Using euphemisms and jargon in health economics

Are they drug addicts or the chemically dependent?

Are they old people or senior citizens?

Do health economists really need to use the politically-correct (PC) euphemisms of medicine? When is it okay to use jargon?

As noted by our editor, David Woods, euphemisms have been referred to as verbal placebos – a way of discussing unpleasant topics in a more palatable manner. But do euphemisms really change the way we think? And should Health economists be encouraged to use them when discussing their economics research of medical topics?

In a recent essay in the Archives of Neurology , the author suggested that the word ‘dementia’ be replaced with actual name of the disease (e.g. corticobasal disease) or the term ‘cognitive impairment’, to avoid the image of a demented individual (i.e. someone who is crazy or out of their mind). Although these terms avoid the stigma of dementia, are they any more relevant to a lay audience? Do they confer the desired information to the patient and loved ones about the condition? One could argue that they simply create more confusion.

We see many other examples of euphemisms in both lay and medical lexicons, such as cancer survivor, instead of cancer patient; people with diabetes, instead of diabetics; differently abled, instead of disabled. The rationale for encouraging PC euphemisms is to remind physicians (primarily) and other healthcare providers that patients are, first and foremost, people; to avoid letting the patient fall into role of ‘the sick person’; and to avoid any stigma associated with a condition.

An informal survey of a few physicians revealed that euphemisms can have a role to play in avoiding confusion with patients, but the key is honest, open communication in language that all parties understand. However, when discussing medicine among colleagues, more-direct, less-PC language is appropriate. As gynaecologist Margaret Grotzinger, MD, notes, ‘I don’t think it would make a difference in terms of how a doctor views or treats a patient – I think that is rooted in the physician’s personality and not by what words [he or she] uses’.

There is also the shorthand that doctors use amongst themselves (e.g. an OCDer, which is a patient with obsessive-compulsive disorder, or ‘the transplant’ in Room 310). Traditionally we have been taught to avoid jargon in formal communication (oral and written), but with colleagues, we often use jargon, if only because it’s easy. According to veteran medical editor Edie Schwager, jargon ‘is not a pejorative term in itself. It’s simply a shorthand way of communicating with colleagues, a specialised language used within specialised groups. There’s good jargon and there’s bad jargon. But it all depends on how it’s used. If it’s used to obfuscate, to defraud, it’s very, very bad.’

Should this encouragement of euphemisms or PC language apply to those on the periphery of medicine (e.g. health economists, statisticians, clinical trial designers)? Should Health economists be able to use jargon when discussing their work? In true PC fashion, the answer is, it depends. The health economist, like any physician or any other speaker, must know his or her audience. After all, clarity – not soothed feelings or pedantry – is the ultimate goal. If euphemisms or jargon will best reach those targets, health economists should use them. As politicians learn, time and time again, words do mean things.

How to write a good sentence – length and rhythm

A sentence should not only make sense but should also be capable of standing alone as a complete unit; a good sentence will also have shape and form.

Sentence length is important in any piece of writing. While there are no set rules for this, shorter sentences are better. If the length of an average sentence is 15 to 20 words, then it’s best to vary length around this norm rather than sticking to a single pattern which can become monotonous.

If you want to introduce an element of pace or urgency to your work then very short sentences are ideal. But be careful not to overdo this staccato form: a succession of short statements can become just as tedious as long sentences.

Longer sentences can be useful but must retain logic and clarity; the great danger with longer sentences is that the message becomes blurred and readers lose touch with the first part of the sentence by the time they have reached the last part. This last, for example, was 45 words long, but I hope that the message retained clarity. When you edit your writing, work on your sentences; some might need shortening and others lengthening.

Another aspect of sentence structure is rhythm. This is not easy to teach; it is more instinctive and comes from experience, both of writing and reading. Good writing has a certain rhythm which, unlike poetry, is not regular or repeated; more a subtle satisfying sequence of sentence flow. Such flow makes it easier to get the sense of the piece at the same time as enjoying the reading.

Making molehills out of mountains – of clinical data

By Mary Gabb (mgabb@rxcomms.com)

Writing a manuscript can be daunting, even for a seasoned researcher. How does one synthesise a coherent publication out of the mountain of accumulated data?

The most traditional approach is to start with the IMRaD principle: Introduction, Methods, Results, and Discussion. But how to summarise all of those results?

This is a common challenge, but it can be overcome with a straightforward approach and by being mindful of two key principles:

• Always keep in mind the original research question. All of the data you choose should be able to answer the original research question. Data that do not answer the primary question should not be included (although if secondary endpoints or hypotheses were tested, relevant data for those questions can be included, depending on your word count limits).

• Be as clear and transparent as possible. After reading your manuscript, the reader should be able to duplicate your study design and results. Regarding the data, be sure to include:

• All data related to the study sample (eg, race/ethnicity, education, socioeconomic status, etc)
• Statistical analyses
• Characteristics of diagnostic tests
• Study limitations (eg, sample size, type of data, low response rate).

It is also important to present your data clearly:
• Write in short, direct sentences
• Try to present as much data as possible, and in short tables and figures
• Report data comparisons clearly (for example, actual “raw” data as well as absolute or relative risk reduction, confidence intervals as well as P values).

Finally, consult checklists used by journal editors, such as the Consolidated Standards of Reporting Trials (CONSORT), the Quality of Reporting of Meta-analyses (QUOROM), the Meta-analysis of Observational Studies in Epidemiology (MOOSE), and the Standards for Reporting of Diagnostic Accuracy (STARD).

How to write a book review

By David Woods

So the editor has asked you to write a book review. You’re flattered. After all, the editor has presumably chosen you because you are knowledgeable about the book’s subject – possibly even an expert.

On the other hand, the editor might be desperate… looking for someone capable of reading a book without lips moving, and with the potential – maybe – to provide illuminating commentary. For it’s true that book reviews and not obituaries are the real graveyard of publishing.

Nonetheless, there are certain guidelines to help you write a reader-friendly and reader-useful critique:

• Read other reviews, especially in such medical journals as the BMJ;
• Clearly identify the book’s title, author, publisher, price, and ISBN number;
• As with any other kind of writing, start with an arresting lead paragraph;
• Make sure you read the whole book;
• Briefly describe the author’s qualifications and intent;
• Comment on the presentation and the quality of the writing – the emphasis should be on quality and flow, not in nitpicking comments about poor grammar or spelling unless they’re so prevalent as to wreck the overall project;
• Don’t inject too much of yourself. Remember, your objective is to say what this book is about, and to recommend whether your reader should bother to buy it. It should not be an ad hominem attack on the author, nor an unbridled rant… although that doesn’t mean your criticism shouldn’t be strongly-worded where that is justified; and
• Finally, ask yourself: is this a book you would want to buy – and why?

A sample book review, previously published in the British Medical Journal, is available here.

Top clichés of 2006

The Wall Street Journal has published a list of the top clichés of 2006 based upon the number press citations. The undisputed leader, with 21,430 citations, was “at the end of the day.”

This was followed by such examples as “level playing field,” “time is running out,” and “outpouring of support.”

Clearly, the WSJ is “thinking outside the box,” although that tired phrase didn’t make the list.

How to make the best use of graphics: Line graphs

Line graphs are an extremely useful way of showing changes and trends, especially over time. The following pointers are helpful when considering the use of line graphs:

• Use when graphing a continuous variable by a continuous variable. A common example is a time series. In a graph of a time series, time should run horizontally.

• Display a maximum of three dependent variables (as lines) on any one graph. Otherwise the graph can become crowded and difficult to read.

• Use a different line style for each variable, even if the lines are also distinguished by colour. This facilitates black-and-white printing and photocopying.

• Where multiple lines overlap such that they are difficult to distinguish, consider using more than one graph to display the data, or perhaps a grouped bar graph.

• Consider using a vertical bar graph for time series where the series is short and the message relates to comparison of individual quantities (e.g. yearly results) rather than to changes.

• Where there is a visible seasonal component in a time series then at least two years’ data should be graphed, or the seasonal component of the variation may be mistaken for a trend.

• Equal intervals (of time, for example) should be equally spaced.

• Where there is a discontinuity in the data do not join the points across the discontinuity, and explain this in the caption.

How to make the best use of graphics

The power of a graph lies in its ability to convey a variety of complex relationships in a way that is difficult to describe in words, but is easily comprehended from a picture. When designing a graph, consider these points:

• Avoid fussy, excessively complicated graph design;

• Don’t use 3D graphs. They are usually harder to interpret and more cluttered than 2D graphs (see Figure 1);

• Reduce clutter by removing key borders and gridlines (see Figure 1b);

• Avoid bold shading or cross hatching which can cause distracting visual effects (Figure 2);

• Use colour and shading sparingly as it distracts from the message;

• Avoid graph designs that use keys. Where keys are unavoidable, use the simplest key available (Figure 1b);

• When adding text, use plain English, and avoid jargon and repetition. In addition, use the same typeface as the graph (preferably a sans serif font), avoid fancy lettering and fonts, don’t mix upper and lower case lettering, and don’t box the text;

• Where several graphs are used for similar types of information use, where possible, the same scales on the x- and y-axes; and

• Where practicable avoid truncating the axes, unless it will inform rather than mislead the reader (Figure 3).

The essentials of foolproof proofreading

Proofreading is the final stage of the editing process, focusing on surface errors such as misspellings and mistakes in grammar and punctuation, and should be done only after you’ve completed other editing revisions. Some proofreading pointers:

• Choose an environment that is quiet and free from distractions;
• Read the whole document for the ‘big picture’;
• Scan for visual style, word division and word spacing;
• Read the document several times;
• Proofread for only one type of error at a time;
• Don’t rely on spell or grammar checkers;
• Read very slowly; read out loud and read one word at a time;
• Read what is actually on the page, not what you think is there;
• Re-read, focusing on the types of errors you often make; and
• Circle each punctuation mark and look at each one separately.

It is rare to find a piece of writing that is completely error-free. Professional editors proofread as many as ten times. Publishing houses hire teams to read in pairs, out loud, and errors can still occur. The important thing is to make the process systematic and focused so that you catch as many errors as possible in the least amount of time.

Overcoming writer’s block

by David Woods

Asked if she liked writing, American author Dorothy Parker (1893–1967) replied that, no, she liked having written.

Any writer who has sat facing a blank computer screen and a fast approaching deadline will know what she meant. Just getting started – or restarted – that’s the challenge; and if you can’t, then you’ve come up against the dreaded writer’s block.

Experienced writers deal with this in different ways. For some, it’s trying to find a lead sentence or paragraph that will create a natural ‘trickle down’ to the rest of the story. This calls for meticulous preliminary work on the purpose and structure of your text.

For those inclined to flight rather than fight, turn away from the screen and do something completely different. Go to the fridge, or go for a walk. But remember: only so much diversion and procrastination can ward off the looming deadline.

Another tactic is to write in different locations and at different times of the day (or night). Knowing when your level of creativity is higher or lower is helpful.

Some well-known authors could write only in the early morning. W. Somerset Maugham, for example, jump started his work by thinking of the first two sentences he wanted to write while still in his morning bath. He then set himself a goal of 1,000 words a day, stopping for a martini at noon … and even though some critics have noted his carelessness, he never suffered from writer’s block.

While of course Maugham predated computers and their blank screens, he was adamant that visual distractions were harmful to the writer, and he always sat down to write in front of a blank wall. Something to consider.

Flexibility and a degree of ruthlessness may also be helpful to the blocked. Prepare to jettison whole sections of the text that don’t seem to work.

Finally, don’t let writer’s block get you in a sweat. Relax. The more you worry, the harder it gets to think clearly.

The Gunning Fog Index: a useful tool for targeting an article to an audience

In the 1930s, psychologists began to research how our brains process written information. They found that the longer a sentence the more difficult it is for a reader’s short-term memory to hold its meaning, so clearly shorter sentences improve comprehension.

Readability formulas determine how difficult it is to read and understand a piece of writing.

Robert Gunning’s Fog Index (GFI) was one of the first efforts to quantify the readability. The number that results from the following calculation correlates to the grade level:

GFI = [(number of words / number of sentences) + number of ‘difficult words’] x 0.4

1. Count the words and sentences in a representative passage of about 100 words.
2. Divide the number of words by the number of sentences to give the average length of each sentence.
3. Count the number of words of three or more syllables that are not (a) proper nouns, (b) combinations of easy words, or (c) made three syllables by suffixes such as ‘ed’, ‘es’ or ‘ing’.
4. Add the average sentence length from step 2 and the number of ‘difficult’ words from step 3 and multiply by 0.4.

So the GFI in pulp novels is 8–10; that of tabloid newspapers is 10–12; while medical journals score 14–16. Not surprisingly, insurance policies score an daunting 18–20!

Professional writing should score between 10 and 15. Below 10, and you are in danger of over-simplifying your message. Over 15, and your reader may struggle to understand.