reading

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers.

First published in 2002
by BMJ Books, BMA House, Tavistock Square,
London WC1H 9JR

Introduction

True ease in writing comes from art, not chance, As those who move easiest have learnt to dance.

Everything is easy when you know how! The skill of scientific writing is no exception. To be a good writer, all you need to do is learn and then follow a few simple rules. However, it can be difficult to get a good grasp on the rules if your learning experience is a protracted process of trial and error. There is nothing more discouraging than handing a document that has taken hours to write to a coworker who takes a few minutes to cover it in red pen and expects you to find this a rewarding learning exercise.

Fortunately, there is a simple way into the more fulfilling experience of writing so that readers don’t feel the need to suggest corrections for every sentence in every paragraph. Once you can write what you mean, put your content in the correct order, and make your document clear and pleasurable for others to read, you can consider yourself an expert writer. By developing good writing skills, you will receive more rewarding contributions from your coauthors and reviewers and more respect from the academic community. If you can produce a document that is well written, the review process automatically becomes a fulfilling contribution of academic ideas and thoughts rather than a desperate rescue attempt for bad grammar and disorganisation. This type of peer review is invaluable for improving the quality of your writing.

If your research is important for progressing scientific thinking or for improving health care, it deserves to be presented in the best possible way so that it will be published in a well-respected journal. This will ensure that your results reach a wide range of experts in your field. To use this process to promote your reputation, you will need to write clearly and concisely. Scientific writing is about using words correctly and finding a precise way to explain what you did, what you found, and why it matters. Your paper needs to be a clear recipe for your work:

In this book, we explain how to construct a framework for your scientific documents and for the paragraphs within so that your writing becomes orderly and structured. Throughout the book, we use the term “paper” to describe a document that is in the process of being written and the term “journal article” to describe a paper that has been published. At the end of some chapters, we have included lists of useful web sites and these are indicated by a reference in parenthesis (www¹) in the text.

We also explain how the review and editorial process functions and we outline some of the basic rules of grammar and sentence construction. Although there is sometimes a relaxed attitude to grammar, it is important to have a few basic rules under your belt if you want to become a respected writer. To improve your professional status, it is best to be on high moral ground and write in a grammatically correct way so that your peers respect your work. You should not live in the hope that readers and editors will happily sort through muddled thoughts, struggle through verbose text, or tolerate an uninformed approach. Neither should you live in the hope that the journal and copy editors will rescue your worst grammatical mistakes. No one can guarantee that such safety systems will be in place and, to maintain quality and integrity in the research process, we should not expect other people to provide a final rescue system for poor writing.

The good news is that learning to write in a clear and correct way is easy. By following the guidelines presented in this book, the reporting of research results becomes a simple, rewarding process for many professional and personal reasons. We have tried not to be pedantic about what is right and what is wrong in pure linguistic or grammatical rules but rather to explain the rules that work best when presenting the results of scientific studies. We hope that novice writers will find this book of help to start them on a meaningful path to publishing their research, and that seasoned scientists will find some new tips to help them refine their writing skills.

*The opening quote was produced with permission from Collins Concise Dictionary of Quotations, 3rd edn. London: Harper Collins, 1998: p 241.

We extend our thanks to the researchers who were noble enough to allow us to use their draft sentences in our examples. None of us writes perfectly to begin with or expects to see our first efforts displayed publicly. We are extremely grateful to the many people with whom we have worked and learnt from and we hope that they, in turn, receive satisfaction from helping others to become better writers.

Foreword

Editors need authors more than authors need editors. All authors and editors should remember this. Authors may be prone to despair and editors to arrogance, but authors are more important than editors. I was reminded of this eternal truth, which all editors forget, as I lectured yesterday in Calabar, Nigeria, on how to get published. I talked of the difficulty of writing and described the BMJ’s system for triaging the 6000 studies submitted to us a year. It’s nothing short of brutal. After the talk one of the audience asked: “What I want to know is what can you do for us?” Cheers went round the room.

All readers of this excellent book should remember their power over editors as they battle with the sometimes-difficult process of writing scientific papers. When the editor sends back a curt, incomprehensible, and unjustified rejection, you don’t need necessarily to submit. Wise and experienced authors often will, sending their papers elsewhere and consoling themselves with the thought that the loss is to the journal not them. But if you feel like appealing, do. Don’t explode into anger. Use the scalpel not the sword to refute the assertions of the editors and their reviewers. Perhaps they have said something sensible, in which case you might revise your paper accordingly. It’s really the same technique that you should apply when stopped by the police. The result may well be acceptance.

Charged with the knowledge of your importance, I urge you to write. It can be a pleasure. Novelists describe how their characters take on lives of their own, beginning to amaze and fascinate their creators. Something similar can happen with scientific papers. As you write you may think new – and sometimes exciting – thoughts. Certainly you will be forced to clarify your thoughts. If you can’t write it clearly then you probably haven’t thought it clearly. As you wrestle with the words new insights should occur. What you didn’t understand you will have to understand. I probably shouldn’t admit this, but I never quite know what I think until I write it down. The same goes for my speaking, which causes me much more trouble: what’s written can and should be edited, whereas what’s said cannot be withdrawn.

The broad messages I try to deliver when talking on how to get published are the same as those in this book. The first reason to write is because you have something important to say. Ideally you will want to describe a stunning piece of research. You will have a valid answer to an important scientific or clinical question that nobody has answered before. If you have such a treasure, then you would need to be a worse author than McGonigle was poet in order to fail to achieve publication. Only if you achieve the opacity of London smog will we fail to discern the importance of your research.

Once you have something to say you need a structure for your paper. This, I believe, is the most important part of writing. There is nothing more awful for readers to be lost in a sea of words, unsure where they came from, where they are, and where they are headed. They will stop reading and move on to something more interesting. “Remember” I tell authors, “you compete with Manchester United, Hollywood films, and the world’s greatest writers. A very few people may have to read your paper (perhaps you supervisor), but most won’t. You are part of ‘the attention economy’ and competing for peoples’ attention.”

There are many structures. At school you were probably taught to have “a beginning, a middle, and an end.” Unfortunately, this usually becomes what the poet Philip Larkin called “a beginning, a muddle, and an end.” You might try a sonnet, a limerick, or a haiku (in our 2001Christmas issue of the BMJ we published a haiku version of every scientific study), but both you and your readers probably want something easier. Another English poet, Rudyard Kipling, described the structure used by most reporters:

I keep six honest serving men
(They taught me all I know),
Their names are What and Why and When,
And How and Where and Who?

And these questions are the basis for the famous IMRaD (Introduction, Methods, Results, and Discussion) structure of scientific papers. The introduction says why you did the study, the methods describe what you did and the results what you found, and the discussion (the most difficult part of the paper by far) the implications of your findings.

The beauty of the IMRaD structure is not only that it is ready made for you but also that it is familiar to your readers. They won’t be lost. Even if it’s unconscious they know their way around a paper written in the IMRaD structure. Peter Medawar, a great scientist and writer, was scornful of the IMRaD structure, arguing correctly that it doesn’t reflect how science happens. The doing of science is much messier. If you can write as well as Medawar then you can safely ignore the IMRaD structure, but almost none of us can – which is why we should pay homage to and use the IMRaD structure.

Once you have your structure you must spin your words, and here, as every expert on style agrees, you should keep it as simple as possible. Use short words and short paragraphs, always prefer the simple to the complex, and stick to nouns and verbs (the bone and muscle of writing). “Good prose,” said George Orwell, “is like a window pane.” Mathew Arnold defined “the essence of style” as “having something to say and saying it as clearly as you can.” I suggest that you take a child rather than Henry James as your model. There is a place for highly wrought, beautiful writing, but it isn’t in a scientific paper – and most of us can’t do it anyway.

Most of us can’t write like James, Hemingway, or Proust, but all of us should, with help, be able to write a scientific paper. This excellent book provides that help.

Competing interest: Richard Smith is the chief executive of the BMJ Publishing Group, which is publishing this book. He is, however, paid a fixed salary and will not benefit financially even if this book sells as many copies as a Harry Potter book. He wasn’t even paid to write this introduction, illustrating Johnson’s maxim that “only a fool would write for any reason apart from money.”

Scientific writing

The objectives of this chapter are to understand:

the importance of publishing research results
how to organise your time to write a paper
the components of writing that make up a paper

Reasons to publish

Scientists communicate the fruits of their labour mostly in writing, and mostly in scientific journals. Conferences and other forms of verbal communication, including the evening news, play an important role but the written word reaches the widest audience and constitutes the archival message.

It is important to publish research results for many reasons. In the most basic sense, it is unethical to enrol participants in a research study with their understanding that you will answer an important research question and then fail to report the study results in a timely manner. It is also unethical to accept a grant from a funding body and then fail to publish the results of the research that you conducted using the funds. Failure to publish reflects badly on your reputation as a scientist and is likely to have a significant influence on your future career and your ability to attract further funding. On the other hand, success in publishing contributes to rewards such as job promotion and professional recognition.

A scientific article that is published in a well-respected, peer-reviewed journal is an important goal for any researcher and remains one of the ultimate markers of research success. For this reason, it is important to write your paper well so that it has clear messages, is readily accepted for publication, and is something that you can always be proud of.

A well-written paper is one that is easy to read, tells an interesting story, has the information under the correct headings, and is visually appealing. It is a sad fact of life that few researchers or clinicians read a journal article from beginning to end. Most readers want to scan your paper quickly and find the relevant information where they expect it to be. If you want the information in your paper to be read and to be used, you must be certain that you have presented it in an organised and accessible format.

In the current academic climate, publications are imperative for career advancement and for the economic survival of research departments. In many institutions, the number of successful publications is used as a measure of research productivity. In addition, other attributes of publications, such as the number of collaborators, the number of resulting citations, and the impact factor of the journal, are often considered. As such, publications are a fundamental marker of accountability. Box 1.1 summarises some of the important reasons for publishing your work.

Box 1.1 Reasons to publish your research results

It is unethical to conduct a study and not report the findings

You have some results that are worth reporting

You want to progress scientific thought or improve health outcomes

You want to give credibility to your research team

You want your work to reach a broad audience

Your track record will improve

You will add credibility to your reputation

You will improve your chance of promotion

You are more likely to obtain research grants

Motives to publish vary widely. Some researchers may have a driving force to contribute to advancements in scientific knowledge and improvements in patient care, or may simply love their work and want to share it with others. Other researchers may work in a unit that has a “publish or perish” imperative so that journal articles are essential for professional survival. Whatever your motive, you will need something important to say if you want your results to be published. A report of the sixtieth case of a rare condition is unlikely to be published even if it makes fascinating reading. Similarly, reports of uncontrolled clinical studies, inadequately evaluated interventions, or laboratory data that do not address the underlying mechanisms of a disease are unlikely to be published in a good journal. To improve your chances of being published, your study must have a rigorous design, your results must answer an important question, and your paper must be written well. A well-designed and well-reported study is always a good candidate for being accepted by a respected journal.

Rewards for being a good writer

Generally keep it short and to the point. It is not a novel you are writing. If you get stuck, take a break. Leave the draft by your bedside. Sometimes a phrase just comes to you and it is a shame to lose it.

Having good scientific writing skills can not only bring career success but also brings many other personal rewards as shown in Box 1.2. These rewards are often fundamental for job promotion in a world in which grant applications, published journal articles, and oral presentations are used as formal indicators of research performance. These indicators may also be critical at a departmental level where the number of successful grant applications, postgraduate students, and publications are used as formal markers of team productivity.

Box 1.2 Reasons to be a good writer

Writing time is more productive and less frustrating

Peers will take you more seriously

Your research is more likely to lead to publications

Your grant applications are more likely to be funded

Your expertise will help you to become a good reviewer or editor

A well-written paper is one that is very publishable, adds credibility to your reputation, and is much more likely to be read in its entirety and thus taken seriously by the scientific community. Bad science is not usually publishable (although it happens) but good science reported well is more highly respected than good science reported badly. Of course, mind-blowing discoveries will always be respected no matter how they are written. Few of us are lucky enough to have such discoveries to report but even exciting new findings are better appreciated if they are written elegantly. The famous phrase “It has not escaped our notice that …” from Watson and Crick when they reported their discovery of the double helix² is a prime example. The sentence that they wrote was It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material. This was a modest way to declare that they had discovered a structure for DNA that was both biologically feasible and would facilitate the replication of genetic material. The article was a model in concise writing in that it occupied only one page of Nature.

Most researchers will never be able to emulate the importance of the findings of Watson and Crick, although we may strive to emulate their concise writing style.

There is no doubt that good writing skills will bring you a more rewarding research career because fewer keyboard hours will need to be spent on each published paper. Long hours spent at the computer rearranging pages of print are not the best way to achieving a happy and healthy life. By reducing the time it takes from first draft to final product, good writing skills are a passport to both academic success and personal fulfilment.

In being a good writer, you will automatically become a good reviewer. By definition, reviewers are experts in their field who are asked to assess the scientific validity of submitted papers or grant applications. Being an experienced reviewer also leads to invitations to participate in advisory bodies that make decisions about the scientific merit of proposed studies, that judge posters or presentations at scientific meetings, or that have the responsibility of marking a postgraduate thesis. All of these positions are rewarding recognition that you have that certain talent that has an important currency in the scientific community.

Making it happen

“Do it every day for a while” my father kept saying. “Do it as you would do scales on the piano. Do it by pre-arrangement with yourself. Do it as a debt of honour. And make a commitment to finishing things.”

Scientific documents cannot happen unless they are given priority in life. To achieve this, it is important to develop good time management skills that enable you to distinguish between the urgent and the important issues in your working day.⁴ Before you begin writing, you need to get on top of the urgent and important tasks for the day. It’s a matter of addressing the crises, completing the deadlines, and getting the pressing matters off your desk and out of your mind. It is also a good idea to be aware of, and minimise, the urgent but unimportant matters such as unnecessary mail and meetings that tend to waste the day away. If you let the unimportant matters fill up your day, you will never find enough time to write.

Committed researchers need the skills to programme dedicated writing time into their working week. In an excellent book on time management, the focus on important tasks is described as spending time on “quadrant II activity”.⁴ An adaptation of the quadrants in which you can spend time is shown in Table 1.1. By definition, quadrant II activities are not urgent but they have to be acted upon because they are important to career success. By minimising the amount of time you spend on the urgent and important activities in quadrant I and by avoiding non-important activities in quadrants III and IV, you can spend more time on prime writing and thereby become more productive. It is prudent to remember that there is no such thing as having no time to write. We all have 24 hours each day and it is up to each of us to decide how we allocate this time.

If you are serious about wanting to publish your work, you need to schedule adequate time for the activity of writing in the “important but non-urgent” quadrant. There is good evidence that this works. By rising at 5am every morning and writing for several hours every day, Anthony Trollope completed more than fifty books and became one of England’s most renowned 19th century novelists. Although many of us would argue that Jane Austen or Thomas Hardy wrote much more interesting novels, no one can doubt that Trollope’s commitment to his writing and his time management skills led to greater productivity.

When you are researching, scheduling time for quadrant II activities ensures that you can give priority to designing the study, collecting the data, analysing the results, and writing the papers. Many researchers have no problem finding time to conduct the study but have difficulty in finding time for writing. The good news is that constructing a paper will be more rewarding if you develop good writing skills and you will come to enjoy using your “quadrant II” activity time more effectively.

Once your data analyses are underway and the aims of the paper are decided, you should begin writing in earnest. Ideally, you will have presented your results at departmental meetings, at local research meetings, or even at a national or international conference. This will have helped you to refine your ideas about how to interpret your data. You may also have a feel for the topics that need to be addressed in the discussion. With all this behind you and with good writing skills, putting the paper together should be a piece of cake.

Achieving creativity

You should allow yourself to get into a writing mood. Finish the background reading, the review of the literature, and the work to date. You know it inside out. Relax. Take deep breaths. Just let it flow. Many people find music a help but choose carefullly … Wear comfortable clothes; a sweater and jeans are fine.

To write effectively, you need to find a physical space where you can both work and think. This space is probably not going to be the same office from which you conduct consultations, direct staff, take phone calls and answer endless emails and voicemails in the course of everyday business. For most people, a clear, thinking space needs to be a place where interruptions are minimal and so, by necessity, will be away from your daily work environment.

Your thinking space needs to be a place where you can feel comfortable and relaxed, where you don’t have to power dress if you don’t want to, and where you can play thinking music if you find that helps you to write.¹ “Mufti” days were invented so that people could relax in the freedom of not having to wear their working uniform. If it helps, award yourself a mufti day and choose some appropriate music. For some people baroque or flute music is ideal, for others Mark Knoffler or Red Hot Chilli Peppers does the job perfectly. Italian opera is definitely too dramatic and blues or jazz may leave you focused on some of the sadder events in life. You need music that will relax but not distract you – the choice is entirely up to you.

To write effectively, you must also tune in to your creative day and your creative hour. For some people, Thursdays, Fridays, and Saturdays are best because most of the urgent processes of the week are over. Others may find the pending excitement of the weekend distracting and thus prefer to begin writing refreshed on a Monday. Some people who are morning writers can happily word process their ideas whilst ignoring everything around them that will wait until later in the day when their creativity has burnt out. Others may be afternoon writers who need to deal with the quadrant I matters first and work up to writing when the urgent list is clear. It doesn’t matter when or where you write, as long as you choose your best opportunities and organise yourself accordingly.

Whatever your creativity pattern, it is important to visit your writing as often as possible, every day if you can. Writing new text may take a significant amount of work but reading and reviewing written text to polish it up can often fit into short time blocks and can be done anywhere. When you have spare moments to edit your writing, you need to inspect your sentences and your paragraphs for needless words, silly flaws, and clumsy transitions. Writing is a process of constant repair but if you are passionate about your research this will not be arduous. It will be exciting to see your paper taking shape, becoming simple and clear, and acquiring impact. Refining your writing so that it takes on more form and character and becomes easy to read is well worthwhile. This is one of the hallmarks of scientific writing.

Thought, structure, and style

And whenever I see a first novel dedicated to a wife (or a husband), I smile and think “There’s someone who knows”. Writing is a lonely job. Having someone who believes in you makes a lot of difference. They don’t have to make speeches. Just believing is enough.

Scientific writing is a well-defined technique rather than a creative art. The three basic aspects to effective scientific writing are thought, structure, and style.

When you ask for feedback on the thoughts and structure of your paper, you are asking for a macro-review of the basic content. On the other hand, if you ask for feedback on the style you are asking for a micro-review of the words, grammar, and order. In a sense, there is little point in a reviewer providing feedback on the style until the thoughts and structure are in place. To gain the most from peer review, you should be clear about the type of feedback you would appreciate most and whether your paper is sufficiently advanced to ask for micro-feedback.

Constructing a well-organised paper is the first step to improving accessibility and readability. A nicely structured paper with no worthwhile results, or worthwhile results in a badly structured paper, are unlikely to be published. Moreover, papers that are written in a poor style in terms of expression and grammar are unlikely to appeal to editors, reviewers, or fellow scientists, and are also unlikely to be published in a good journal. In Chapters 2 and 3, we explain how to present your thoughts and academic ideas using the correct structure, and in Chapters 8–11 we give examples of how to write in a clear style. The web site resources that may be of help are listed at the end of each chapter and are referenced as (www¹) throughout. All website addresses were current when this book went to press.

The thrill of acceptance

Seeing your name in print is such an amazing concept: you get so much attention without having to actually show up somewhere… There are many obvious advantages to this. You don’t have to dress up, for instance, and you can’t hear them boo you straight away.

There are relatively few high points in research but most of us recognise one when we see one. Some high points that spring to mind are the acceptance of a paper by a journal, conducting a data analysis that confirms your hypothesis, and news that a grant application has been successful. Certainly, having a paper accepted is one of the most far-reaching successes. The corollary is that having a paper rejected is a depressing and crushing event that is worth trying to avoid.

After a paper has been sent to a journal, there is always a time of apprehension while you wait for a reply. This can take from weeks if you are lucky, to months if you are not. For some journals, electronic submission and electronic communication with external reviewers has expedited the review process. Whether electronic or manual, the first letter that returns from the journal generally confirms the arrival of your paper on the editorial desk. The next letter is much more fundamental in that it is likely to signal acceptance or rejection. This letter always brings a frisson of terror and expectation as you open it, and then either elation or devastation when you read it. It’s never any different. All papers are important to their authors and there is no middle ground between potential acceptance and outright rejection. If you ever have difficulty in writing, it may be encouraging to think of the thrill of the moment when your paper is accepted for publication. It is a heady moment, one of the true highs in research and an event that is worth striving towards.

Acknowledgements

King quotes have been reprinted with the permission of Scribner, a Division of Simon & Schuster, Inc., from On Writing: A Memoir of the Craft by Stephen King. Copyright © by Stephen King. The Johnson quote has been produced with permission from Collins Concise Dictionary of Quotations, 3rd edn. London: Harper Collins, 1998 (p 175). All other referenced quotes have been produced with permission.

Websites

References

2 Watson JD, Crick FHC. Molecular structure of nucleic acids. A structure for deoxyribose nucleic acid. Nature 1953;171:737–8.

3 Lamott A. Some instructions on writing and life. Peterborough: Anchor Books, 1994; p xi–xxxi.

4 Covey SR, Merrill AR, Merrill RR. The urgency addiction. In: First things first. London: Simon and Schuster, 1994; p 32–43.

Word choice

Like all art forms, writing is a craft and takes practice. The sooner you start, the sooner you will become more proficient in choosing your words and arranging them on the page in a way that best expresses what you have to say. It’s not easy, but the effort is immensely rewarding.

The objectives of this chapter are to understand how to:

choose the correct words
avoid the wrong words
write neat sentences that mean what you want them to mean

Because most of us think in groups of words, we need to be able to write in groups of words for the benefit of our readers. To achieve this, every scientist needs to become something of a wordsmith. The words that we choose for our purpose must be selected and assembled using correct syntax and grammar. In this chapter, we explain how to choose words that are appropriate for scientific writing and how to avoid some common mistakes.

Label consistently

The reader’s job is to follow the author’s thinking and to agree or disagree; it is not to decode and reconstruct the paper. Thus, if you want your readers to get your message, you will have to make it abundantly clear to them.

When you are writing about the participants whom you enrolled in your study, the equipment that you used, the outcomes you measured, or the results that you found, always use terms in your paper consistently. This seems a fairly obvious thing to say, but it is surprising how often writers freely switch between different terms to mean the same thing. For example, it is common to see the words children, participants, respondents, persons, cases, and controls all used interchangeably. However, chopping and changing suggests that you are talking about many different groups of participants and leads to confusion. The example in Box 10.1 shows how much clearer the text becomes when standardised terms are used to describe the study participants. In the corrected version, the term children to describe the study group is defined and used consistently.

Box 10.1 Standardising terms

	Meningococcal disease is most prevalent in children under 2 years of age. Approximately 400 healthy toddlers aged 12–15 months will be enrolled in this trial. Children will be randomised to receive either the new vaccine or a standard immunisation schedule. Children who are randomised to the control group will be offered the new vaccine at completion of the study.

	Meningococcal disease is most prevalent in children under 2 years of age. Approximately 400 healthy children aged 12–15 months will be enrolled in this trial. Children will be randomised to receive either the new vaccine or a standard immunisation schedule. Children who are randomised to the control group will be offered the new vaccine at completion of the study.

If you use different terms, they should mean different things and should be afforded separate definitions accordingly. Never be tempted to switch and change between different terms to describe the same outcome. For example, terms such as atopy, allergic sensitisation, skin prick test positivity, allergen reactivity, and clinical allergy all mean much the same thing but should not be used interchangeably. For indexing in databases such as MEDLINE®, it is better to select the most commonly used term, define it in the methods, and use it consistently. This is essential, even when quoting work from the literature in which the authors have used different terms to the ones you are using. For example, if you use the phrase airway hyperresponsiveness, then use it throughout and do not switch to bronchial hyperreactivity even if the researchers that you are quoting have used that term in their publications.

In standardising your terms, you need to select the appropriate term for your audience. If you are writing for a journal that specialises in allergic diseases, you would use the term allergic rhinitis, but if you were submitting the same paper to a general journal, you would use the term hay fever.

Even more importantly, you must always stick to the same point of view and use the same way of presenting data. It becomes quite confusing if you compare, for example, mortality rates in one group with survival rates in another. Also, do not compare risk factors for being underweight from one study with risk factors for being overweight from another study. This switching does not add interest but merely creates confusion. Always reword the work you are citing from other researchers’ papers or rework their results if necessary, for example by changing mortality rates to survival rates, so that direct comparisons can be made.

Participants are people

Individual. A yucky word. Usually unnecessary. Use person or someone. Use individual only when you mean to distinguish an individual from a group or corporation.

Participants are people not “things” and must always be described as such. The terms subjects and individuals are widely used, but the term participants is more politically correct because it reflects the role of people in the research process.³ In clinical studies, it is important to refer to your participants as a child or a patient rather than a case. Be careful not to write sentences such as Three cases were admitted to hospital. A case is an episode of a disease; a patient is admitted to hospital.

It is also important to avoid pejorative terms such as psychotics or schizophrenics or other labelling of participants with their illness conditions, for example asthmatics or diabetics. For example, it is better to write patients with diabetes rather than diabetic patients. Also be careful not to dehumanise your participants by using the wrong noun or pronoun. For example, it is correct to write participants who and dehumanising to write participants that … .

Box 10.2 Using the correct pronouns or descriptors for participants

1		There was an increase in the proportion of children that reported having asthma over the study period
		There was an increase in the proportion of children who reported having asthma over the study period
		The proportion of children with asthma increased during the study period

2		At present we have two patients who are waiting for testing that would be suitable
		We have two patients waiting for testing who would be suitable

3		Neonatal infections affected babies that were smaller and born more premature
		Neonatal infections affected babies who were smaller and more premature
		Small and premature babies were more susceptible to neonatal infections

4		The wheezy infant remains a conundrum for both primary care teams and hospital paediatricians
		Treatment for wheezy infants remains a problem for primary care teams and hospital paediatricians
		Consensus treatment strategies for wheezy infants have not been developed

Box 10.2 shows how the wrong pronoun can sneak into a sentence and how it can be corrected. In example 1, the pronoun that refers to children and should be who. The sentence can also be shortened by replacing the phrase who reported having with the preposition with. In the second example, the pronoun that has become separated from its antecedent patients. When rejoined, it becomes clear that the pronoun is incorrect. In the third example the pronoun who is more appropriate than the word that and the sentence benefits from some rearrangement. In the fourth example, better words can be chosen to describe infants who present to hospital with a wheezing illness. It is the choice of appropriate treatment that is a challenge for physicians, not the infant itself.

Word choice

In striving to write in an unambiguous way, you need to select the correct words. Ideally, use short words instead of long words. Sometimes long words are chosen in a thinly veiled attempt to appear academic. This is a big mistake. In fact, it is scholarly to choose a short word with the correct meaning rather than choose a long word with the wrong meaning. Most readers are busy people who will not appreciate having to find a dictionary to look up the meanings of obscure words or expressions. Making your readers work to decipher your message is an unfriendly act. Always choose short, clearly understood words. Table 10.1 shows some long words and word phrases with some alternative shorter versions that can be used.

Long words can clutter up a sentence. When you are choosing words, shorter ones are always better. For example, in the sentence The centre has established an agreement with the museum to utilise either information collection system, the phrase has established an agreement can be replaced with has agreed, and the term utilise with use. Thus, the sentence becomes simpler and more factually correct written as The museum research committee has agreed that we can use their information collection systems.

Sometimes a long word is not only long but may have the wrong meaning. For example methodology means the study of methods not the methods used in the study. If you use the word dosage, you mean the total amount of medication to be taken in a given period and not the amount to be taken at one time. Also, be clear about the different meanings of terms such as prevalence and incidence and do not use them interchangeably to mean the same thing.

Avoid emotive terms

Why is it that night falls but day breaks, and that the third hand on a watch is called the second hand?

Emotive terms are strictly off limits to scientific writers, who must be circumspect in their writing. We need to be factual and describe what we think or what we saw in a non-emotive way. In this quest, there is no place for jazzing up the human interest in your story. It is important to write about participants who have back pain, not participants who suffer back pain, or patients who have HIV or who have anorexia nervosa rather than patients who are HIV sufferers or anorexia nervosa sufferers. When the P value gets below 0∙001, it is also best to limit your enthusiasm and describe something as a strong rather than a powerful risk factor. Some uses of emotive terms and suggestions of how to remedy them are shown in Box 10.3.

Box 10.3 Removing emotive terms

1		In order to capture clinically significant effect sizes with a power of 80% and a significance of 5%, 21 participants will be necessary in each group
		To show that the effects are significant at the 5% level with a power of 80%, 21 participants are required in each group

2		Surprisingly, it appears that feather pillows may protect against asthma
		There is good evidence that feather pillows protect against asthma

3		To plan effective interventions to arrest and reverse this trend, we need a better understanding of the risk factors that are involved
		To plan interventions to reverse this trend, we need a better understanding of the risk factors involved

4		Unfortunately, with our questionnaire, we had no way of knowing if subjects had wheeze only on exertion
		Our questionnaire did not allow us to identify participants who only experienced wheeze on exertion

5		It is unethical to mislead others by broadcasting results that turn out to be a mistake at a later date
		It is unethical to mislead others by reporting results that may turn out to be incorrect

6		Yet it is precisely those children who reap the greatest benefit from treatment and have the highest risk of treatment failure
		The children who may receive the greatest benefit from the treatment have a higher risk of treatment failure

A common word used is reveal as in The present study reveals that more than half of the children studied were exposed to tobacco smoke in their homes. Reveal is a funny word that suggests something was found perhaps by magic – like the rabbit in the hat when the magician sweeps his cloak away. Clothing is also described as revealing when it shows something that is probably best not shown. As such, the word reveal has connotations of disclosure rather than of demonstrating a scientific finding. It is much better to select a more straightforward word such as showed or indicated to describe your research results.

Because

In fact, really bad writing is rarely a matter of broken rules – editors can clean these up with a few pencil marks. It’s more often the result of muddled thought. Bad writers consider long words more impressive than short ones, and the use of words like usage instead of use or methodologies instead of methods without knowing what they mean. The facts get buried under loads of useless words …

In addition to avoiding long or emotive words, it is important to use small words correctly. In recent times, there has been an increasing trend to use the word as incorrectly. Examples of incorrect uses of the word as are shown in Box 10.4. In these sentences, the word as should be replaced by the word because. The Oxford English Dictionary describes the meaning of because as for the reason that. In the first example, the use of cases and controls to describe participants is dehumanising and also needs to be changed.

Box 10.4 Using “because” to mean “because”

	There may be bias as the cases were visited more regularly than the controls
	There may be bias because participants in the case group were visited more regularly than participants in the control group

	It is the general belief that the complex needs of these children, both in acute crisis and long term, are not being met as there is a lack of available and appropriate services
	The complex needs of these children, both in acute crisis and long term, are not being met because appropriate services are not available

The use of as to mean because began quite recently. This use is not listed in many dictionaries and is an exceedingly minor interpretation in others. The Pocket Oxford English Dictionary has only a very minor, subsidiary reference for as as follows:

	Urgent	Not urgent
Important	Quadrant I Crises, deadlines, patient care, teaching, some meetings, preparation	Quadrant II Research, writing, reading, professional development, physical health, and family
Not important	Quadrant III Some phone calls, emails, mail, meetings, and popular activities, for example morning and afternoon teas	Quadrant IV Junk mail, some phone calls and emails, time wasters, and escape activities, for example internet browsing, playing computer games, reading magazines, watching TV

Long or incorrect version	Shorter or more correct version
Determine, detect	Assess, measure, investigate
Correlated (as an adjective or verb)	Associated
Due to the fact that, for the reason that, on account of, owing to the fact that, on the basis that	Because
Level (in solution)	Concentration
Documentation	Documents
Taken into consideration	Considered
Dosage	Dose
Elucidate, clarify	Explain
Functionality	Function
In the event of, in the eventuality of	If, when
Alleviate, moderate	Lessen, ease
Methodology	Methods
In close proximity to	Near
At the present moment, at this point in time	Now
The majority of	Most
Dyads	Pairs
Prioritise	Rank
Revealed	Show, found
Abuse (substance drug)	Misuse
Symptomatology, complaints, events, clinical picture	Symptoms
Terminology	Term
In order to	To
Usage, utilise	Use