set of standardized emotion-matched and emotional-label linguistic and control tasks. Their accuracy, response time, and average brain activation was acquired in the amygdala and other important brain regions of interest (ROIs). Specifically, we found that…

9. Why Does Grammar Matter? • Your paper must convey clearly and accurately your purpose, method, result, and conclusion • Free of ambiguity and misinterpretation • The scientific community is world-wide • If English is sloppy, ungrammatical, ambiguous in meaning, your meaning is obscured • Peer reviewers and editors will translate this to your research • Delayed or rejected publication

10. Writing Deficiencies Most commonly cited by journal editors • Wordiness and redundancies • Poor flow of ideas • Poor syntax and grammar • Excessive abstraction • Unnecessary complexity • Excessive compression • Unnecessary qualification • Cut, condense, combine • Outline to catch logic problems • Consult an editor • Be specific and descriptive • Keep it simple and direct • Do not overly compress writing • Qualify statements as necessary

11. Writing Clarifies Thought • Unclear writing means unclear thinking • Simply writing ideas down for critical appraisal helps clarify the thought • Clear writing, then, will clarify: • the purpose • the conclusions • the significance • Speaking it aloud clarifies the thought

12. Write Like We Talk? • In the elevator, Jane asks William about his recent study on medical curriculum. ”What did you find in your study?” “Basically, we found that medical teachers of undergraduates tend not to let students look after the difficult patients.” • Later that evening, William sits down at his computer and writes: “The study confirmed the hypothesis that clinical instructors of undergraduate medical students would choose instructional techniques limiting active student involvement in patient care activities when faced with problematical situations.”

13. Clear Writing Essentials PRECISION CLEAR WRITING LOGIC BREVITY DIRECTNESS

14. Poor Medical Writing • Poor Grammar/Punctuation • Superfluous words, phrases • Misused words, phrases • Repetition • Unnecessary Complexity • Overuse of passive voice • Unnecessary Qualification • Poor flow of ideas

15. Omit Needless Words, Phrases • Vigorous writing is concise. • A sentence should contain no unnecessary words, a paragraph no unnecessary sentences for the same reason that a drawing should have no unnecessary lines and a machine no unnecessary parts. • This requires not that the writer make all his sentences short or that he avoid all detail and treat his subjects only in outline, but that every word tell.

16. Needless Modifiers • Audible to the ear • Tetrahedral in shape • Small in size • Red in color • In close proximity • Final outcome • Important essentials • Adequate enough • Advance planning • Fewer in number • Add together • Equally as well as • Starts out • Cools off • Surrounded on all sizes • Consensus of opinion • Entirely complete • Add together • Absolutely essential • Skin rash • Soft in consistency • Still continues • Estimated at about

17. Superfluous Phrases • It is clear that… • clearly • In the event that... • If • At the present time • now, currently • Due to the fact that • since • Subsequent [prior] to • After (before) • Due to circumstances that • because or since • In a careful manner • Carefully • Have an effect (impact) on • Affect (not impact)

18. Needless Phrases • It is interesting to note… • It should be pointed out… • It is obvious that… • Of course… or It is clear that... • Needless to say… • Call your attention to the fact… • This is a subject that… • In the event that • In the nature of • The point I am trying to make.. • It may be argued that… • In a very real sense • For the most part • In the case of • In regards to…

19. Needless Phrases • It is interesting to note… • It should be pointed out… • It is obvious that… • Of course… or It is clear that... • Needless to say… • Call your attention to the fact… • This is a subject that… • In the event that • In the nature of • The point I am trying to make.. • It may be argued that… • In a very real sense • For the most part • In the case of • In regards to… O M I T

20. Wordy Phrases • in view of the foregoing circumstances therefore • are found to be in agreement agree • has the ability to can • has the capability of can • (with) the passage of time (with) time • at this point in time now • due to the fact that because • examined in comparison to compared to • for the purpose of for • by means of by • a small number of few • a large number of many

21. Word Usage

22. Word Usage • Fewer vs less • Fewer used for number: Fewer interventions may mean less care…We evaluated fewer than 100 studies… • Lessused for mass or volume indicating degree or value Less than 50 mg of drug was used…

23. Word Usage • Case/patient/subject/control (subject) • In research, case is a particular instance of a disease, patient is a person under medical care, subject is a person with a characteristic or disorder under study (but not treated), control subject is a person not sharing the same characteristics as subjects under study. A case of diabetes… We report 14 cases of diabetes in patients.. In this study, we report on 14 diabetic patients Subjects (patients) were treated with… But… It is too early to judge if this is the case or not… It is too early to judge if this is so...

24. Misused Words, Phrases • Do not use impact as a verb in place of to affect The temperature impacts the growth rate of the bacterial sample.. The temperature affects the growth rate of the bacterial sample • Do not use impact as a noun in place of effect The release of hydrocarbons has had a significant impact on the depth of the ozone layer... The release of hydrocarbons has had a significant effect on the depth of the ozone layer.

25. Misused Words, Phrases • Because, sinceBecause preferred—since implies from the time of (since yesterday) • As Avoid because it means while • Continualrepeatedly • Continuouswithout interruption For two weeks, the sperm whales continually dived to great depths in search of food. The spectrum of refracted light is continuous.

26. Misused Words, Phrases • Abnormal/NormalNot used for patients or tests per se • Negative/PositiveApply to results, findings The physical exam was normal The findings from the exam were normal (or positive, negative) The throat culture was negative The throat culture was negative for beta-hemolytic streptococci The electroencephalogram ( or any other test) was positive The electroencephalogram (test) showed abnormalities in… the temporal lobe

27. Misused Words, Phrases • Compare to vs. Compare with • Compare to— to point out similarities between different things • Compare with— (used more often in science)— to point out differences between similar things Children with fragile X syndrome are often compared to those with autism because of similarities in behaviors… Brain tumors are relatively rare compared with more common cancers, such as lung, breast, prostate, and colorectal.

28. Misused Words, Phrases • Prevalence vs. Incidence • Incidence is a rate = number of NEW cases of a disease occurring in a population within a specified period of time, normally 1 year. • Prevalence refers to the current number of people suffering from an illness in a given year. This includes all those who may have been diagnosed in prior years, and newly diagnosed. • The incidence of a cancer is 20,000 per year with a prevalence of 80,000means 20,000 new cases of cancer are diagnosed every year and there are 80,000 people with this illness, 60,000 of whom were diagnosed in previous years and are still living with the disease.

29. Misused Words, Phrases • Rational — adjective, meaning sane or logical • Rationale — noun, meaning justification • The patient appeared to be a rational human being. • Their rationale for the subject selection was based on age of disease onset.

30. Misused Words, Phrases • Parameter, Variable • Parameter is a mathematical term meaning “measurable (numeric) characteristic of a population” • The mean and the standard deviation were the parameters of the distribution…half-life of drug A is a pharmacokinetic parameter… • Parameter does not mean variable or measurement —or limit, boundary, or condition. Cigarette and alcohol use were the two parameters measured ... It is important that the patient be informed about the parameters of treatment... …all are without meaning—use variable or measureor better, don’t label them.

31. Misused Words, Phrases • Age, Aged Aged not age designates a person’s age. Give precise age when possible The patient, aged 70 years, had symptoms of dementia [The 70-year-old patient had…]Note compound adjective The program was designed for children aged 5 through 8 years. The teenaged patients with tinnitus... (or better) The patients with tinnitus, aged 14, 16, and 17 years… • It is redundant to add of age after the years, since it is implied in the adjectives younger and older The patient group comprised women younger than 25 years [of age].

32. Misused Words, Phrases • Assure, Ensure, Insure • Assuremeans to provide positive information to a person and implies removal of doubt (British: insure)—set set the mind at rest The technician assured the subjects that their results would be confidential • Ensuremeans to make sure or certain The technician ensured that the patient’s test was positive • Insuremeans making precautions beforehand; cover with insurance; guarantee persons against risk People should insure their possessions...

33. Misused Words, Phrases • Respectively and former/latter • Both force the reader to stop and backtrack • “The mean values for men and women were 50.9 and 48.4, respectively” • “The mean value for men was 50.9 and for women was 48.4.” • “Men and women were given drug based on body weight; the former required adjustments based on age, and the latter …” • “Men and women were given drug based on body weight. Men required adjustments based on their age, but women…” • And/or • Avoid • Your meaning is usually conveyed by “or” alone. • If necessary add “or both” at the end of a phrase • “Subarachnoid hemorrhage can cause headaches or stiff back, or both.”

34. The Sentence

35. The Sentence • Subjects and Verbs • Clarify subject • Vigorous verbs • Improve subject-verb relationship • Parallelism • Placement of Information in Sentence • Brevity and Conciseness

36. Write with Clear Subjects, Strong Verbs • The physiciannoticedthe smell of acetone on his breath… SVO • The smell of acetone on the patient’s breath was something the physician noticed… (Passive) • Make the topic your subject and choose a strong actionverb: • Researchersmeasured the atomic mass of the element … • Patient heart ratesincreased during the procedure.

37. Subject-Verb Must Agree • A review of all patients with grade 3 tumors was undertaken… • The patient, together with her physician and family, makes the surgery decisions.

38. Subjects as Adjectives (Stacked Modifiers) • A series of fixed duration sequential constant rate infusions… (which adjective is qualifying which noun?) • -Fixed-duration sequential constant-rate infusions • -Sequential infusions of constant rate and fixed duration… • …mouse marrow-derived macrophage colony-stimulating factor (M-CSF) dependent monocytes • Monocytes, derived from mouse marrow, whose growth was dependent on macrophage-stimulating factor (M-CSF). • Another aspect of spinal fluid biochemical profile complexity. • Another aspect of the biochemical complexity of spinal fluid.

39. Passive or Active? • Active • “We studied the behavior of children…” • Passive • “The behavior of children was studied…”

40. Passive Voice Breeds Weak Constructions • In the present study, it was decided to.. • Measurements were taken… It was necessary to … • In this study, we decided … We measured … We had to… • In the present study, an increase in sugar consumption was observed both in female and male children 1-2 hours after drug A was taken. However, there was no significant sugar consumption increase 3 hours after taking drug A. (39 words) • [We observed that] girls and boys ate more sugar 1 to 2 hours after taking drug A; within 3 hours, sugar intake decreased (23 words)

41. Passive Voice • Too much passive voice • is monotonous • shows a lack of conviction • requires more words • extends reading time • may be ambiguous A new process for determining white matter tract direction from DTI imaging was studied. The MRI derivation from DTI was determined. An algorhythm to determine tract direction and density is proposed.

42. Active Voice Breeds Strong Constructions • The feedthrough was composedof a sapphire optical filter, which was pressed against the pyrotechnic that was used for the confinement of the charge. • The feedthrough contained a sapphire optical filter, which pressed against the pyrotechnic and confined the charge.

43. Active vs. Passive in Manuscript • Active is shorter, clearer, more emphatic • Abstract • Introduction • Discussion • Passive is appropriate for • Methods • Results

44. Present/Past Tense in Manuscript • Present Tense • Describing established knowledge or previously published results—“Lesions of internal capsule cause…” • For presentation—“Figure 1 shows that…” • Past Tense • When describing methods and results in current paper— “we used” • For attribution—“Smith reported that…” • Avoid Present (Past) Perfect Tense • “Smith has (had) reported that”

45. Choose Strong Verbs • Strong Verbs: • Prepare, study, think, teach • Not weak verbs: • Am, was, been ,were, is • The reason we understood that one-man rule is undesirable was our experience with the hospital expansion system. • The hospital expansion project taught us that one-man rule is undesirable.

46. Strong vs. Weak Verbs • STRONG verb (active) • Arranged • Decided • Developed • Measured • WEAK verb phrases • Made the arrangement for • Made the decision • Performed the development of • Made the measurement of The human immune system is responsible not only for the identification of foreign molecules, but also for the actions leading to their immobilization, neutralization, and destruction. The inhibition of the reaction was carried outby… An increase in heart rate occurred The human immune system not only identifies foreign molecules, but also immobilizes, neutralizes, and destroys those molecules. The reaction wasinhibitedby…. Heart rateincreased

47. More…Nouns From Verbs • The development of memory systems has been of interest... • How memory develops has been of interest… • Our results indicate that the interpretation of this data should be taken with caution. • Our results indicate that data should be interpreted cautiously. • In this patient, the infusion of glucose followed a timed course of every 2 hours • In this patient, glucose was infused every 2 hours.

48. How To Spot Bad Sentences • Avoid “There were”…. “there existed”…. “were present” “There were 10 patients with temporal lobe seizures.” “Temporal lobe seizures existed in 10 patients.” “Temporal lobe seizures were present in 10 patients.” “Ten patients reported temporal lobe seizures.”

49. Passive Writing Not Forceful • A new process for eliminating nitrogen oxides from diesel exhaust engines ispresented. Flow tube experiments to test this process are discussed. A chemical reaction scheme to account for this process is proposed. • In this paper, we present a new process for eliminating nitrogen oxide from the exhaust of diesel engines. To test this process, we studied this process in flow tubes. To explain the process, we developed (proposed) a scheme of chemical reactions.

50. Passive Sometimes OK • When the actor is unknown, unimportant, or receiver of action should be emphasized, use passive. • The 45-year-old man had been shot in the abdomen and was brought to the emergency department. • Proponents of this theory are not believed… • Readers of this work have little esteem for proponents of this theory… • Sometimes the passive is more natural. Particularly, in Methods section, use passive. • The value of “x” was found to be… • Subjects were scanned using a novel fMRI method… • Patients were excluded from the study… • Measurements of optical refraction were summarized...