AMA Manual of Style – What is in that manual anyway?

I’ve been talking a lot about different aspects of the AMA Manual of Style, but I haven’t as yet provided an overview of the contents in their entirety. So, I thought that would be a good thing to do. Perhaps you are new to medical writing and you haven’t really taken a look at the manual. I suggest that you go to the website and take a look. Spend a couple of hours digging in. Some of it makes for quite interesting reading and will certainly be helpful for your day-to-day work.

Let’s first go ahead and click on the contents link on the AMA manual of style homepage. Just as a side note, I always find that the contents link the best way to get back to square one if I’ve gotten lost in the search or something like that, so remember that contents link on the top left-hand side of the homepage; it will help you navigate the site.

Five Major Sections

The entire contents of the style guide can be pretty overwhelming at first glance, but they are well organized and are divided into only five sections. The first section is all about preparing an article for publication; the second section is about style, and that is actually where I have spent most of my time as a medical writer when using this manual. Section 3 is terminology, which covers abbreviations, nomenclature, acronyms, and Greek letters.  Section 4 covers measurement and quantitation. Finally, Section 5 covers technical information, specifically typography, manuscript editing and proofreading, publishing terms, and resources.

Two Important Subsections

First of all, let’s drill down into a couple of the sections so we can take a closer look. The style section covers grammar, punctuation, plurals, capitalization, correct and preferred usage, non-English words phrases and accent marks, and medical indexes. And if you drill down further into section two, the grammar subsection, you’ll see it covers all the major parts of speech and challenges, such as parallel construction and subject-verb agreement. If you have to study one section of the AMA manual of style as a medical writer, that one would be it.

There’s also the punctuation subsection, which is also important reading. This subsection covers all the different punctuation marks and when they should be used; you might be surprised, even if you’ve been writing for quite a while, at some of the mistakes that you may inadvertently have been making. At least that’s how I felt. 

Quizzes for Self Evaluation

If you want to challenge yourself by taking some quizzes, you can go up to the top navigation bar of the homepage and click on style quizzes. The link will bring you to several tests on the style section, and actually all five sections of the AMA manual of style are covered by these quizzes. But for the style section alone, there are over 20 individual quizzes that are useful in testing your knowledge.

Other Important Sections

Another section that is very helpful to medical writers is measurement and quantitation and specifically the study design and statistics subsection. It’s of course very important for us to be aware of the different types of studies that are used to communicate scientific information.  There is also information on P values and other aspects of reporting scientific information.

If you do a lot of writing in a specific area, such as cancer for example, you might want to delve into the terminology section which is Section 3. If you take a look in the nomenclature Subsection 15, which is in section 3, you’ll find 15.2 cancer, which covers cancer stage, the TNM staging system, the Bethesda system and other aspects that are specific to describing cancer. Other topics covered in the nomenclature subsection include cardiology; drugs; equipment, devices, and reagents; genetics; hemostasis; immunology; neurology; and the list continues.

Another useful section that might often be overlooked is in Section 5, Technical Information–the subsection on resources. Included are various resources listed for dictionaries, including general, medical, and scientific; a list of books on writing in general; resource suggestions for illustrating and displaying data; and also a listing of professional organizations and groups associated with scientific writing and editing.

So as I mentioned there are five sections and each contains a wealth of information in their own right. I strongly recommend that you check out the AMA manual online and depending on your specific area of expertise, you may uncover other sections that are even more relevant to you.

Well that’s it for now. If you need medical writing help, please email us at info@nascentmc.com, and if you are interested in getting into medical writing, please visit 6weekcourse.com.

P-Value Pointers

How to format P values in AMA style

In this post, I’ll be going over P values and how to express them according to the AMA Manual of Style.

Many of you probably already know this, but I’ll first briefly define what a P value is. When you are comparing a treatment with a placebo, for example, you will have a null hypothesis, which states that the treatment is no better than placebo. This is in contrast to the alternative hypothesis, which states that the treatment is better than placebo.

A low P value (generally defined as P < .05) suggests that your sample provides enough evidence that you can reject the null hypothesis for the entire population. It does not measure support for the alternative hypothesis, but it is saying that your result, if your P value is < 0.05, would be very unlikely if the treatment were, in reality, no better than placebo. You could say that if P < 0.05, that the probability that you would get your result by chance alone is < 5%.

This is not by any means a complete explanation of P values. There’s a lot to it, and of course if you’re interested in learning more, then please check out your favorite statistics textbook.

Now, when it comes to expressing and styling P values, we have to do that all day long as medical writers. Here’s a couple of pointers that will helpyou align the formatting according to the AMA Manual of Style. We’ll mainly be referring to sections 20.8.2 and 20.9.

Express P Values to 2 Digits After the Decimal

So first of all, P values should be expressed to 2 digits to the right of the decimal point (regardless of whether the P value is significant), unless P < .01, in which case the P value should be expressed to 3 digits to the right of the decimal.  So, for example, for P < .0085 you would write as P < .0085 not P < .01. Also when rounding P from 3 digits to 2 digits would result in P appearing nonsignificant, such as P  = .046, expressing the P value to 3 places may be preferred.

Smallest P Value Is P < .001

The smallest P value that should be expressed is P < .001 since additional zeros do not convey useful information. So, if you had a P value of .0001, you would still express it as P < .001.

Certain Study Types Do Require Expressing P to More Than 3 Digits.

An update was made in 2011: “Although our style manual recommends (Section 20.9) that “[expressing] P to more than 3 significant digits does not add useful information to P < .001,” in certain types of studies (particularly GWAS [genome-wide association studies] and other studies in which there are adjustments for multiple comparisons, such as Bonferroni correction, and the definition of level of significance is substantially less than P < .05) it may be important to express P values to more significant digits. For example, if the threshold of significance is P<.0004, then by definition the P value must be expressed to at least 4 digits to indicate whether a result is statistically significant. GWAS express P values to very small numbers, using scientific notation. If a manuscript you are editing defines statistical significance as a P value substantially less than .05, possibly even using scientific notation to express P values to very small numbers, it is best to retain the values as the author presents them.

Watch Out for Trends

Also, when you have a P value that just misses statistical significance, for example, P = 0.06, watch out for language from yourself or others describing the findings as “trending toward significance,” “having a trend toward significance,” “approaching significance,” “borderline significant,” or “nearly significant.” None of these terms is correct. Results do not trend toward significant—they either are or are not statistically significant based on the prespecified study assumptions. The term trend should only be used when reporting the results of statistical tests for trend. Other uses of trend or approaching significance should be removed and replaced with a simple statement of the findings and the phrase not statistically significant.

P values Should Not Be Listed as Not Significant

You should include a valuebecause for a meta-analysis the actual values are important and not providing exact P values is, according to the AMA Manual of Style, a form of incomplete reporting.

Format Correctly

Finally, you want to format the P value correctly. The zero before the decimal point is omitted. There is a space either side of the < or = sign and the P is italicized.

Well that’s it for now. If you need medical writing help, please check out our website nascentmc.com, and if you are interested in getting into medical writing, please visit 6weekcourse.com.

How to Format Figures in AMA Style


In this blog, I describe information provided in the AMA Manual of Style that covers how to deal with figures. This information is located in Section 1 “preparing an article for publication”, subsection 4: visual presentation of data, and sub-sub section 4.2, there you have the information about figures. Of course, for all the finer details about this topic, please do visit the AMA Manual of Style.

Ok, so here is what the AMA Manual of Style has to say about figures.

First of all, this section is broken out into several categories. These are

4.2.1 Statistical Graphs

4.2.2 Diagrams

4.2.3 Maps

4.2.4 Illustrations

4.2.5 Photographs and Clinical Imaging

4.2.6 Components of Figures

4.2.7 Titles, Legends, and Labels

4.2.8 Placement of Figures in the Text

4.2.9 Figures Reproduced or Adapted From Other Sources

4.2.10 Guidelines for Preparing and Submitting Figures

4.2.11 Consent for Identifiable Patients

The first few sections drill quite deeply into the various types of graphs, diagrams, maps and illustrations. It’s worth checking this out. In this discussion, I will focus in on the Components of Figures, which is section 4.2.6, and also the Title, Legends and Labels, section 4.2.7.

According to the AMA Manual of Style, “clear display of data or information is the most important aspect of any figure.”

They go to a little bit into scales for graphs, describing the range of values, axis scales and axis labels. An important point is that the range of values on the axes should be slightly greater than the range of values being plotted so that the entire data set can appear within the area defined. And, ideally the range should include zero on both axes if zero is a possible value for what’s being displayed. And then, if there’s a break needed in the axes because of the extent of the range of data, then you can signify a missing portion of the range with paired diagonal lines.

When talking about axis scales, simple multiples of the quantities plotted should be included and the values on the axis scale should be centered on their respective tick marks. Both linear and logarithmic scales can be used. For linear scales, the axis must appear linear, with equal intervals and spacing between tick marks.

Axes should be labeled with the type of data plotted and the unit of measure used.

Symbols, line styles, colors, and shading characteristics can be directly labeled or included in a key. This information can also be included in a figure legend.

The form of labeling or the key used should be consistent throughout figures in a single article. It’s also important to use two easily differentiated colors or shades for different data. Often an unfilled circle will depict placebo and a filled circle will depict study drug for example, which is clear and makes sense. 

They also point out that shading is preferable to crosshatching and other types of patterns to differentiate different groups. And then often error bars are included and this should be drawn to encompass the entire range of variability not just one direction. The error bars should always be defined either in the legend or on the plot itself.

In most cases figures should not be presented in a 3-dimensional way.

Next is titles legends and labels which is section 4.2.7

Titles

The figure titles in most journals are published directly under the figure and will be numbered consecutively, unless only one figure is included in the article and then it will be called just “figure”. I always remember that tables begins with “T” and therefore their title goes on Top, above the table, whereas, figure does not begin with T and so the figure title goes beneath the figure. Just a little pneumonic to help remember…

Figure titles should be written as a clause or phrase identifying the specific topic of the figure and each major word (of 4 letters or more) of a title should be capitalized which would follow the same rules as for article titles.

Titles of figures should not begin with a phrase identifying the type of figure. So you would not say “a photograph showing x,y,z”  you would just say “x,y,z”, although a description of the type figure may be required in certain circumstances,  to avoid confusion and to add clarity, eg multislice CT-angiography.

Legends

Figure legends should be written below or next to the figure in sentence format. The legend contains information that describes the figure and it shouldn’t be longer than 40 words in general but longer legends may be used if more detailed explanation is required for a given figure. Figure legends should also contain expansions of abbreviations and footnotes for information that is too much to include in the figure itself.

Labels                                                                                                                                                

When it comes to labels, axis labels should be capitalized, similar to a column heading in a table. Sentence style capitalization should be used for non-axis labels within the figure itself (easier to read)

Well that’s it for now. Thanks for joining me. If you need medical writing assistance, please check out info@nascentmc.com, and if you are interested in getting into medical writing, please visit 6weekcourse.com

Checklist for Creating Tables in AMA Style


This is a checklist for tables so that you can follow the AMA style guide. This is based on information at Section 1 Preparing an Article for Publication, subsection visual presentation of data, 4.1 Tables. If you are fiercely interested in this topic, you should check it out from the source. I have included most but not all of the finer details included there.

1. Make primary comparisons horizontal rather than vertical.

During the planning and creation of a table, the author should show the primary comparisons horizontally across the table, which makes them easier to compare. Independent variables conventionally are displayed in the left-hand column (stub) and the dependent variables in the columns to the right. Note that the second table more easily allows the reader to compare the differences based on color, which in this example, is the primary variable of interest.

  Red Blue Green
Number 10 12 15
Diameter, inches 1 5 3
Material Glass Clay Plastic
  Number Diameter, inches Material
Red 10 1 Glass
Blue 12 5 Clay
Green 15 3 Plastic

2. Limit the amount of information presented in a single table (use multiple tables if necessary).

For the sake of clarity, you want to limit the amount of information presented and use more than one tables if needed. In general, tables in print publications can, depending on the content, contain up to 9 or 10 columns of data (including the first column, or stub). Cells that contain words will be wider, thereby reducing the number of columns that will fit, so keep that in mind.

3. Indent stubs to depict hierarchy.

Stubs (the left most column) should be left-justified, and indentions are used to depict hierarchical components of the stubs. However, some publications use bold stubs or shading instead.

4. Line up data with the first line in the stub entry.

5. Use a suitable title with a correct format.

If a manuscript contains only 1 table, it is referred to in the text as “Table.” If more than one table, you would number it 1, 2, etc. Table titles should use title case (words 4 or more letters capitalized). The title should convey the topic of the table succinctly but should not provide detailed background information or summarize or interpret the results.

Table. Bead Characteristics According to Color

  Number Diameter, inches Material
Red 10 1 Glass
Blue 12 5 Clay
Green 15 3 Plastic

6. Shorten column titles and expand abbreviations in a footnote if needed.

In column headings, style guidelines regarding numbers and abbreviations may be relaxed somewhat to save space, with abbreviations expanded in a footnote. However, when space allows spelled-out headings, expansions are preferable to abbreviations. Superscripted letters a-z should be used sequentially based on the order of placement in the table of the item to which the footnote refers. You can take a look at this table as an example. The placement of the footnote is tied to what is included in the reference. For example, in this table, the letter “i” is at the end of the subsection header, because the detail in the footnote refers to that entire section.

7. Use correct units of measure.
In tables, units of measure, including the variability of the measurement if reported, should follow a comma in the table column heading or stub. The following are examples of stub entries with units of measure:

Age, mean (SD), y
Systolic blood pressure, mean (SD), mm Hg
Body mass index, median (IQR)
Duration of hypertension, mean (SD) [range], y
Change in rate, % (SE)

8. Modify punctuation as needed (either for space or clarity).

Punctuation may abbreviated in tables to save space. For example, slashes may be used to present dates (eg, 1/24/19 instead of January 24, 2019) and hyphens may be used to present ranges (eg, 50–100 for 50 to 100). Phrases and sentences in tables may use end punctuation if required for readability (eg, if cells contain multisentence entries).

9. Use abbreviations properly.

Abbreviations can be used for space or clarity, however, spelled-out words should not be combined with abbreviations for units of measure. For example you should not use First y. Instead you would use “First Year” or “1st y” or “Year 1”. Abbreviations or acronyms should be explained in a footnote.

10. Present numbers accurately.

It’s possible to go into detail here, but the AMA Manual includes a lengthy discussion of how to present numbers accurately in any kind of medical writing, not just tables, and these same rules apply. For example, additional digits (including zeros) should not be added after the decimal point, to provide all data entries with the same number of digits. Doing so may indicate more precise results than actually were calculated or measured. In most cases, P values should be expressed to 2 digits to the right of the decimal point, unless the first 2 digits are zeros, in which case 3 digits to the right of the decimal place should be provided (eg, P = .002).

If we can assist with medical writing, please email info@nascentmc.com. If you are interested in getting into medical writing, please visit 6weekcourse.com

4 Tips for Searching the AMA Manual of Style

I’m going to talk about a couple of aspects of searching the AMA Manual of Style. This is based on information provided on the AMA Manual of Style site. There’s a helpful PDF in the quizzes section that outlines this information. Basically there are four approaches to searching the style guide.

Start With the Search Box on the Top Right

First, you can use the standard search box at the top right corner of the website. This is most helpful if you know what you’re looking for. If you have a two-part phrase, for example such as “side effect”, “P value” or “confidence interval” then you can just go ahead and put quotations around the phrase and the search will retrieve exact mentions of that phrase.

Narrow Your Choices on the Left

If you want to narrow your search down further, then go to the left side of the page where there’s a box that says “Narrow Your Choices”. By reviewing the options in “Narrow Your Choices” you can identify more precisely what part of the style book to review. For example, if you wanted to know more about study design and statistics involving confidence intervals, you would access that section in the “Refine By Sections” box.

Refine Terms

By hitting the plus sign under this heading you will access the sections in this chapter. You can also use the “Refine Terms” function in the “Narrow Your Choices” box. This link allows you to more specifically delineate your search parameters and you can search for your word or phrase in Full Text, Headings, Bibliography, Tables, Figure Captions, Abstracts DOI/ISBN, you can search one term or multiple terms and if you click “Add Row”, you can add a Boolean operator such as “and”, “or” or “not”.

“Contents” Link Gives You the Expandable List of Contents

You can also use the “Contents” tab at the top left of the main page, and by clicking on the “Contents” tab you are taken to an expandable list of the contents of the Style Guide. Finally, you can access the “Index” under the “End Matter” heading, and this will bring up the same list of index entries that appears in the hard copy version of the style book. Each entry is followed by a link, for example if you want information on book edition numbers you would just click on the word “link” by that entry and you’ll be taken directly to the information on book edition numbers.

Alright well that’s it for now. Thank you so much for joining me, if you need medical writing assistance, please contact us at nascentmc.com and if you’re interested in getting into medical writing then please check out 6weekcourse.com that’s numeral 6weekcourse.com. Thank you so much.

Time for a Mid-Life Skills Upgrade?

I became a medical writer (what’s that? Someone who writes about medicine) in my early 30s after earning my PhD in molecular biology and an MS in technical communication. I now run my own medical writing business, which has several writers, and which has grown organically to pretty healthy annual revenues. It’s going well, and I can’t complain.

However, the early fifties, the age at which I now find myself, can be a scary time for some working professionals. While your earnings and job title are likely ramped up, you are nowhere near wanting to retire. You may start worrying about the crop of workers coming up behind you, whom you suspect came out of the womb being able to code. You may start wondering if your own well-honed skillset could become obsolete. With the emergence of artificial intelligence, as a writer, I consider that a possibility. And, as a small business owner, if I ever needed a real job (for example, if I wanted affordable health insurance), what’s the chance of me being hired when they could hire a more tech-savvy 30-year-old whom they could pay less? Not high. Fortunately, my business is doing great, but what if it weren’t?

To help myself sleep better at night, I decided I needed to upgrade my skillset. I started looking around at some online programs. What set of skills would be most useful given my current career? I toyed with the idea of learning artificial intelligence, or python, or data science, but I landed on Udacity’s Digital Marketing Nanodegree Program. I thought this program would be a great fit because it would help me with the marketing in my current business while providing me with a set of valuable and marketable (pun intended) skills. It was a great choice. I am learning all about content marketing, social media management, Google ads, targeted ads, and the like. Udacity’s program is reasonably priced and has the added benefit of office hours and feedback on projects. The videos and instructors are top notch. Udacity is also based out of Silicon Valley and has partnerships with certain tech companies of which I’m a fangirl. I am using my own company, Nascent Medical, to do my project work on, so I’m not wasting any time on theoretical projects.

I look forward to increasing both my skills and my business revenues even further with the help of this program. Maybe we will be looking to hire some of those up-and-coming tech-savvy 30-year olds!

Emma Nichols, PhD

Medical writers are not ghost writers!!

Someone sent me an article published in 2016 about ghost writing where at the end, a scientist stated the following: “I think major journals should discourage and eventually prevent the use of professional medical writers, and I think investigators should be required to write their own papers.

My response: Dr. Tannock’s quote reflects a common lack of understanding about the role of medical writers in scientific publication writing. Medical writers are to scientific publications as accountants are to taxes. No aspersions are cast simply because an accountant works on someone’s taxes. In fact, it means the taxes are more likely to be done correctly. The same is true when medical writers work on journal articles.

The problem arises when transparency is lacking. If medical writing assistance is used, it’s best practice to acknowledge that at the end of the manuscript. It’s up to medical writers to make sure that happens. And most of us do.

Medical writers perform a much needed function. Just because a doctor made it through medical school doesn’t mean they have the writing ability to describe their findings. After all, writing skills are rarely taught in medical school–doctors have enough to learn as it is.

Medical writers (many of whom have an advanced science degree themselves) bring expertise to publication writing. We are distinct from ghost writers in that we write things only when our work is reviewed by the contributing scientists whose papers we are writing. It’s a red flag to us when a scientific expert is not involved in approving the outline and reviewing the final manuscript.

In summary, medical writers are a group of highly educated professionals who provide an important service. We are committed to ensuring accuracy and maintaining integrity in medical communications. Dr. Tannock is simply misinformed about that issue.

Breaking news on off-label promotion and the first amendment

Today the FDA made an announcement. This commenced before the new administration takes office, the FDA released a “memorandum” taking positions on the First Amendment of truthful off-label speech.  However with no particular regulatory significance it may be  an attempt to put agency views on record before the change in administration.   

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The top 5 medical writing mistakes

In my role of reviewing the work of multiple medical writers on a daily basis, I see the complete variety of what’s possible in medical writing. Here are 5 mistakes in medical writing to avoid. I could probably include more than 5, but these are the most common.

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How to grow your small medical writing business, what to do and not do

Tuesday, Feb 23, 2016
How to grow your small medical writing business, what to do and not do

In this episode, Emma Hitt Nichols talks to her business partner Chrystie Leonard, co-owner of Nascent Medical. This is the second part of a three-part series. We talk about strategic planning, how to grow a business, and the key metrics that are needed to evaluate the growth of you medical writing business.

In the first part, aired a week ago, we talked about what to look for when buying a business. Next week, in the final third, we’ll talk about getting the business ready for sale.