Dr. Abel Scribe's Review of the AMA Manual of Style

CURMUDGEON'S DELIGHT!

Style manuals are written either for editors or for authors, rarely for both. The AMA manual is a text only editors could love, it serves the interests of authors mostly as an afterthought. The "Instructions for Authors" on JAMA's website presents the essential requirements of the style in a more concise format for journal articles, the vehicles of research reporting. This is also two texts in one, a text on style and a text on medical terminology and ethics, a dubious combination. Style, by its very nature, is well served by a ten-year publication cycle. It should change only very slowly. Medical terminology, on the other hand, is in a constant state of flux. Authors working in a field are well aware of the accepted nomenclature without the need to be reminded by an inevitably dated style manual. This text is written for editors at some remove from medical practice and research. This review, on the other hand, is from an author's point of view.

New! The last edition of the AMA manual (1997) sought to impose the metric system on clinical measures. This initiative failed. It was simply ignored in preference to the conventional measures used in clinical practice. The new AMA style requires a conventional measure to be followed by a metric conversion factor. For example, the new AMA manual is a heavy tome, the one-thousand-plus page text weighs 4.2 pounds (to convert to kilograms multiply by 0.45). This is a sensible and useful requirement. However, you need not buy the manual to get the exhaustive conversion table, it's available on the JAMA website.

New! The new manual also accepts the "versioning" of online documents as research references. In effect, an online clinical or research report can be changed once published, without the change being documented, and still be considered a credible reference. I find this practice wholly unacceptable, and I'm a mere anthropologist, not an MD. Corrections, retractions, revisions, errata, and so forth to print articles are documented in print. The same standard must apply to electronic documents. Those who argue that the practice of medicine is more an art than a science may be right, but it is not a whimsical craft.

Curmudgeon's delight! For example, the table of contents lists a section on "Measurement and Quantitation." Do they mean to say "quantification," not "quantitation?" Alas, my dictionary has no such word. Abbreviations are used for the names of journals when composing references to articles. On at least three instances, the AMA manual refers readers to different sources where the standard abbreviations can be found. None get it right. The standard reference used to be the "Index Medicus" published by the National Library of Medicine. The name has changed to the "List of Journals Index by Medline" and is available free online.

What's in a name? If you are sufficiently knowledgable to write authoritatively on a subject, then you are familiar with how the research community talks about it, and they have litttle regard for style guides. For example, a highly lethal virus was first identified in the American Southwest in the early 1990s. A new virus is typically named for the locale where it is discovered. This was a problem for this new hantvirus strain. It was found in the Canyon del Muerto in northeast Arizona, so named for a massacre in the 1800s. Imagine the public reaction to a new, lethal, "Canyon of Death" virus loose in their neighborhood. Thought turned to naming it the "Four Corners" virus, but the local Chamber of Commerce muttered something about tarring and feathering those responsible. It was finally christened the "sin nombre virus," Spanish for "no name." This should have been written lowercase since "sin nombre" is not a proper noun, just a phrase. But the literature soon came to capitalize it as if it were a place name, the Sin Nombre Virus (SNV). The story continues. When in the process of publishing a review paper on the hantavirus my editor changed the capitalization to lowercase in the galley proofs. This was absolutely correct according to the style guides. I sent her portions of six articles from research journals to illustrate the practice of capitalization that had taken hold in the literature. To lowercase the virus name would have been stylistically correct, but it would have discredited the paper, suggesting the author was not in touch with the literature. It was capitalized in the published article. The moral? Use style guides warily when it comes to nomenclature.

Foot-in-Mouth Disease? The AMA's lead editor makes this charming observation in her preface: "I never cease to be amazed by the general inability of physicians, other health professionals, and scientists to communicate through the written word. Their scholarly and creative ideas and insightful data interpretation of them seem to get lost in the translation from brain to page" (p. v). The quality of medical writing has dramatically improved since a young Dr. Michael Crichton (Jurassic Park, tv's ER) wrote in the pages of the New England Journal that "medical writing is bad, but its functions are perfectly understandable as a display of scientific [editorial?] profundity, not as an attempt to communicate experience" (December 11, 1975;293:1257-1259). Apparently this malaise, and foot-in-mouth disease to boot, now afflicts the AMA's editors.

Curmudgeoning aside, is the 1000-page text usable? AMA style generally dispenses with periods after abbreviations, but if the abbreviation for "saint" is used in a name, as in William St. James, a period is required. If the abbreviation is used with a city in a reference, as in St Louis, no period is needed. Is this the answer to a question you would ever think to ask? What other pitfalls and traps lurk in this massive text? Instructions for the general use of abbreviations are found near pages 450 and 500; those for the use of colons are on pages 34 and 241; and those for numbers are on pages 795 or 850. The text may be well organized for editors, but if you are looking for guidance on the most common problems confronted by a writer, you have a monumental task before you. While there is some useful information for authors in the first 60-80 pages, especially on references, this a tedious volume to work through. It is a reference, not a guide. A reference demands that you know what questions to ask. A guide answers the questions you didn't think to ask. As an author, I need a style guide.