Let thy words be few

Inrernatronal

Journal

Elsevier Biomedical

of Cardiolog): Press

2 (1982) 127-132

Medical Writing Let thy words be few

“Loquacity and lying are cousins.” That German proverb, pregnant with meaning for inflated prose and its offspring, but frugal with words, merits reflection, gobbledygook, alienate the reader and compromise credibility in medical writing. Medicant, our term for medical gobbledygook, is characterized by verbosity, complexity, ambiguity, obscurity, and even incomprehensibility [ 11. Examples: Although no data are available from randomized studies with respect to the efficacy of medical or surgical therap_y, or both, to reduce the risk of sudden death or recurrent ischemic events in such patients, it seems important to develop methods that estimate not only the extent but also the functional importance of underlying coronary artery disease in patients who survive myocardial infarction [2]. In a word, no attempt is made to distinguish between what we observe in persons who are ill, on the one hand, and the general notions we form in respect of like illnesses in different persons, together with the ‘linguistic accessories’ made use of by us for purposes of communication concerning the same, on the other [3]. A bushel of words thrown aimlessly at an idea is less likely to hit its target than a few well-chosen words. “In one case out of a hundred,” wrote Edgar Allen Poe, “a point is excessively discussed because it is obscure; in the ninety-nine remaining it is obscure because excessively discussed.” Literary courtesy decrees that the author convey a useful message in language that does not exact undue mental effort from the reader. No writing is perfect. We have all sinned. But we can rid our manuscripts of considerable distention by applying a few simple principles of condensation. Superfluity Deleting trite, superfluous phrases like physical examination revealed, suffice it to say, for all intents and purposes, in the matter of and in respect to will facilitate the reader’s comprehension and invigorate your style without jeopardizing your meaning. Equally dispensable are such introductory encumbrances as it is interesting (important) to note that, it is obvious (clear, well known, readily seen) that, it should be remembered that [4]. Delaying tactics do not arouse suspense in medical writing as they do in fiction. Circumlocution is contagious. Physicians who read primarily scientific publica-

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tions are likely to mimic the wordy. cumbersome, desiccated phrases they find in conventional medical publications. In the mistaken belief that pomposity is more professional, they will write effectuate an alteration for change, found to be for was, give rise to for cause, in close proximity to for near, in the event that for if; in view of the fact that for since, and produce an inhibitory’effect on for inhibit. It is the opinion of the author is also difficult to justify when 1 think is more precise and straightforward. If the longer phrase appears within a discussion of the ideas of others, the reader must guess whether “the author” refers to the writer of the article being read or to the last-named author in the discussion. The most proficient medical authors do not imitate the writing of their peers or predecessors but seek a more natural, pleasing, and individual style. Redundancies Our language is inherently redundant, and we are being extravagant when we impose further redundancy on it. Repeating the same idea in different words is condescending to your reader: abdominal ascites, diagnostic x-rays, employ the use of, exact@ the same, friction rub, glandular adenopathy, green in color, human volunteer, obviate the necessity of past history, psychogenic origin, still remains, successful resuscitation, symmetrical in shape, systolic contraction, traumatic injury, and tumor mass. Excess verbal baggage buries your message, and few readers today will take the trouble to excavate the meaning when the burial is deep. Deliberate repetition for emphasis is a different matter. Winston Churchill used repetition masterfully: “ . . we shall fight on the beaches, we shall fight on the landing grounds, w’eshall fight in the fields and in the streets, we shall fight in the hills . . . .” (italics ours). Latin The scientific vocabulary is heavily Latinate, the long, obscure terms giving medical writing a dreary, ponderous effect. The preponderance of Latin derivatives distends and obscures the content: per OS means oral!\‘; ad libitum, jree!,,; and in extremis, dying. The prolific et al. is better replaced by the more precise and co-authors, and et cetera, which contributes nothing to meaning. should simply be abandoned. Since students are rarely taught Latin today, the need for the English terms is more compelling. Platitudes Knowing that novices “warm up” for writing by recording platitudes, trivia. and inanities, an English teacher routinely asked his students, when he collected their compositions, “Did you remember to throw away the first page?” Too bad authors and editors do not discard the vapid introductory statements in some medical articles: The anti-platelet properties of aspirin are well known [5]. A large hods of literature describes the complications of cerebral angiography [6]. Controlling pain associated with incurable malignant disease is an all too common problem faced by

129

physicians

[7]. Such generalities

belabor the obvious and should be purged in an early manuscript. In abstracts, statements like The implications of these findings are discussed are similarly gratuitous. draft

of your

Sentence structure A useful abridging 35-year-old farmer.

device is the combination

of sentences.

While riding his tractor, he experienced

For The patient was a

sudden, severe pain in his

chest, write While riding his tractor, a 3%year-old farmer felt sudden, severe pain in his chest.

Word-lovers use words sparingly, choosing them artfully and arranging them dextrously to make the most of each. By self-discipline and the application of proved literary technics, professional writers pack abundant substance into a few crisp words. One well-known astringent is the series. This sentence uses a series to combine three separate statements: On the day after operation, the patient’s temperature rose abruptly, dropped gradually after medication,

and by the fifth day reverted

to

normal. Deadly passive

Blanket condemnation of the passive voice is misguided, since the passive is not only appropriate but preferable when the agent of the action is irrelevant or unknown. Aside from being tedious, a series of sentences beginning with “I” and detailing the sequence of events under “Method’ places undue prominence on the agent rather than the technic. When, however, the agent is named in the sentence, the active voice is more direct and more vigorous. Weak and incontinent: Breaking [grammatical] rules . . . is now employed in medicine by the educated writer to confuse his equally educated reader [8]. Recast in the active: The educated medical writer breaks [grammatical] rules . . . to confuse his equally educated reader. (Improving the syntax does not, of course, remedy the inaccuracy of the statement.) Be wary of abstract nouns (recurrence, closure, resection, improvement, radiation) as subjects; they are usually accompanied by weak verbs (accomplished, encountered, performed, observed) in the passive voice and by prepositional phrases that needlessly elongate the sentence. The lifeless Dissection of the aneurysm was carried out carefully by the surgeon takes on vitality when recast as The surgeon dissected the aneurysm carefully because dissected evokes an image of action. Converting the abstract noun dissection to its corresponding verb dissect in no way sacrifices objectivity. Dummy

words

Medical writers are fond of the beginning of a sentence is one of its lexically inert words (aptly called ference, for example, between the

surrogate subjects there and it, but because the strongest positions, sacrificing that place to such dummy words) debilitates style. Note the difinvertebrate There was free drainage from the

130

incision and the trenchant The incision drained freely. Besides being more direct, the second sentence contains the concrete, active, graphic verb drained, in sharp contrast to the abstraction drainage. Not that you need’avoid there is at al1 costs, but if you can extract a verb from an abstract noun that follows such a construction, you will condense, tone up, and animate your prose. As you examine each sentence, identify the key words (nouns and verbs) that carry the meaning and provide the backbone. If you have written There were only four patients who remained alive for one year, you can save five words by deleting There were and who: Or+ four patients lived one year. Similarly It is possible that patients will mistake certain cardiac symptoms for indigestion can be reduced to: Patients may mistake certain cardiac symptoms for indigestion. Words like oh which, that, and parts of the verb to be may also lure the inexperienced writer into a circuitous course. Often, a word, strategically arranged, can replace a phrase and a phrase can replace a clause to express an idea more economically. Compression Brevity does not supersede clarity. Overcompression may not only be but may lead to ambiguity. Consider: On examination he was clubbed, cyanosed, and had bilateral basal crackles [9]. At first glance, that seems statement about brutality by a physician. Equally ambiguous: The patient bypassed last year.

awkward centrallv to be a had been

Multiple qualifiers Tandem qualifying nouns, common in medical writing. are lumpy and unappealing: intra-group recognition function, human blood Group B cell immune horse sera, Legionnaires’ antibody lung tissue test, the World War II head injury anterior horn cell disease patient, fasting and two-hour postprandial serum bile acid concentration determination screening test. Stacked nouns require the reader to extricate the meaning by supplying the appropriate prepositional phrases, which are not always evident. Does physician venereal disease education mean education by physicians about venereal disease, education of physicians about venereal disease, or education about venereal disease in physicians? Prepositions show grammatical relations among other words, and the ambiguity their omission creates is perhaps most notable in headlines. Telegraphese Conciseness does not mean not always the most desirable ear, negative lungs, neurogenic place in scholarly writing. The of the classics and of his own

a telegraphic or cryptic style. The fewest words are or eloquent. Shorthand like this t_ype injury, chronic bladder, and right heart are barbarisms that have no accomplished writer, on the basis of his wide reading literary experience, knows intuitively when to expand

131

his words and when to prune them. Deletion of all padding will permit the addition of words needed for clarity and literary grace. Nonuniversal abbreviations, although possibly convenient for the writer, are discourteous to the reader because they impede comprehension and invite misinterpretation. Does CV mean cardiovascular or costovertebral? Is MI myocardial infarction or mitral insufficiency? Does CDH refer to coronary disease of the heart. congenital disease of the heart, or congenital dislocation of the hip? Abbreviations like FLK (funny looking kid), in a hospital chart, and Ass, in a published title, “Science and the British Ass” [lo], are difficult to justify. Prose that is overly taut is unpleasant to read. Fog index

of expository prose. The “fog index”, recently promoted to test the readability may appeal to arithmomaniacs but does little to improve writing. Counting the number of syllables in words, words in sentences, and sentences in paragraphs for insertion in a spurious formula ignores the social and aesthetic components of language and imposes a mechanistic artifice on writing. Since the writings of many literary masters like Henry James and Victor Hugo would fail the “fog index”, we are fortunate that the editors of these and other eminent authors did not judge manuscripts by such an artificial device. The principles discussed here are general guidelines for those who want simple ways to relieve verbosity. Writing is not a precise science to which hard and fast rules apply. As a writer matures, he will know when he needs to adhere to these principles and when he may safely disregard them. Two precepts, however, are requisite: clear. orderly thinking and clear, orderly language. Your writing reflects your thinking, your attitudes, your character, and your personality. As Buffon noted, “The style is the man.” If your writing is swollen and dull, your reader will think you are a bore. If it is pretentious, he will consider you stodgy. If it is incoherent, he will question your logic. Loose, obscure writing is inevitably linked to loose, imprecise thinking. Cluttering your writing with the irrelevant and the superfluous suggests an inability to stay on a straight mental path. When you have not thought through your thesis clearly and completely, or when you have allowed your thinking to digress into peripherally related matters or to meander aimlessly, you risk having those mental lapses show in your writing. In the words of Richardson [ 1 I], “In science, words, names, and expressions invariably indicate thoughts, and, therefore, cannot play a neutral part. They either advance or obstruct. They are either foolish or wise: and as they are, so are the thoughts which they represent.” If you want vigor in your writing, put it on a diet; slim it down until it is lean and sinewy. Be a verbal gourmet, not a verbal glutton.

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References 1 DeBakey L, DeBakey S. Medicant. Forum on Medicine 1978; 1: 38-40. 42-43, 80-81, 83-86. 2 Gibson RS, Watson DD, Carabello BA, Holt ND, Be&r GA. Clinical implications of increased lung uptake of thallium-201 during exercise scintigraphy 2 weeks after myocardial infarction. Am J Cardiol 1982; 49: 1586-1593. 3 Crookshank FG. The importance of a theory of signs and a critique of language in the study of medicine. In: Ogden CK. Richards IA. The meaning of meaning. Supplement II. New York: Harcourt, Brace and Company, 1947: 337-355. 4 DeBakey L. English today: are we speaking in tongues? In: Ttmmons C, Gibney F. eds. Britannica book of English usage, Part I. Garden City, New York: Doubleday & Company. Inc. 1980: 9-20. 5 Merriman E. Bell W, Long DM. Surgical postoperative bleeding associated with aspirin ingestion. Report of two cases. J Neurosurg 1979; 50: 682-684. 6 Ramirez-Lassepas M, McClelland RR. Snyder BD. Marsh DG. Cervical myelopathy complicating cerebral angiography. Report of a case and review of the literature. Neurology 1977; 27: 834-837. 7 Roberts M, Vilinskas J. Control of pain associated with malignant disease by freezing: cryoleucotomy. Conn Med 1973; 37: 184-186. 8 Crichton M. Medical obfuscation: structure and function. N Engl J Med 1975; 293: 1257-1259. 9 Du Bois RM, Branthwaite MA, Mikhail JR, Batten JC. Primary pneumocystics carinii and cytomegalovirus infections. Lancet 1981: 2: 1339. 10 Dixon B. Science and the British Ass. New Scientist 1977: 75: 514. 11 Richardson BW. The vocation of the medical scholar, being the eighty-third anniversary oration delivered

before the Medical

Society of London.

Glasgow

Med J 1856; 4: 91.

Lois DeBakey * Selma DeBakey

Buylor College of Medium 1200 Moursund Aoe Housron. TX 77030, U.S.A.

* Member

Editorial

Board, inrernorronal

Journal of Cardiology.