The Good, the Bad, and the Ugly of Scientific Writing

1. The Good, the Bad, and the Ugly of Scientific Writing Mark H. Ebell MD, MS

2. To quote Dave Barry, “I didn’t make any of this stuff up”

3. Avoid stilted language Chest pain is often a harbinger of disease that can threaten the life of the organism. So, when a patient presents with significant chest pain, the prudent examiner is at once poised to exclude dangerous disease.

4. Concise, clear, active voice Before It has been shown that rye, wheat, and barley, as well as multiple processed products containing gluten, may in some cases elicit this immune response. After Rye, wheat, and barley, and many processed foods contain gluten and may elicit this immune response.

5. Concise, clear, active voice • Before: Though the spiral computed tomogram (CT) has revolutionalized the management of emergent abdominal pain (2, 3, 4), the currency of this approach remains the judicious application of a focused history and physical exam. • After: Even with access to advanced diagnostic imaging studies, a careful history and physical examination helps the clinician interpret the results of these studies and remains a critical part of the evaluation.

6. Simple…clear…don’t use fancy words. • There have been several randomized controlled trials that have evaluated the effectiveness of mammography as a screening modality. • Several randomized controlled trials have evaluated mammography as a screening test.

7. Examples of good and bad style • Really bad (wordy, stilted, passive voice): • “It has been proposed that chest radiography should be considered…” • Bad (passive voice, weasel words): • “Chest radiography should be considered…” • Good: • “Order a chest radiograph if…”

8. Examples of good and bad style: the dreaded parenthetical fever • Bad: “Admission was less likely in patients taking the cephalosporin (43%) than in those taking placebo (32%), a difference that was statistically significant (p = 0.03).” • Good: “Admission was significantly less likely in patients taking the cephalosporin than in those taking the placebo (42% vs 32%, p = 0.03).”

9. A case of commarhea • Chronic kidney disease and more severe stages of CKD, can affect not only glomerular blood flow and filtration, but also tubular secretion and reabsorption, and renal bioactivation and metabolism. • Chronic kidney disease and more severe stages of CKD can affect not only glomerular blood flow and filtration, but also tubular secretion and reabsorption and renal bioactivation and metabolism.

10. Any problems with this? Because the differential diagnosis of abdominal pain is extensive and includes multiple disease entities that can be placed into the broad categories of abdominal and extra-abdominal disorders and sub-divided as follows: Abdominal disorders include four categories of intraperitoneal conditions (inflammatory, mechanical, malignancy, and vascular disorders) and a limited list of extraperitoneal conditions. Run-on (and on and on) sentence Let’s rewrite it

11. …edited into three sentences Because the differential diagnosis of abdominal pain is extensive, it is helpful to organize it anatomically into abdominal and extra-abdominal disorders. First, recognize that abdominal disorders can be intraperitoneal or extraperitoneal. Intraperitoneal disorders can be further divided into four categories (inflammatory, mechanical, malignancy, and vascular disorders), each of which is further subdivided by whether they affect hollow, solid, or pelvic viscera or the mesentery

12. Anything wrong here? Chest Pain can be defined as an unpleasant sensation perceived in or on the anterior trunk (costal margin to clavicles) resulting from actual or potential tissue damage that may be unrelenting, causing the patient to seek the advise of a Physician. Non-standard capitalization. Rules are just like those for any other writing!

13. Say it well and say it once – avoid repetition Data from the 2000 U.S. National Center for Health Statistics reveals an incidence of abdominal pain of 63/1000 emergency department (ED) visits with admission rates for abdominal pain varying from 18 to 42 percent, with rates as high as 63 percent reported in patients over 65 years of age (6). While in 2002, there were approximately 15 million office visits to Physicians and approximately 7 million emergency department visits for abdominal complaints in the United States, almost all of them were due to abdominal pain

14. Proofreading! Internally inconsistent and just plain wrong • The physical examination is unremarkable between attacks so this entity has been termed biliary colic. Additionally, the patient is afebrile with significant right upper quadrant tenderness and positive Murphy’s sign. • Can’t be both unremarkable and with positive Murphy’s sign! And Murphy’s sign is cholecystitis, not gallstones.

15. Unclear headings Pathophysiology and differential diagnosis Pathophysiology The pathophysiology… Differential diagnosis The differential diagnosis is… Hard to tell what is a heading and what is text, and what hierarchy is intended.

16. Use clear heading indicators <H1>Pathophysiology and Differential Diagnosis <H2>Pathophysiology Blah, blah, blah… <H2>Differential diagnosis The differential diagnosis for chest pain includes…

17. How would you rewrite this? • Before: The clinically relevant pathophysiology of significant abdominal pain is based on whether pain is parietal or visceral in nature. • Don’t state the obvious • After: The pathophysiology of significant abdominal pain is based on whether pain is parietal or visceral. • If it wasn’t “clinically relevant” why would you be talking about it in a clinical article? Also, “in nature” adds nothing.

18. Anyone see a problem here? • Before: Patients with suspected gallbladder disease have been traditionally thought of with the terms of “fat, forty, fertile, and female.” • Don’t offend your readers! • After: Gallbladder disease is more common in women, obese patients, and it becomes more common as adults age.

19. Don’t name authors in text • Before: According to Jensen (8), many patients for whom this diagnostic code is chosen have irritable bowel syndrome, muscle strains, ovarian cysts, or any of the other conditions listed in the table (Table xx). • After: Many patients for whom this diagnostic code is chosen actually have irritable bowel syndrome, muscle strains, ovarian cysts, or one of the other conditions listed in Table xx (8).

20. Don’t name books in text • Before: According to Osler’s Medical Handbook (1), the approach to evaluating abdominal pain includes separating potential emergency and urgency from low risk or chronic disease and acting accordingly. • After: Although most patients do not have a serious condition, and in many cases a final diagnosis is never made, it is always important to exclude serious or life-threatening disease (1).

21. Vague statements that reflect traditional wisdom… • Patients on beta-blockers sometimes complain of fatigue and difficulty concentrating… • Patients with depression or sleep disorders may be adversely affected by all adrenergic blocking agents, including clonidine, beta-blockers, methyldopa, and reserpine… • Sexual dysfunction has been ascribed to all of the antihypertensive medications, particularly beta-blockers.

22. Replaced with evidence… • It is important to note that beta-blockers have a much better tolerability profile than previously thought. A meta-analysis of 15 trials involving 35,000 patients found no significant increase in the risk of depression and only small increases in the risk of sexual dysfunction (NNH = 200 per year) and fatigue (NNH = 57 per year).(78)

23. Do not cite other reviews except as a last resort. • Do cite • Original research • Systematic reviews and meta-analyses • Authoritative or evidence-based guidelines.

24. Traditional wisdom or evidence? • Before: Beta-blockers may trigger bronchospasm in patients with asthma or chronic obstructive lung disease • After: While it has been conventional wisdom that beta-blockers are contraindicated in patients with asthma or chronic obstructive lung disease because they might trigger bronchospasm, cardioselective beta-blockers have proven to be safe in such patients and should be prescribed when indicated.(63, 64)

25. Avoid weasel words • It has been suggested that… • Some might consider… • There is growing evidence that… • Preliminary evidence suggests that…

26. So much for grammar and style… • …on to formatting

27. Properly format your article • Double space all articles submitted to a journal • Adequate margins, i.e. 1 to 1.5” • Insert hard page breaks after title page, abstract, body of paper, and each table • Ctrl-Enter • Do not use hard line breaks (i.e. “Enter”) except for a new paragraph DEMO WITH WORD

28. Properly format your article • Use appropriate subheadings • <H1>Main heading • <H2>Subheading • <H2>Subheading • <H1>Next main heading • Use a nice font (not Courier!) • Arial • Times New Roman • Courier

29. References • Don’t bury me with references (~ 30 is a good target) • Don’t cite 5 randomized trials when a single systematic review or meta-analysis will suffice • Don’t use other review articles or monographs – leads to “medical gossip” • Do use original research, meta-analyses, evidence-based guidelines, and systematic reviews.

30. References • Use proper format • AMA style: • Authors. Title. Journal Year; Volume: Page range. • Ebell MH, Barry HC. POEMs in the medical literature. J Fam Pract 1998; 43: 341-4. • For Web citations include URL and date last cited. • Journals in social sciences use APA style

31. I have seen… • No abstract • No title page • Single-spaced • No references • 10 or more spelling, grammatical, or typographical errors on the first page • Handwritten!

32. Follow the author instructions!!! • Be concise overall. • One idea per sentence • Write clearly and in a conversational tone • Use active voice • Remember, if it doesn’t sound like something you could say in the hall to a colleague or in a lecture, you probably shouldn’t write it.

33. Good luck!