Grammar Points on

Medical Writing

Dr Steve Wallace

Introduction and outline of speech

- Active and passive voice in medical writing

- “Hedging” in medical writing - Dangling modifiers - Misplaced modifiers - Latin and Greek plurals - Other Grammar points

Active and passive

voice

What Is Active Voice?

The active voice emphasizes the performer of the action:

Wind disperses plant seeds.

Smith et al. investigated the relationship.

We have analyzed the results.

The active voice is direct (performer–verb–receiver), clear, and concise.

What Is Passive Voice?

The passive voice, emphasizes the receiver of the action:

Plant seeds are dispersed [by wind].

The relationship was investigated [by Smith et al].

The results have been analyzed [by us].

The passive voice is indirect and can be weak, awkward, and wordy.

Tradition and the Passive Voice

More than a century ago, scientists wrote in the first-person pronouns I and we.

Example: Charles Darwin

“I have called this principle by the term of Natural Selection, in order to mark its relation to man's power of selection.”

Beginning in the 1920s scientists adopted a passive writing style.

The passive voice was thought to be objective, impersonal, and well suited to science writing.

Exception

“We wish to suggest a structure for the salt of deoxyribose nucleic acid (D.N.A.).”

Watson and Crick's classic article is simple, direct, and clear.

“In this paper, a structure is suggested for the salt of deoxyribose nucleic acid (D.N.A.).”

Emphasize the Active Voice

Currently, most medical and scientific style manuals prefer active voice

Some journals ask authors to limit first-person pronouns or restrict them to certain sections.

Other journals prefer authors to use first-person pronouns over passive voice.

AMA Manual of Style

recommends that:

“In general, authors should use the

active voice, except in instances in which the author is unknown or the interest focuses on what is acted upon.“

AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007.

The Journal of Trauma and

Dissociation:

"Use the active voice whenever possible: We will ask authors that rely heavily on use of the passive voice to re-write manuscripts in the active voice.“

Guidelines for authors. International Society for the Study of Trauma Web site: The Journal of Trauma & Dissociation. http://www.isst-d.org/jtd/journal-trauma-dissociation-info-for-authors.htm. Accessed March 5, 2009.

Ophthalmology

"Active voice is much preferred to passive voice, which should be used sparingly....Passive voice...does notrelieve the author of direct responsibility for observations, opinions, or conclusions (e.g., 'The problem of blood flow was investigated...' vs. 'We investigated the problem of blood flow...').“

Guide for authors. Elsevier Web site: Ophthalmology: Journal of the American Academy of Ophthalmology.http://www.elsevier.com/wps/find/journaldescription.cws_home/620418/authorinstructions. Accessed March 5, 2009.

The Journal of Neuroscience

"Overuse of the passive voice is a common problem in writing. Although the passive has its place—for example, in the Methods section—in many instances it

makes the manuscript dull by failing to identify the author's role in the research....Use direct, active-voice sentences.“

Westbrook G, Cooper L. Writing tips: Techniques for clear scientific writing and editing. The Society for Neuroscience Web site:The Journal of Neuroscience. http://www.jneurosci.org. Accessed March 5, 2009.

British Medical Journal

"Please write in a clear, direct, and active style....Write in the active [voice] and use the first person where necessary.“

The essentials of BMJ style. BMJ Publishing Group Web site: British Medical Journal.http://resources.bmj.com/bmj/authors/bmj-house-style. Accessed March 5, 2009.

The Publication Manual of the American Psychological

Association (APA) has similar advice:

"Prefer the active voice....The passive voice is acceptable in expository writing and when you want to focus on the object or recipient of the action rather than on the actor.“

American Psychological Association. (2001). Publication Manual of the American Psychological Association (5th ed.). Washington, DC: Author.

Behavioral Ecology

“Active voice is preferable to

the impersonal passive voice.“Instructions to authors. Oxford Journals Web site: Behavioral Ecology.http://www.oxfordjournals.org/our_journals/beheco/for_authors/general.html. Accessed March 5, 2009.

Science

"Use active voice when suitable, particularly when necessary for correct syntax (e.g., 'To address this possibility, we constructed a lZap library ...,' not 'To address this possibility, a lZap library was constructed...').“

http://www.sciencemag.org/about/authors/prep/res/style.dtl. Accessed March 4, 2009.

Nature

"Nature journals like authors to write in the active voice as experience has shown that readers find concepts and results to be conveyed more clearly if written directly.“

How to write a paper: writing for a Nature journal. Nature Publishing Group Web site: Nature. http://www.nature.com/authors/author_services/how_write.html.

Accessed March 4, 2009.

When should an author choose the passive voice?

1. If the performer is unknown,

unimportant, or obvious

“Up to 90% of the energy in light bulbs is wasted in the form of heat.”

“The first edition of Freud's earliest writings on dreams was published in 1899.”

“Drosophila melanogaster has been one of the most extensively studied species in genetics research.”

2. If the performer is less

important than the action“The honey bees were kept in a humidified chamber at room temperature overnight.”

“The solution was heated to 90°C for approximately 30 minutes and then allowed to cool.”

If active:

“We kept the honey bees in a humidified chamber at room temperature overnight.”

“We heated the solution to 90°C for approximately 30 minutes and then allowed it to cool.”

3. Put important information at

the beginning of the sentence

Green plants produce carbohydrates in the presence of light and chlorophyll.

If, "carbohydrates" (the receiver of the action) is the opening topic, passive is better:

Carbohydrates are produced by green plants in the presence of light and chlorophyll.

Watson and Crick (1953)

“We wish to suggest a structure for the salt of deoxyribose nucleic acid (D.N.A.). This structure has novel features which are of considerable biological interest. A structure for nucleic acid has already been proposed by Pauling and Corey.”

The authors used the active voice in the first and second sentences, but the passive in the third. If the third sentence is changed to active voice, it becomes:

Pauling and Corey have already proposed a structure for nucleic acid.

Summary on Passive Voice

Choose the active voice whenever possible.

Choose the passive voice when: 1) The performer is unknown, irrelevant,

or obvious. 2) The performer is less important than

the action. 3) The recipient is the main topic. You can also use the passive voice to

hedge (i.e., to be noncommittal). Not recommended

Hedging in

Scientific Writing

"Hedging" in Scientific Writing

Report the limits of their findings

Protect themselves from the risk of error

Show humility

Cautious language is important, but not use too much

3 hedging techniques:

Qualifiers (modifiers)

Passive voice

Apologetic quotation marks

1. Word choice: Unnecessary

qualifiers Qualifiers modify or limit the meaning of other

words. Qualifiers are added to scientific writing to

express:

approximation probability doubt limit the scope of a statement

Examples of qualifiers

Adjectives: apparent, certain, consistent with, few, many, most, possible, presumed, probable, putative, several, some, supposed

Adverbs: about, apparently, arguably, fairly, in general, largely, likely, more or less, mostly, often, perhaps, possibly, presumably, probably, quite, rather, somewhat, unlikely, usually

Nouns: appearance, indication, inference, likelihood, possibility, probability, suggestion, tendency, to my knowledge

Verbs: aim, appear, assume, can, could, estimate, indicate, infer, intend, may, might, presume, propose, seem, seen as, should, speculate, suggest, suppose, tend

Unnecessary qualifiers (continued)

Qualifiers reduce a researcher's certainty about a method or observation

Double, triple, and quadruple synonyms are unnecessary

Example: may be possible seems to suggest rather likely to indicate may be seen as rather likely

How would you modify

this sentence?

“A possible cause is likely the apparent tendency of a certain number of patients with diabetes to develop indications of retinopathy.”

“A possible cause is the tendency of patients with diabetes to develop retinopathy.”

2. Point of view: Unnecessary

passive voice A noncommittal form of the passive voice occurs

when authors fail to name themselves (with the personal pronouns I, we)

Often begins with the word It Example: It was apparent... It has been noted... It was decided... It is known to be... Who reported the results? To whom was it

apparent? The reader is forced to guess who holds the view

Passive in the Methods Section

“It was concluded that sleep deprivation has three effects on cognitive performance.”

The passive voice protects the authors from the risk of uncertainty. However, who concluded?.

The reader may find it difficult to determine who did the action when authors use the passive voice to describe their own work other researcher’s work.

Unless you have good reason to write in the passive voice, use the active voice to identify the performer (e.g., We concluded that...).

3. Punctuation: Unnecessary

quotation marks Some authors add quotation marks to

emphasize expressions that are being used for irony or in a nonstandard sense:

“Many patent "medicines" in the 1800s contained little more than alcohol and water.”

Apologetic quotation marks tell the reader that an expression is not being used in the usual way.

The author hedges by adding quotation marks rather than trusting readers to draw their own conclusions or to recognize the irony or special use.

Many style guides consider them unnecessary.

Summary on Hedging

1) Eliminate unnecessary qualifiers 2) Use the active voice when

necessary 3) Seldom apply apologetic quotation

marks

Dangling Modifiers

A dangling modifier is a word or phrase that modifies the wrong subject in a sentence. This occurs because the implied subject is missing.

Most are verbal phrases:Participles (verbs used as adjectives)Gerunds (verbs used as nouns)Infinitives (verbs used as nouns adjectives,

or adverbs)

Dangling Participles

(end in “ing” or “ed”) Example

Using the survey data, the effects of education on job satisfaction were examined.

(Who is using the data? Implied subject = we/researchers; grammatical subject = the effects)

CorrectionUsing the survey data, we examined the effects of education on job satisfaction.

Dangling Gerunds (end

in “ing”) Example

After preparing the samples, our focus was on collecting the data.

(Who did the preparing? Implied subject = we/ researchers; grammatical subject = our focus)

CorrectionAfter preparing the samples, we focused on collecting the data.

Dangling Infinitives

(include the word “to”) Example

To investigate the relationship, a series of experiments were designed.

(Who is going to investigate? Implied subject = we/researchers; grammatical subject = a series)

CorrectionWe designed a series of experiments to investigate the relationship.

Quick Tips: Dangling Modifiers

Watch for dangling modifiers at the beginning of sentences.

Ask who or what is doing the action and make sure the implied subject is doing it.

Write in the active voice whenever possible.

The passive voice "encourages" dangling modifiers to appear.

Misplaced Modifiers

Misplaced modifiers are an error in sentence structure involving the order of words

A misplaced modifier has been incorrectly placed in a sentence, describing the wrong word or phrase

Adjectives and adverbs are easily misplaced, producing unclear results

The word only modifies the word that

directly follows it. Example

Only eradication of this disease can be achieved through immunization. (Eradication, but no other outcome, can be achieved.)

Alternative 1Eradication of only this disease can be achieved through immunization. (Eradication of this disease, but not of any other, can be achieved.)

Alternative 2Eradication of this disease can only be achievedthrough immunization. (Eradication can be achieved, but no other action can occur.)

Alternative 3Eradication of this disease can be achieved only through immunization. (Eradication can be achieved through immunization but not by any other means.)

Quick Tips: Misplaced Modifiers

Place words and groups of words as close as possible to the words that they are describing.

Place words such as only, almost,and even just before the word that you want them to describe.

Pronoun Errors

The Ambiguous Antecedent

A pronoun (e.g., you, ours, she, this, whom, which, himself) takes the place of a noun. The noun, pronoun, or clause that a pronoun refers to, called an antecedent, usually appears earlier in the sentence.

A pronoun should refer to one specific antecedent.

An ambiguous pronoun antecedent occurs when a pronoun has two or more possible antecedents.

Example: Does the pronoun it refer to the first

study or to the second study?

“The second study was designed to enroll 2000 more participants than the first study. It tested three dose levels of the study drug.”

Correction 1The second study, which tested three dose levels of the study drug, was designed to enroll 2000 more participants than the first study.

Correction 2The second study, designed to enroll 2000 more participants than the first study, tested three dose levels of the study drug.

Example of an unclear

antecedent

Smith et al. compared their study results with those of previous researchers and presented them at the conference.

At the conference, Smith et al. presented their study results, which they had compared with those of previous researchers.

Quick Tips: The Ambiguous

Antecedent

Make sure that each pronoun refers to only one antecedent.

To correct:

remove the pronoun,

shorten the sentence, or rearrange sentence elements.

You may need to do all three.

The Missing Antecedent

A missing pronoun antecedent is when the author implies an antecedent but does not include it in the sentence.

The true antecedent, or reference, is missing.

How can we modify this

sentence?After reading the nursing professor's recent publication on patient care, the students contacted her to obtain more information.

Correction 1 After reading the recent publication on patient care by their nursing professor, the students contacted her to obtain more information.

Correction 2After reading the recent publication on patient care by Johnson, the students contacted her to obtain more information.

Correction 3The students contacted the nursing professor to obtain more information after reading her recent publication on patient care.

Quick Tips: The Missing

Antecedent

Look for missing antecedents when the implied antecedent of a pronoun is in possessive case (and thus an adjective).

To correct a missing antecedent

1) Replace antecedent adjectives with nouns or noun phrases; or

2) Replace pronouns with nouns or noun phrases.

The Vague Antecedent

Sometimes authors use the pronouns this,that, it, or which to refer to a noun or clause (called an antecedent) in the previous sentence.

If the reference is not obvious readers may not review the previous sentence to understand what the author is saying.

A vague pronoun antecedent occurs when a pronoun refers to one or more groups of words and the reference is not clear.

The Vague AntecedentExample 1Patients with a latent infection may need to be monitored for several months because they are at risk of developing the active form of the disease. This diminishes over time.

orExample 2

Patients with a latent infection may need to be monitored for several months because they are at risk of developing the active form of the disease, which diminishes over time.

The Vague Antecedent

Correction 1Patients with a latent infection may need to be monitored for several months because they are at risk of developing the active form of the disease. This risk diminishes over time.

Correction 1Patients with a latent infection may need to be monitored for several months because they are at risk of developing the active form of the disease. The need to monitor these patients diminishes over time.

Correction 1Patients with a latent infection may need to be monitored for several months because they are at risk of developing the active form of the disease. As the risk diminishes over time, so too does the need to monitor these patients.

Quick Tips: The Vague

Antecedent

Be careful with the pronouns this, that, it, and which.

Correct vague pronoun antecedents by:

changing the pronoun into anadjective,

replacing the pronoun with a noun or noun phrase, or

revising the sentence more extensively.

Other Grammar Errors

Latin and Greek Plurals

Common in scientific and medical writing.

The preferred plural form of many of these words is the same as in the original language. But for other plurals, the usual English rules of adding "s" or "es" now apply.

The acceptability of an English plural form may differ by journal

Caution: Read the dictionary entry carefully. Sometimes the English plural is used for only a narrow definition of the term.

Common traditional endings for Latin or

Greek singular nouns and their

corresponding plural endings Singular ending Plural ending -a → -ae -en→ -ina -ex→ -ices -is → -es -itis→ -itides -ix → -ices -on→ -a -um→ -a -us→ -i

Singular and Plural Nouns Derived From

Latin and Greek

Singular form Plural form

alga algae or algas analysis analyses bacterium bacteria basis bases criterion criteria or criterions datum data focus foci or focuses foramen foramina or foramens formula formulae or formulas fungus fungi or funguses genus genera hypothesis hypotheses index indices (math) or indexes

Singular and Plural Nouns Derived From

Latin and Greek (continued)

Singular form Plural form

larva larvae or larvas

matrix matrices or matrixes

medium media

nephritis nephritides

nucleus nuclei or nucleuses

parenthesis parentheses

phenomenon phenomena

radius radii or radiuses

stimulus stimuli

stratum strata

synthesis syntheses

vertebra vertebrae or vertebrasa

Do not insert a comma before but also in a

sentence with not only...but also

Correlative conjunctions are pairs (not only...but also, either...or,

neither...nor, and both...and). These conjunctive pairs are used when

there is a continuous flow of ideas. A comma signifies a pause in the line

of thinking so no comma should be used to separate the elements joined by correlative conjunctions.

Do not insert a comma before but also.

How would you change

this sentence? We observed that poor drug

efficiency was due to not only lack of absorption, but also increased clearance.

We observed that poor drug efficiency was due to not only lack of absorption but also increased clearance.

How would you change

this sentence? Radiotherapy is valuable not only in

reducing the number of courses of chemotherapy, but also in producing superior overall survival.

Radiotherapy is valuable not only in reducing the number of courses of chemotherapy but also in producing superior overall survival.

Avoid double negatives

Double negatives are used in English to make a very positive statement, but this is not appropriate for a scientific paper.

In Chinese a double negative can actually strengthen the negativeness of a statement, which does not translate into English.

How would you change

this sentence?

"No background staining was not seen..."

"No background staining was seen..."

Do not use the same or similar

word/phrase in quick succession in two

consecutive sentences

The baseline characteristics are shown in Table 1. Table 2 shows the body temperature of all female subjects.

The baseline characteristics are shown in Table 1, and the body temperature of all female subjects are shown in Table 2.

Table 1 and Table 2 show the baseline characteristics and body temperature of all female subjects, respectively.

How would you change

these sentences? Percutaneous RF ablation of the lung

tumors was approved by our institutional review board. The institutional review board also approved tumor biopsy and specimen analysis with the novel approach.

Our institutional review board approved percutaneous RF ablation of the lung tumors as well as tumor biopsy and specimen analysis with the novel approach.

Asian Fonts

Asian fonts such as MS Mincho and SimSum possess characters with different widths from those of Latin fonts

Do not use Asian fonts in your manuscripts

Frequently encountered problems include those caused by Asian-font brackets, plus and minus signs and other mathematical symbols, and units of temperature

“temperature was increased （1 ° C/min”)

Use the present tense

for in-text reference to

figures and tables

The vital signs upon presentation were summarized in Table 1.

The vital signs upon presentation are summarized in Table 1.

How would you change

this sentence?

Figure 1 showed the relationship between age and incidence of dementia.

Figure 1 shows the relationship between age and incidence of dementia.

Do not use a period at the end of

the title of a manuscript

Title and subtitles are not full sentences and do not need a period at the end.

Do not insert a period after the title

How would you change

this title?

Prespondylosis and some Pain Syndromes following Denervation Supersensitivity.

Prespondylosis and some Pain Syndromes following Denervation Supersensitivity

How would you change

this title?

Acupuncture and the Peripheral Nervous System: A Radiculopathy Model.

Acupuncture and the Peripheral Nervous System: A Radiculopathy Model

Do not use a comma after a salutation in

a formal letter written in the American

style

In American English, the salutation ends in a colon in a formal letter and ends in a comma in an informal letter.

In the British style of writing, a salutation is followed by a comma in both formal and informal letters.

How would you change

this salutation?

Dear Editor,

Dear Editor:

How would you change

this salutation?

Dear Dr. Thomson,

Dear Dr. Thomson:

Sources

Zeiger M. Essentials of Writing Biomedical Research Papers. 2nd ed. New York, NY: McGraw-Hill; 2000.

Gopen GD, Swan JA. The science of scientific writing. Am Scientist.1990;78:550-558.

Watson JD, Crick FHC. Molecular structure of nucleic acids. Nature.1953;171:737-738.

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.

American Psychological Association. (2009). Publication Manual of the American Psychological Association (6th ed.). Washington, DC: Author.

Instructions to authors. Oxford Journals Web site: Behavioral Ecology.http://www.oxfordjournals.org/our_journals/beheco/for_authors/general.html. Accessed March 5, 2009. Accessed March 4, 2009.

Sources (continued)

The essentials of BMJ style. BMJ Publishing Group Web site: British Medical Journal.http://resources.bmj.com/bmj/authors/bmj-house-style. Accessed March 5, 2009.

Westbrook G, Cooper L. Writing tips: Techniques for clear scientific writing and editing. The Society for Neuroscience Web site:The Journal of Neuroscience. http://www.jneurosci.org. Accessed March 5, 2009.

Guidelines for authors. International Society for the Study of Trauma Web site: The Journal of Trauma & Dissociation. http://www.isst-d.org/jtd/journal-trauma-dissociation-info-for-authors.htm. Accessed March 5, 2009.

How to write a paper: writing for a Nature journal. Nature Publishing Group Web site: Nature. http://www.nature.com/authors/author_services/how_write.html. Accessed March 4, 2009.

Guide for authors. Elsevier Web site: Ophthalmology: Journal of the American Academy of Ophthalmology.http://www.elsevier.com/wps/find/journaldescription.cws_home/620418/authorinstructions. Accessed March 5, 2009.

Some notes on Science style. American Association for the Advancement of Science Web site: Science. http://www.sciencemag.org/about/authors/prep/res/style.dtl

Sources (continued)

Merriam-Webster's Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster, Inc.; 2007.

Sternberg RJ. The Psychologist's Companion: A Guide to Scientific Writing for Students and Researchers. 4th ed. New York, NY: Cambridge University Press; 2005.

Matthews JR, Bowen JM, Matthews RW. Successful Scientific Writing: A Step-by-Step Guide for the Biological and Medical Sciences. 2nd ed. Cambridge, England: Cambridge University Press; 2000.

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.

American Psychological Association. Publication Manual of the American Psychological Association. 6th ed. Washington, DC: American Psychological Association; 2009.

The Chicago Manual of Style. 15th ed. Chicago, IL: The University of Chicago Press; 2003.

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