11.0 Correct and Preferred Usage

Style, not least, adds beauty to the world. To a literate reader, a crisp sentence, an arresting metaphor, a witty aside, an elegant turn of phrase are among life’s greatest pleasures. . . . [T]his thoroughly impractical virtue of good writing is where the practical effort of mastering good writing must begin.

Steven Pinker¹

Following simple rules for correct and preferred usage of common words and phrases is important in scientific communication because it increases clarity, provides consistency, and helps avoid miscommunication.

Note: All terms (and pairs of terms) are in alphabetical (not preferential) order.

ability, capability, capacity—These near-synonyms have slightly different meanings. Ability means an actual (as opposed to potential) skill, either mental or physical; it may be native or acquired. Capability is a unique fitness for a defined end; the word is sometimes used in place of ability, but its use in place of capacity is rarely correct. Capacity is the potential to exercise or develop a skill, usually mental; it is native as opposed to acquired.

The ability to select candidates who will thrive and successfully complete a residency is especially critical for general surgery programs.

The capacity of the patient to make medical decisions should be evaluated within the context of specific medical conditions.

In this study of the association between walking and future risk of dementia, findings are based on a sample of physically capable elderly men.

abnormal, normal; negative, positive—Examinations and laboratory tests and studies are not in themselves abnormal, normal, negative, or positive. These adjectives apply to observations, results, or findings (see 19.0, Study Design and Statistics). Avoid the use of normal and abnormal to describe persons’ health status. Results of cultures and tests for specific reactions or microorganisms may be negative or positive. Other tests display a pattern of activity rather than a single feature, and in these a range of normal and abnormal results is possible. These tests include electroencephalograms and electrocardiograms and modes of imaging, such as isotopic scans, radiographic studies, and tomograms.

See 11.10, Laboratory Values.

abort, terminate—Abort means to stop a process prematurely. In pregnancy, abortion means the premature expulsion—spontaneous or induced—from the uterus of the products of conception. A pregnancy, not a fetus or a woman, may be aborted. The synonym terminate—to bring to an ending or a halt—may also be used.

about, approximately, around—Although each of these words is used to refer to a value that is estimated and therefore imprecise, whether it is acceptable to use them interchangeably depends in part on context and the level of accuracy being implied. When referring to an inexact value in casual conversation, around, about, and approximately are all acceptable. When referring to an inexact value in medical or other technical writing, about may very occasionally be used if one carefully assesses the context; approximately is nearly always the best choice. Also, an estimated may be better.

accident, injury—According to the National Center for Injury Prevention and Control of the US Centers for Disease Control and Prevention,²  accident should not be used to refer to injuries from any cause. Although accident implies a random act that is unpredictable and unavoidable, epidemiologic studies and injury control programs indicate that injuries may be predictable and therefore preventable. The preferred terms refer either to the external cause (eg, injury from falls, injury from motor vehicle crashes, gunshot injury) or to the intentionality (unintentional injury for injuries resulting from acts that were not intended to cause harm and violence for any act in which harm was intended).²

Accident (and accidental) is considered by the public health community to be imprecise and should therefore be avoided. The injury-causing event can be described as noted above or with other terms, such as motorcycle crash, shooting, drowning, collision, poisoning, suffocation, fall from stairs, burning, paintball injury.

Note: Do not change accident if it is integral to the terminology being used, for example, an established injury classification system or as established terminology within a specific discipline (eg, Fatality Analysis Reporting System of the US National Highway Traffic Safety Administration, the World Health Organization’s International Classification of Diseases, cerebrovascular accident).

acute, chronic—These terms should be used to describe symptoms, conditions, or diseases; they refer to duration, not severity. Avoid the use of acute and chronic to describe patients, parts of the body, treatment, or medication.

Exception: Acute abdomen is a specific serious intra-abdominal condition—for example, appendicitis—with pain, tenderness, and muscular rigidity and for which emergency surgery may be indicated.

A note on short- and long-term patient care: According to Kane and Kane,³ “acute care hospital is preferred to short-term care hospital. Long-term care has come to include both an acute component (sometimes called subacute care or postacute care), which effectively provides the care formerly offered in hospitals, and the more traditional chronic component, which includes both medical and social services. As the name implies, subacute care has a shorter time frame and serves patients who are expected to recuperate or die, while the more chronic form provides more sustained supportive services.”

adapt, adopt—To adapt means to modify or adjust to fit a particular circumstance or requirement. To adopt means to take by choice into a relationship.

Despite health being vulnerable to the vagaries of climate, humans have adjusted their behavioral patterns and technologies to adapt to a diverse range of climates.

Purchasers, plans, practitioners, and organizations that certify or license clinicians or accredit training programs should adopt systems for measuring, monitoring, and improving quality for psychosocial interventions.

adherence, compliance—Although these terms are often used as synonyms, there are differences. Adherence can be defined as the extent to which a patient’s behavior (in terms of, for example, taking medication, following a diet, modifying habits, or attending clinics) coincides with medical or health advice. Use of the term adherence is intended to be nonjudgmental, a statement of fact rather than of blame of the prescriber, patient, or treatment.⁴  Noncompliance has a negative connotation that may indicate a stigmatizing image of rule, enforcement, and control; dominance and submission; and deviance from expected social roles. Whether a patient chooses to adhere to a therapeutic regimen may depend on many aspects of his or her experience with the disease and the medical encounter itself.⁵

Continued interaction with patients may provide an opportunity to identify barriers to medication adherence as well as a chance to suggest potential strategies to overcome them (eg, use of a pill box or cueing the taking of medications with a routine activity, such as toothbrushing).

Possible exception: A patient with a mental illness may be required to comply with court-ordered therapy.

adverse effect, adverse event, adverse reaction, side effect—Side effect is the secondary consequence of implementing an agent (usually a drug). The term is often used incorrectly when adverse effect, adverse event, or adverse reaction is intended. Because a side effect can be either beneficial or harmful, a specific term should be used.

A recent study examined the incidence of serious and fatal adverse drug reactions in hospitalized patients.

The beneficial side effects of aspirin include preventing myocardial infarctions and reducing the severity and damage from thrombotic strokes.

affect, effect—Affect, as a verb, means to have an influence on. Effect, as a verb, means to bring about or to cause. The 2 words cannot be used interchangeably.

Ingesting massive doses of ascorbic acid may affect his recovery [influence the recovery in some way].

Ingesting massive doses of ascorbic acid may effect his recovery [produce the recovery].

Affect, as a noun, refers to immediate expressions of emotion (in contrast to mood, which refers to sustained emotional states). Effect, as a noun, means result. Affect is often used as part of psychiatric diagnostic terminology.

The patient’s general lack of affect was considered an effect of recent trauma.

Note: In reports of research, use of the word effect should be limited to studies with designs that permit assessment of causal findings (eg, randomized trials, controlled laboratory experiments) and should not be used in reports of observational studies (eg, cohort, cross-sectional, case-control, case series, and meta-analysis) unless related to a statistical measurement such as effect size. See also association, relationship and 19.0, Study Design and Statistics.

age, aged, school-age, school-aged, teenage, teenaged—The adjectival form aged, not the noun age, should be used to designate a person’s age. Similarly, school-aged and teenaged are preferred to school-age and teenage. However, a precise age or age range should be given whenever possible (see 11.7, Age and Sex Referents).

The patient, aged 75 years, had symptoms of mild cognitive impairment.

Alternative: The 75-year-old patient had symptoms of mild cognitive impairment.

The US Preventive Services Task Force recommends chlamydia and gonorrhea screening for all sexually active women younger than 25 years (including teenaged girls), even if they are not engaging in high-risk sexual behaviors.

Note: In some expressions regarding age, it is redundant to add of age after the number of months or years because it is implied in the adjectives younger and older.

Influenza vaccination is not recommended for infants younger than 6 months.

See 11.2.1, Redundant Words.

aggravate, irritate—When an existing condition is made worse, more serious, or more severe, it is aggravated (also exacerbated), not irritated. Irritated indicates reaction, often excessive (eg, inflammation) to a stimulus.

Symptoms of gastroesophageal reflux disease can be aggravated by certain foods, such as chocolate, citrus fruits, spicy and tomato-based foods, caffeine, and alcohol, or by eating just before going to bed.

Wool, chemicals, soaps, and other substances can irritate the skin and cause itching.

alternate, alternative—Alternate is an adjective, adverb, or verb and alternative is usually a noun. Alternate means “occurring in turn” and alternative means “another possibility.”

Medications that interfere with testing should be stopped only if safe alternatives can be substituted.

The drugs should be taken on alternate days.

although, though—Although and though may be considered interchangeable. However, although is preferable as a complete conjunction because though in this construction is an “abbreviation” and thus may be less appropriate for formal prose. Though in the adverbial construction, meaning “however” or “nevertheless,” is correct.

Although the analysis was performed correctly, the terms of the investigation were too narrow to be interesting.

Squamous cell skin cancer, though common, remains largely unreported and unstudied.

ambiguous, equivocal—The 2 words are close in meaning but distinct in usage. Ambiguous means able to be understood in more than one way, having more than one possible meaning, or not expressed or clearly understood. Equivocal is defined as having 2 or more possible interpretations or not easily explained or understood.

The student was faulted for her ambiguous answer to a crucial question.

Further assessment for the presence of human papillomavirus can clarify an equivocal result from Papanicolaou testing.

among, between—Among usually pertains to general collective relations and always in a group of more than 2. Between pertains to the relation or association of 1 item and 1 other item. For instance, a treaty may be made between 4 countries because each is defining a relationship with each of the others, but peace may exist among them.

The patients shared the library books among themselves.

Between the two of us, we are certain to find the common factor among the patients we have examined.

analog, analogue—Use analog when referring to items related to computers or electronic equipment. Use analogue when “something similar to something else” is meant or when referring to chemical compounds. Use visual analog scale (not visual analogue scale).

apt, liable, likely—Apt connotes a volition or habitual tendency and should not be used in regard to an inanimate object. Apt also means suited to a purpose. Liable connotes the possibility of risk or disadvantage. Likely merely implies probability and thus is more inclusive than apt.

A child is apt to cry when frustrated.

Patients receiving immunosuppressant drugs are liable to acquire fungal infections.

The computer system is likely to crash if it is overloaded.

article, manuscript, paper—An unpublished study, report, or essay—that is, the document itself—may be referred to as a manuscript or paper. When published, it is an article.

The authors thank Frank J. Kobler, PhD, for statistical review of the manuscript.

Nancy MacClean, ELS(D), assisted with manuscript preparation.

The content of this article does not necessarily reflect the views or policies of the US Department of Health and Human Services.

The article by Carrozza and Sillke addresses the therapeutic options for a 69-year-old woman with disease of the left main coronary artery.

as, because, since—As, because, and since can all be used when “for the reason that” is meant. However, in this construction, as should be avoided when it could be construed to mean while.

Similarly, since should be avoided when it could be construed to mean “from the time of” or “from the time that.”

assure, ensure, insure—Assure means to provide positive information to a person or persons and implies the removal of doubt and suspense (assure the study’s participants that their test results will be held in complete confidence). Ensure means to make sure or certain (ensure the statistical power of the study). Insure means to take precaution beforehand (insure his life).

The insurance company assured the families of workers the provision of adequate funds for a proper burial.

The journal editors can assure readers that research was conducted ethically by mandating that every relevant paper include a statement that an institutional review board reviewed the study protocol.

because of, caused by, due to, owing to—Traditionally, due to and caused by were considered to be adjectival phrases and owing to and because of were adverbial phrases. Substituting caused by or resulting from for due to indicated whether due to was being used appropriately, or if that is or that are could be inserted before due to. If the meaning of the sentence changed or did not make sense with these substitutions or additions, the recommendation was to use because of or owing to instead.

However, because of, caused by, due to, and owing to are now accepted as prepositions and can be used without restriction.

biopsy—Biopsy refers to the removal and examination (usually microscopically) of tissue or cells from the living body. Use of biopsy as a verb was previously considered to be incorrect. However, such use has become common and acceptable.

Observations are made of the biopsy specimen, not on the biopsy itself.

The utility of standard biopsy in addition to targeted biopsy for prostate cancer was found to be limited.

Millions of breast biopsies are performed annually.

blinding, masking—The statistical term blinding (or blinded review or assessment) is the evaluation or categorization of an outcome in which the person assessing the outcome is unaware of the treatment assignment; blinding is used to avoid bias. The term is also used to refer to peer review, for example, single-blind review, where the reviewer can see the author’s name and affiliation on the paper but the reviewer’s identity is concealed, or double-blind review, where both reviewer and author identities are concealed. The equivalent term masking (or masked review or assessment) is preferred by some investigators and journals, particularly those in ophthalmology (see 5.7.1, Confidentiality During Editorial Evaluation and Peer Review and After Publication, and 19.5, Glossary of Statistical Terms).

breastfeed, nurse—When referring to human lactation, use breastfeeding (breastfeed, breastfed). This term is more specific than nursing and prevents any confusion with the profession of nursing.

cadaver, donor—When describing the source of human organs and tissues used for transplant, avoid cadaver (or dead body). Correct usage is deceased donor (or recovered from deceased organ and tissue donors). When referring to a deceased person whose body is to be used for anatomical dissection, cadaver is correct (cadaveric as an adjective).

can, may, will—Bernstein,⁶ in his classic The Careful Writer, perhaps said it best: “Whatever the interchangeability of these words in spoken or informal English, the writer who is attentive to the proprieties will preserve the traditional distinction: can for ability or power to do something, may for permission to do it.” When summing up findings, will is used to express futurity or inevitability; may suggests the possibility to do something.

Use of the most common antibiotics in early life may increase the risk of autoimmunity in children at increased genetic risk.

Use of the most common antibiotics in early life will increase the risk of autoimmunity in children at increased genetic risk.

Improved air quality can promote molecular longevity from birth onward.

Improved air quality will promote molecular longevity from birth onward.

case, client, consumer, participant, patient, subject—In biological research, a case is a particular instance of a disease. A patient is a particular person under medical care. A research participant (preferred to subject; see below) is a person with a particular characteristic or behavior or a person who undergoes an intervention as part of a scientific investigation. A control participant is a person who does not have at least some of the characteristics under study or does not receive the intervention but provides a basis of comparison with the case patient (see 19.0, Study Design and Statistics). In case-control studies, it is appropriate to refer to cases, patients in the case group, or case patients and controls, participants in the control group, or control patients.

Some consider subject (as in study subject) to be impersonal, even derogatory, as if the person in the study were in a subservient role. Similarly, the use of case is dehumanizing when referring to a specific person. For example,

Note: Make the distinction between person and patient:

Many persons in the United States have type 2 diabetes [persons with type 2 diabetes regardless of care].

Many patients in the United States have type 2 diabetes [only persons under medical care].

A case is evaluated, documented, and reported. A patient is examined, undergoes testing, and is treated. A research participant is recruited, selected, sometimes exposed to experimental conditions, and observed. See also diagnose, evaluate, examine, identify and follow, follow up, follow-up, observe.

Note: In general, patients should not be referred to as clients or consumers. However, persons enrolled in substance use treatment programs, for example, or persons undergoing treatment at a dialysis center are sometimes referred to as clients. Client may also be used by social workers or psychologists and in some research settings where patient or participant is inappropriate. Consumer—one who consumes goods or services—has worked its way into the medical lexicon and may be appropriate in certain discussions. For instance, in the following example, patient would not fit the context:

The internet has become an important mass medium for consumers seeking health information and health care services online.

case-fatality rate, fatality; morbidity, morbidity rate; mortality, mortality rate—Fatality is the occurrence of death and case-fatality rate is the probability of death among people diagnosed as having a disease. The rate is calculated as the number of deaths during a specific period divided by the number of persons with the disease at the beginning of the period.⁷  Morbidity is a diseased state, and morbidity rate is the frequency with which a disease appears in a population. Mortality is the number of deaths in a given time or place, and mortality rate is the death rate described by the following equation: [(Number of Deaths During Period) × (Period of Observation)]/(Number of Individuals Observed)⁷ (see 19.5, Glossary of Statistical Terms).

catatonic, hysterical, manic, psychotic, schizophrenic—Do not use these terms when referring to patients. It is dehumanizing to refer to a patient as “a schizophrenic.” Use “a patient with schizophrenia” (see 11.12.6, Terms for Persons With Diseases, Disorders, or Disabilities).

cerebrovascular accident, stroke, stroke syndrome—Cerebrovascular accident (abbreviated CVA) is an older but acceptable generic term synonymous with stroke and stroke syndrome. However, when using any of these terms, an author should also specify, if possible, the subtype(s) under discussion (eg, ischemic stroke, hemorrhagic stroke, and/or transient ischemic attack).

cesarean delivery, cesarean section—According to the American College of Obstetricians and Gynecologists Publications Department, the preferred terms are cesarean delivery or cesarean birth. Most etymologists believe that cesarean and section originated from the Latin verbs that both mean “to cut”; therefore, cesarean section is redundant.⁸ Do not capitalize cesarean.

chief complaint, chief concern—Chief complaint has been traditionally used by physicians when taking a patient’s medical history. However, chief concern may be a better description because complaint may be construed as pejorative and confrontational. Also, patients report symptoms and concerns. Avoid “patient complaint.”

classic, classical—In most scientific writing, the adjective classic generally means authentic, authoritative, or typical (the classic symptoms of myocardial infarction include angina, dyspnea, nausea, and diaphoresis). In contrast, classical refers to the humanities or the fine or historical arts (the elements of classical architecture can be applied in radically different architectural contexts than those for which they were developed).

Primary liquid dysphagia is a classic symptom suggestive of achalasia.

Darkening of the iris pigmentation and eyelash hypertrichosis are classic findings associated with the use of a prostaglandin analogue agent.

The figure represents the aesthetic of the age: clear, beautiful, simple, and clean design, with a background of twirling leaves reminiscent of classical themes.

However, some disciplines (eg, genetics, immunology) use classical for specific terms:

Classical lissencephaly may be caused by sequence variations of genes in chromosome bands 17p13.3 and Xq22.3-q23.

The classical and alternative pathways of complement components are described in 14.8.3, Nomenclature, Complement.

The authors suggest how to present results of data analysis under each of 3 statistical paradigms: classical frequentist, information-theoretic, and bayesian.

clinician, practitioner—Depending on context, these terms can be used to describe persons in the clinical practice of the health fields of medicine, nursing, psychology, dentistry, optometry, and podiatry, as distinguished from those specializing in laboratory science, research, policy, or theory, for example. When referring to a particular type of clinician or practitioner, it is preferable to use the more descriptive term (eg, physician, nurse, dentist, optometrist, podiatrist). The plural forms clinicians and practitioners may be appropriate to refer to a group of such professionals from different fields. Avoid use of the nonspecific term provider. See also provider.

compare to, compare with—One thing or person is usually compared with another when the aim is to examine similarities or differences in detail. An entity is compared to another when a single striking similarity (or dissimilarity) is observed or when a thing of one class is likened to one of another class, without analysis (ie, one entity is comparable to another).

Patients in both active treatment groups had greater improvements from baseline in psychosocial functioning compared with patients receiving only routine medical care.

Few medical discoveries can compare to the discovery of penicillin.

compose, comprise—Comprise means to be composed of or to include; it takes the active voice, whereas compose takes the passive voice. The whole is composed of its parts and comprises its parts.

The chemotherapeutic regimen is composed of several toxic ingredients.

The chemotherapeutic regimen comprises several toxic ingredients.

Clue to usage: Never use of with comprise.

A good alternative for comprise is to use “consist of” or “include.”

condition, disease, disorder—Although these terms are frequently used interchangeably, differences between them exist and can assist in using them in more specific senses. Condition is perhaps the least specific, often denoting states of health considered normal or healthy but nevertheless posing implications for health care (eg, pregnancy). The term might also be used to indicate grades of health (eg, a patient might be described as in stable, serious, or critical condition). Condition indicates a state of health, whether well or ill. A condition conferring illness might further be classified as a disease or disorder; however, condition might be used in place of disease or disorder when a non–disease-specific term is indicated.

Disease is often used in a general sense when referring to conditions that affect a physical system (eg, cardiovascular disease) or a part of the body (eg, diseases of the eye). The term also may be used in specific senses; for example, a writer might refer in general terms to neurologic disease or cognitive impairment or in more specific terms to Alzheimer disease or dementia with Lewy bodies.

Disorder, in contrast, denotes a condition characterized by functional impairment without structural change. Although certain disorders or categories of disorders might be accompanied by specific signs and symptoms, their presence is not required for a condition to be termed a disorder.

continual, continuous—Continual means to recur at regular and frequent intervals. Continuous means to go on without pause or interruption.

The patient with emphysema coughed continually.

His labored breathing was eased by a continuous flow of oxygen through a nasal cannula.

contrast, contrast agent, contrast material, contrast medium—Distinguish between contrast (ie, blackness and whiteness on an image) and contrast material (or contrast agent, contrast medium) (ie, a compound administered to enhance portions of the anatomy on an image).

criterion standard, gold standard—Criterion standard is a test considered to be the diagnostic standard for a particular disease or condition, used as a basis of comparison for other (usually noninvasive) tests. A commonly used synonym, gold standard, is considered jargon by some in the methodological literature but not in the medical literature⁹ (see 19.5, Glossary of Statistical Terms).

diabetes—The types of diabetes currently recognized by the American Diabetes Association are as follows:

Prediabetes refers to blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes. The term prediabetes is sometimes referred to as impaired glucose tolerance or impaired fasting glucose, depending on what test was used when it was detected.¹⁰

“Mellitus” need not be specified when referring to diabetes, even at first mention; the term mellitus has etymologic significance (and there are other, rarer, types of diabetes, such as insipidus), but mellitus need not be added.

For other specific types of diabetes, consult Diabetes Care.¹¹

diagnose, evaluate, examine, identify—Diagnose, evaluate, and identify apply to conditions, syndromes, and diseases. Patients are examined. Patients may be evaluated for the possibility of a condition (eg, The patient was evaluated for possible cardiac disease). Although diagnose was formerly avoided when referring to a patient, it is now acceptable to say a patient “was diagnosed.” See also case, client, consumer, participant, patient, subject and management, treatment.

The patient was diagnosed as having schizophrenia.

The patient was diagnosed with schizophrenia.

die from, die of—Persons die of, not from, specific diseases or disorders.

The patient died of complications of disseminated intravascular coagulation.

dilate, dilation, dilatation—According to the American College of Obstetricians and Gynecologists, dilate is a verb meaning to expand or open. Dilation means the act of dilating. Dilatation means the condition of being stretched or expanded.⁸

The patient’s cervix dilated during a period of 12 hours.

The patient was treated with dilation and curettage.

After 4 hours of labor, cervical dilatation was 3 cm.

disc, disk—For ophthalmologic terms, use disc (eg, optic disc); for other anatomical terms, use disk (eg, lumbar disk).

discomfit, discomfort, disconcert—These words are commonly confused, perhaps because they begin with the same 5 letters and sound similar.

Discomfit, although occasionally still used in the sense of “to frustrate or thwart,” is currently most often used to indicate mental, rather than physical, states, specifically in the sense of one’s being perplexed or embarrassed (ie, disconcerted). Discomfort is most often used to indicate one’s feeling physically or emotionally uncomfortable, resulting from the efforts of others, from personal excess, or from a condition or disease state. Disconcert, indicating perplexity or disturbed composure, is still occasionally used as a verb but currently is used much more frequently as an adjective.

The medical student felt discomfited by her palpable grief at the loss of a patient.

The excitement produced by the first meal since bariatric surgery may be followed by a feeling of abdominal discomfort.

I found the discussion to be premature and very disconcerting.

discreet, discrete—Discreet is defined as careful and circumspect in one’s speech or actions, especially to avoid causing offense or to gain an advantage (ie, intentionally unobtrusive). Discrete means individually separate and distinct.

Working with sensitive patient information, physicians and other medical staff must be discreet.

Although the lesions are usually discrete, they can appear grouped and only rarely do they coalesce.

disinterested, uninterested—Although these 2 words are increasingly treated as synonyms in written and spoken language, their differences in meaning are sufficiently useful to be worth preserving. To be disinterested is to be unbiased or impartial and free from selfish motives; to be uninterested is to be unconcerned, indifferent, inattentive, or unbiased. A disinterested judge is admirable; an uninterested judge is not. As with many “word pairs,” context is key:

She was uninterested in a career in basic research.

He was a disinterested observer of the complex procedure.

doctor, physician—Doctor is a more general term than physician because it includes persons who hold such degrees as PhD, DDS, EdD, DVM, and PharmD. Thus, the term physician should be used when referring specifically to a doctor of medicine, such as a person with an MD, MBBS, or a DO or equivalent degree. See also clinician, practitioner and provider, and 11.5, Jargon.

dosage, dose—A dose is the quantity to be administered at one time or the total quantity administered during a specified period. Dosage implies a regimen; it is the regulated administration of individual doses and is usually expressed as a quantity per unit of time.

The usual initial dosage of furosemide for adult hypertension is 80 mg/d, typically divided into doses of 40 mg twice a day. Dosage should then be adjusted according to the patient’s response.

effective, effectiveness; efficacious, efficacy—Efficacy and efficacious, used especially in pharmacology and decision analysis, have to do with the ability of a medication or intervention (procedure, regimen, service) to produce the desired or intended effect under ideal conditions of use. The determination of efficacy is generally based on the results of a randomized clinical trial.

Effective and effectiveness, however, describe a measure of the extent to which an intervention produces the effect in average or routine conditions of use; a measure of the extent to which an intervention fulfills its objectives.

Few safe, effective weight-management drugs are currently available.

The researchers investigated the safety and efficacy of liraglutide vs placebo for weight management in adults with overweight or obesity and type 2 diabetes.

Cost-effectiveness analysis is the comparison of strategies to determine which provides the most clinical value for the cost.¹²  Comparative effectiveness research is the conduct and synthesis of systematic research comparing different interventions and strategies to prevent, diagnose, treat, and monitor health conditions. The purpose of this research is to inform patients, health care professionals, and decision makers about which interventions are most effective for which patients under specific circumstances¹³ (see 19.5, Glossary of Statistical Terms).

eg, ie—eg comes from the Latin exempli gratia: “for example” and ie comes from id est: “that is.” Both should be followed by a comma.

In this study, the general module of messages included information generally provided by secondary prevention programs, eg, on chest pain action plans, guidelines and risk factor targets, and medications and adherence.

With 95% power and a 2-sided significance level of 5%, the study had statistical power to detect a significant odds ratio of 0.76 (ie, a 24% reduced risk) for individuals in the highest quartile of intake.

elicit, illicit, solicit—These words have distinctly different denotations, yet they are often confused or misused. In medical and scientific contexts, it is especially important to preserve the distinctions between them.

Illicit, denoting simply not permitted or unlawful (and sometimes used colloquially to indicate naughty, unseemly, or immoral), has limited use in medical writing. For example, written materials might convey the risks associated with the use of illicit drugs, discuss illicit relationships between researchers and industry, or report on the illicit trade in human body parts. Beyond such instances, the word is not often used in medical literature.

Elicit, however, means to call forth or draw out (as information or a response) or to draw forth or bring out (something latent or potential). The word occurs frequently in medical contexts. It might be used in both senses regarding a patient-physician encounter. For example, a physician evaluating a patient’s pain will ask questions to elicit information about the characteristics of the pain (eg, location, nature, duration, exacerbating factors, severity). Having thus elicited information about a patient’s pain, the physician then tries to elicit the real concern. In materials that cover the basic sciences and their clinical applications, elicit is perhaps most frequently used in the second sense. A writer might report that a new vaccine elicits a given immune response, describe pathological mechanisms that elicit organ damage, or present a theory of how a treatment might elicit changes in gene expression.

Illicit and elicit are easily distinguished from each other; illicit is always an adjective, whereas elicit—in current usage—is always a verb. It also can help to remember that illicit denotes illegal.

Solicit is most frequently used in medical contexts in the sense of to approach with a request or a plea. It is often used interchangeably with elicit. However, such use obscures an important distinction. The Oxford Dictionary of American Usage and Style states, “To solicit a response is to request it. To elicit a response is to get it.”¹⁴ Thus, the physician solicits information regarding the patient’s pain and then performs a physical examination to elicit and evaluate actual pain. In medical contexts, the distinction has obvious implications for reports of survey studies and possibly for discussion of power calculations in reports of clinical trials.

endemic, epidemic, hyperendemic, pandemic—Endemic conditions or diseases are prevalent in a particular place or among a particular group. Epidemic conditions occur abruptly in a defined area and are (usually) temporary. A hyperendemic condition is one that has a high prevalence. A pandemic condition occurs abruptly throughout a wide geographic area, even worldwide, and is (usually) temporary.

Cowpox is an orthopoxvirus infection endemic in European wild rodents but with a wide host range, including human beings.

The Ebola epidemic sparked a much-needed course correction that favored strong health infrastructure.

The researchers used remote sensing and geographic information system technology to identify individual high-risk residences in Westchester County, New York, where Lyme disease has been hyperendemic since 1982.

Internationally, between 50 million and 100 million people died in the 1918-1919 influenza pandemic.

erectile dysfunction, impotence—Erectile dysfunction is the inability to develop and maintain an erection for satisfactory sexual intercourse or activity (in the absence of an ejaculatory disorder). Erectile dysfunction is the preferred term rather than the more commonly used term impotence.

etc—Use etc (or and so on or and the like) with discretion. Such terms are often superfluous and are used simply to extend a list of examples. When, in other instances, omission would be detrimental, substitute more specific phrasing, such as and other methods or and other factors. Etc may be used in a noninclusive listing when a complete list would be unwieldy and its content is obvious to the reader. The term is best avoided in scientific reports.

Etc is not followed by a period except when it is at the end of a sentence.

Gelatin is made from animal ligaments, tendons, bones, etc, that have been boiled in water. Gelatin is often used in confectionery, ice cream, and other dairy products.

fasted, fasting—These terms are derivative forms (adjective and participle) of the noun and verb fast that are often used in the scientific literature.

fellow, intern, internist, resident—Fellows have completed their residency and can elect to complete further training in a specialty. Interns have graduated medical school and are in the first year of post–medical school training. Interns can only practice medicine within their training program. Internists are physicians specializing in internal medicine. Residents have completed their intern year and are still in training.

fever, temperature—Fever is a condition in which body temperature rises above that defined as normal. It is incorrect to say a person has a temperature if “fever” is intended. Everyone has a temperature, either normal or abnormal.

fewer, less—Fewer and less are not interchangeable. Use fewer for number (individual persons or things that are countable) and less for volume, mass, and percentage/proportion (indicating degree or value).

Fewer interventions may not always mean less care.

The report suggests that fewer women are receiving screening mammograms.

Note: We spent less than $1000 (not: We spent fewer than $1000).

There was less than 30% difference in outcomes.

The outcome of interest occurred in less than 30% of the patients.

They reported fewer data (not: They reported less data).

follow, follow up, follow-up, observe—Cases are followed. Patients are not followed but observed. However, either cases or patients may be followed up (eg, the maintenance of contact with or reexamination of a person or patient, especially after treatment). Their clinical course may be followed.

In a study, case or control participants may be lost to follow-up (eg, the investigators were unable to locate them to complete documentation on participants in the initial study groups) or unavailable for follow-up (eg, they could not be contacted or the investigators were unable to persuade them to complete the study).

Patients with retained intracranial fragments have been followed up, and the sequelae of such fragments were analyzed. To date, 9 patients have been lost to follow-up.

foreign-born—This term may be considered derogatory and should not be used. It is preferable to say that a person was born outside the country of interest. For example, use non–US born or non–Canadian born.

The best approach to testing among non–US-born residents is uncertain.

We estimated the cost-effectiveness of testing and treatment for latent tuberculosis infection in residents born outside Canada.

gender, sex—Sex is defined as the classification of living things as male or female and is a “biological component, defined via the genetic complement of chromosomes, including cellular and molecular differences.”¹⁵

Gender comprises “social, environmental, cultural, and behavioral factors and choices that influence a person’s self-identity and health.”⁹ The term gender “includes gender identity (how individuals and groups perceive and present themselves), gender norms (unspoken rules in the family, workplace, institutional, or global culture that influence individual attitudes and behaviors), and gender relations (the relations between individuals of different gender identities).”¹⁵

The terms should not be used interchangeably. In reports of research, if demographic information about human participants is included, the term used should be indicated and defined and the method used to assess sex or gender should be described (eg, self-report, investigator observed, metadata in a database). In many instances, authors of articles in biomedical publications use the term gender when they intend the word sex. As noted by Clayton and Tannenbaum, “[W]hen sex is based on self-report, it will be incorrect in a very small percentage of individuals because some individuals will not be 46XX or 46XY. However, in most research studies, it is not possible to conduct detailed genetic evaluation to determine the genetic make-up of all participants.”¹⁵

A sex ratio of 1.06:1, the ratio of male to female births, has declined in the past decades.

Many studies indicate that women are less likely than men to undergo cardiac procedures after an acute myocardial infarction, raising concerns of sexual bias in clinical care. However, no data exist about the relationship among patient sex, physician sex, and use of cardiac procedures.

Responses to pain and pain therapies differ between men and women. Whether this difference is related to sex-based factors (physiological), gender-based factors (psychosocial), or both has not been determined.

The survey of bias in the workplace asked women and men to self-report their gender.

Transgender means of, relating to, or being a person whose gender identity differs from the sex the person had or was identified as having at birth. Cisgender means of, relating to, or being a person whose gender identity corresponds with the sex the person had or was identified as having at birth.

Avoid using any trans term as a noun; the adjectival form is preferred (not transman or transwoman but transgender man and transgender woman).

Surgeons are seeing an increase in consultations for surgical therapy to help transgender and gender-nonconforming individuals.

The study examined the health status of gender minorities in the United States compared with cisgender peers.

See 11.7, Age and Sex Referents, the GLAAD Media Reference Guide-Transgender Issues website,¹⁶ and the Gender Equity Resource Center website.¹⁷

global, international—Global relates to or involves the entire world; an equivalent term is worldwide (a global system of communication, global climate change, global health security).

Spread of infection with Zika virus among pregnant women has become a global public health concern.

International affects 2 or more nations (international trade, international movement, international consortium).

Researchers conducted an international survey, with respondents selected from Australia, China, France, the United Kingdom, and the United States.

But: global amnesia, global aphasia, global ischemia, global cognitive function, global pain relief, Global Assessment of Functioning Scale

health care—Express this term as 2 words. It is not necessary to hyphenate health care in its adjectival form (see 8.3, Punctuation, Hyphens and Dashes).

historic, historical—Although their meanings overlap and they are often used interchangeably, historic and historical have different usages. Historic means important or influential in history (a historic discovery). Historical is concerned with the events in history (a historical novel).

This historical novel has had a historic impact.

This article considers the historical effect of Medicare and Medicaid on mental health services and discusses this history as a basis for appraising the legislation now before the US Congress.

Note: The aspirant “h” in both historic and historical is not silent (see 7.3.2, Indefinite Articles, and 11.11, Articles).

-ic, -ical—Both “-ic” and “-ical” can be appropriate suffixes for adjectives. Often, the “-ic” and “-ical” forms have the same meaning, eg, anatomic and anatomical, neurologic and neurological, and physiologic and physiological, but there are times when the suffix may change the meaning of the word and it is important to use the correct form. It is preferable to be consistent throughout a document. Examples of such differences in meaning include

immunize, inoculate, vaccinate—Immunize means to induce or provide immunity by giving a vaccine, toxoids, or preformed antibodies. Inoculate means to introduce a serum, a vaccine, or an antigenic substance. Vaccinate refers to the act of administering a vaccine.

To immunize the newborn of an HBsAg-positive woman against hepatitis B, the patient should be inoculated with both hepatitis B immunoglobulin and vaccine.

All participants were inoculated intranasally with influenza A/Texas/36/91(H1N1) virus.

Ten vaccinia-naive participants were vaccinated with undiluted smallpox vaccine.

The World Health Organization is partnering with the United Nations Children’s Fund to conduct a massive vaccination campaign in 7 countries to inoculate more than 20 million children against polio and other diseases.

impaired, intoxicated—These related terms are used in the United States to define impairment in driving performance attributable to the use of alcohol or drugs. For instance, in some jurisdictions, a blood or breath alcohol (ethanol) concentration of 0.08 g/dL is considered legal evidence of impairment for driving. By extension, some injury prevention researchers have considered this concentration of alcohol to be scientific evidence of impairment in other potentially hazardous activities. However, cognitive and other functions may be impaired at even lower concentrations of alcohol, particularly if other psychoactive drugs, including prescription drugs, have been taken. No specific blood or breath concentration of alcohol may be considered to be scientific evidence of intoxication or impairment for all persons in all settings and activities. Authors should explain, justify, and define the use of these terms, preferably in the Methods section of the manuscript.

imply, infer—To imply is to suggest or to indicate or express indirectly. To infer is to conclude or to draw conclusions from facts, statements, or indications.

These results, though cross-sectional, imply that physical fitness is related to fewer coronary risk factors.

Our study relied on cross-sectional data, restricting our ability to infer the causal directions underlying the observed associations.

Note: Inference is the process of passing from observations to generalizations, usually with calculated degrees of uncertainty.

In the presence of missing data, mixed models can provide valid inferences under an assumption that data are missing at random.

See 19.5, Glossary of Statistical Terms (inference).

incidence, prevalence—Incidence refers to the number of new cases of disease among persons at risk that occur over time,⁷ as contrasted with prevalence, which is the total number of persons with the disease at any given time.

See 19.5, Glossary of Statistical Terms.

injecting, injection drug user; intravenous—The terms injecting drug user and injection drug user are not necessarily the same as intravenous drug user. Injecting or injection drug users can inject drugs intravenously, intramuscularly, or subcutaneously. Do not substitute one term for the other. If intravenous is used, ascertain that the route of administration is through a vein. If injecting or injection drug user is used, specify the type of injection (eg, intravenous, intradermal) at first mention, unless all types are meant. If uncertain, query the author.

in order to—In order can often be removed from the phrase in order to without changing its meaning (see 11.2.1, Redundant Words). However, in some cases such a deletion may be awkward or change the meaning.

Our students must have the learning opportunities that they need in order to acquire true understanding. [If “in order to” is removed, the syntax is disrupted (“need to acquire” would seem to apply to “opportunities”). The sentence might be reworded as “to be able to acquire” instead of “in order to acquire.”]

irregardless, regardless—Irregardless—most likely a blend of irrespective and regardless—is incorrect regardless of usage.

life expectancy, life span—Life expectancy is the average period that a person may expect to live. Life span is the length of time a person lives.

limited-income, low-income, resource-limited, resource-poor, transitional—These adjectives are used to describe a nation, region, or group in which most of the population lives on far less money—with far fewer basic public services—than the population in wealthy countries. For the purposes of financing, debt relief, technical assistance and advisory services, and special initiatives, the World Bank also categorizes countries as heavily indebted poor countries, middle-income countries, low-income countries under stress, and small states. There is no universal, agreed-on criterion for describing a country in terms of its economic or human “development” and which countries fit these different categories, although there are different reference points, such as a nation’s gross domestic product per capita or the limited nation’s Human Development Index (HDI) compared with that of other nations.

Choice of an appropriate term will depend on context, and writers should choose respectful terms that reflect a specific country’s economic and social situations.

Use of the terms first world/third world and developed/developing are not recommended as descriptors when comparing countries or regions. The term third world is pejorative and archaic. The term developing may seem like an acceptable alternative, but it too can be considered pejorative and insensitive to the many complexities of metrics used to measure economic, political, resource, and social factors. Best practice is to avoid such general terms and use specific terms that reflect what is being compared, such as low-income or high-income for an article comparing countries based on measures such as gross national product per capita.

long COVID, post-COVID-19 condition (PCC)—After infection with SARS-CoV-2, some people develop long-term effects. This condition has been termed long COVID, post-COVID-19 condition (PCC), post-COVID syndrome, and postacute sequelae of SARS-CoV-2 infection (PASC). Which term to use will depend on the content and the intended audience. However, “long COVID” can be used in scientific content as long as the meaning is clear; it may be helpful to add a definition or cite a source to further clarify features relevant to the content. Note that “long” is lowercase. Avoid jargon terms such as “long haulers” in clinical or scientific content.

malignancy, malignant neoplasm, malignant tumor—When referring to a specific tumor, use malignant neoplasm or malignant tumor rather than malignancy. Malignancy refers to the quality of being malignant.

Relatives of patients with carcinoma of unknown primary (CUP) are at increased risk of CUP and several other malignant neoplasms, including lung, pancreatic, and colon cancer.

management, treatment—To avoid dehumanizing usage, it is generally preferable to say that cases are managed and that patients are cared for or treated. However, constructions such as “the clinical management of the seriously ill patient” and “the management of patients with HIV infection” are acceptable when used to refer to a general treatment protocol. Management is especially applicable when the care of the patient does not involve specific interventions but may include, for example, watchful waiting (eg, for prostate cancer or mitral regurgitation). Management may also be used to refer to the monitoring or periodic evaluations of the patient.

militate, mitigate—These 2 words are not synonymous. Militate means to have weight or effect and is usually used with against. Mitigate means to moderate, abate, or alleviate.

The constraints of nationalism militate against state conformance with global health norms.

An increasing body of evidence presents the possibility of developing drugs to mitigate cognitive decline.

This review considered evidence related to mitigation of risk in the use of opioids for chronic pain.

multivariable, multivariate; univariable, univariate—Multivariable means many variables and refers to any statistical test that deals with 1 dependent variable and at least 2 independent variables. It may include nominal or continuous variables, but ordinal data must be converted to a nominal scale for analysis. Multivariate analysis is similar to multivariable analysis except that there is more than 1 dependent variable. The term multivariate is frequently incorrectly used in the scientific literature when multivariable analysis is meant. Univariable analysis refers to statistical tests involving only 1 dependent variable and no independent variables or may also apply to an analysis in which there are no independent variables. For univariate, the suffix “-ate” means to act on. Because no variable is acted on in a univariable analysis, univariable is a more appropriate term than univariate when there is only a single variable involved.

See 19.0, Study Design and Statistics.

nauseous, nauseated—These terms are often used interchangeably to mean feeling unwell, but they have distinctly different meanings. Nauseous refers to causing an illness or disgust, and nauseated refers to feeling ill or disgust.

The nauseous smell sickened several people in its vicinity.

The patient was nauseated after taking aspirin.

-ology—This suffix, derived from the Greek logos, meaning “word,” “idea,” or “thought,” denotes science of or study of. Many terms with this suffix, like morphology, histology, etiology, and symptomatology, are general and abstract nouns and should not be used to describe individual and particular items. Pathology is an exception and can be used.

on, upon—In scientific articles, upon often simply means on, which is the preferred term.

operate, operate on—Surgeons operate on a patient or perform an operation on a patient. Similarly, patients are not operated but are operated on.

operation, surgical procedure, surgeries, surgery—Surgery can mean surgical care, surgical treatment, or surgical therapy (ie, the care provided by a surgeon with the help of nurses and other personnel from the first consultation and examination, through the hospital stay, operation, and postoperative care, until the last follow-up visit is complete).

An operation is performed on a living body to repair damage or a defect or restore health; it is the surgical procedure.

Surgery is what a surgeon practices or a particular medical specialty. An operation is what a surgeon performs. In this context, there is no such word as surgeries. In the United Kingdom, surgeries are treatment rooms.¹⁸

ophthalmologist, optician, optometrist—Ophthalmologists are specialists in medical and surgical eye disease. Opticians are technical practitioners who design, fit, and dispense corrective lenses. Optometrists are health care professionals who provide primary vision care that ranges from sight testing and correction to the diagnosis, treatment, and management of vision changes.

over, under—Correct usage of these words depends on context.

Note: It is unnecessary and redundant to add of age after the number of years. When the terms older and younger are used, age is implied (see 11.2.1, Redundant Words).

percent, percentage, percentage point, percentile—See 18.7.2, Numbers and Percentages, Forms of Numbers, Percentages.

persons, people—Both terms are acceptable.

place on, put on—The phrase “to put [or to place] a patient on a drug” is jargon and should be avoided. Medications are prescribed or patients are given medications; therapy or therapeutic agents are started, administered, maintained, stopped, or discontinued.

preventative, preventive—As adjectives, preventive and its derivative preventative are equal in meaning. The shorter preventive is preferred.

principal, principle—These words sound the same but have very different meanings. Principal can be a noun or an adjective and has several definitions, including a loan amount that requires repayment, someone who has an important role, or something that is primary or pivotal. Principle is always a noun and only refers to a law or rule.

The patient was hospitalized with a principal diagnosis of chest pain.

The principal investigator observed the first 2 interventions.

The physician studied the principles of ethics of the American Medical Association.

prostitute, sex worker—Epidemiologic studies use the term sex worker (or commercial sex worker) to describe these persons of any gender, rather than the more derogatory prostitute.

provider—The term provider can mean a health care professional, a medical institution or organization, or a third-party payer and is thus unclear. If the usage refers to a specific person or entity (eg, physician, hospital), use the specific name (eg, pediatrician, tertiary care hospital, managed care organization), rather than the general term provider. If multiple professionals and organizations are meant collectively, define them clearly.

Avoid: To protect the public health and safety during recovery operations after a hurricane, the Centers for Disease Control and Prevention has created guidelines of interest to health care providers (trauma surgeons, nurses, and psychologists), relief workers, and shelter operators.

Preferred: To protect the public health and safety during recovery operations after a hurricane, the Centers for Disease Control and Prevention has created guidelines of interest to clinicians (including trauma surgeons, nurses, and psychologists), relief workers, and shelter operators.

The phrase nonphysician provider should be avoided because it is similarly imprecise and can refer to numerous health professionals licensed to provide a health care service. It is better to specify the type of professional (eg, nurse, pharmacist, dentist) or to use health care professional or clinician. If a phrase is needed to describe repeatedly and succinctly the many health care professionals who are not physicians, then physician and other health care professionals may be acceptable as long as the phrase is defined at first mention. This also applies to other professions (eg, avoid use of nonnurses, nonpharmacists, nondentists).

psychiatrist, psychologist—Psychiatrists are trained physicians who can prescribe medications and focus on medication management as a course of treatment. Psychologists cannot write prescriptions and focus on psychotherapy and treating patients with behavioral intervention.

race, ethnicity—For definitions and guidance on appropriate usage, see 11.12.3, Race and Ethnicity.

regime, regimen—A regime is a form of government, a social system, or a period of rule (eg, a military regime). A regimen is a systematic schedule (involving, for example, diet, exercise, way of living, physical therapy, or medication) designed to improve or maintain the health of a patient.

Resistant hypertension is the failure to reach goal blood pressure while adhering to full doses of an appropriate 3-drug regimen that includes a diuretic.

A retrospective study compared mild-, moderate-, and high-intensity exercise regimens in patients with detectable hepatic fat.

repeat, repeated—Repeat and repeated may be used interchangeably as adjectives.

respective, respectively—These words indicate a one-to-one correspondence that may not otherwise be obvious between members of 2 series. When only 1 series, or none at all, is listed, the distinction is meaningless and should not be used.

Low back pain, other muscular disorders, and neck pain rank first, third, and fourth, respectively, among the 30 leading diseases that contribute to years lived with disability in the United States.

safe injection site, safer injection sites, supervised injection facility or site—Use supervised injection facility or site.

section, slice—Use section to refer to a radiologic image; use slice to refer to a slice of tissue (eg, for histologic examination).

But: frozen-section biopsy

See also cesarean delivery, cesarean section.

side effect—See adverse effect, adverse event, adverse reaction, side effect.

signs, symptoms—Signs can be seen and read by other people. Symptoms can only be described by the person feeling them.

substance abuse, substance use—Never use the term substance abuse. Many consider it to be pejorative, but it is a clarity and accuracy issue as well. If what is meant is “use” (“The patient used heroin”), then “use” is sufficient. There is no difference between heroin “use” and heroin “abuse,” so “abuse” adds no information. If what is meant is “The patient had depression and substance use disorder” (eg, both are medical illnesses), then saying “The patient had substance abuse” would be unclear and inaccurate (unless specifically referring to meeting the DSM-IV substance abuse definition). Use “substance use disorder” to mean uncontrolled use of a substance with recurrent consequences. Use “substance use” to mean the action of taking a substance without any conclusions about whether it has harmed the person or whether they have control over its use (“The patient used marijuana last night”). See 11.12.6, Terms for Persons With Diseases, Disorders, or Disabilities.

suffer from, suffer with— See 11.12.6, Terms for Persons With Diseases, Disorders, or Disabilities, for a discussion of usage.

suggestive of, suspicious of—To be suggestive of is to give a suggestion or to evoke. To be suspicious of is to distrust.

suicide—Avoid the phrase committed suicide because it implies criminality or moral failing. Likewise avoid referring to suicide as a “success” or “failure” or that death was a favorable outcome. Factual language is preferred, such as died by suicide or suicide attempt. Person-first language should be used (eg, “person who attempted suicide” instead of “suicide attempter” or “person with suicidal ideation” instead of “suicidal person”).

Avoid: committed or completed suicide; failed suicide attempt; suicide epidemic; killed themselves; took their own life; ended their life

Preferred: died by suicide; death by suicide; suicide death; suicide attempt; fatal suicide behavior; person with suicidal ideation

supine, prone—These terms are antonyms. Supine means lying on the back or with the face up. Prone means lying on the front of the body facing downward.

The patient was placed in supine position for thoracic surgery.

The patient was placed in a prone position for the spinal surgery.

survivor, victim, victimization—In scientific publications, avoid the use of the word victim when describing persons who experienced physical, domestic, sexual, or psychological violence, bullying, or a natural disaster. Similarly, avoid labeling (and thus equating) people with a disability or disease as victims (eg, AIDS victim, stroke victim; see 11.12.6, Terms for Persons With Diseases, Disorders, or Disabilities). The term victimization should likewise be avoided; instead, a term or phrase that describes the specific exposure should be used (eg, exposure to violence, experienced trauma, bullying, being bullied).

Victim may imply a state of helplessness.¹⁹ Characterizing a person who has experienced abuse or other violence as a victim perpetuates the stereotype of a passive person who cannot recover from the experience or trauma. In such cases, survivor may be more appropriate (eg, rape survivor, tsunami survivor, survivor of torture).

Survivors of sexual assault often choose not to speak publicly about their experiences.

Refugees who reported experiencing violence had higher rates of anxiety than those who did not report such experience.

Children who were bullied and participated in the group counseling sessions reported lower scores for symptoms of depression compared with those who did not participate in the group counseling.

If a person who experienced such trauma has died, referring to them as a victim may be appropriate (victim of a landmine explosion or gunshot wound). Victim may also be used in the vernacular (victim of his own success).

titrate, titration—In therapeutics, titrate and titration refer to dosing schedules that start with a small dose and gradually are increased to the recommended or therapeutic dose. Patients are not titrated.

toxic, toxicity—Toxic means pertaining to or caused by a poison or toxin. Toxicity is the quality, state, or degree of being poisonous. A patient is not toxic. A patient does not have toxicity.

Dactinomycin is a toxic antineoplastic drug of the actinomycin group.

The drug had a toxic effect on the patient.

The patient had a toxic reaction to the drug.

The patient had a toxic appearance.

The toxicity of the drug must be considered.

But: toxic shock syndrome, toxic neuropathy, toxic epidermal necrolysis, toxic megacolon

transplant, transplantation—Transplant is both a noun (typically meaning the surgical operation itself but also increasingly referring to the overall field) and a transitive verb. Use graft (or allograft, autograft, xenograft, and so on, depending on the level of precision needed) as the general noun for the organ or tissue that is transplanted, or specify which organ or tissue (eg, liver, skin), rather than use the noun transplant in this context. Transplantation is traditionally the noun used to describe the overall field. Never use the plural transplantations.

For the adjectival form, use transplant, as well as pretransplant and posttransplant (not pretransplantation and posttransplantation).

ultrasonography, ultrasound—These terms are not interchangeable. When referring to the imaging procedure, use ultrasonography. Ultrasound refers to the actual sound waves that penetrate the body during ultrasonography.

use, usage, utility, utilize—Use is almost always preferable to utilize, which has the specific meaning “to find a profitable or practical use for,” suggesting the discovery of a new use for something. However, even where this meaning is intended, use would be acceptable.

We used correlation and hierarchical linear regression analyses.

Vitamin C helps the body use the iron present in the diet.

Some urban survivors utilized plastic garbage cans as “lifeboats” to escape flooding in the aftermath of Hurricane Katrina.

Exception: Utilization review and utilization rate are acceptable terms.

Usage refers to an acceptable, customary, or habitual practice or procedure, often linguistic in nature. For the broader sense in which there is no reference to a standard of practice, use is the correct noun form.

The correct usage of compose vs comprise was discussed earlier.

The style manual determines what the correct usage should be.

Some authors use the pretentious usage where use would be appropriate. As a rule of thumb, avoid utilize and be wary of usage. Use use.

Note: Utility—meaning fitness for some purpose, or usefulness—should never be changed to the noun use. Nor should the verb employ be routinely changed to use. Use employ to mean hire.

vision, visual acuity—Vision is a general term that describes the overall ability of the eye and brain to perceive the environment. Visual acuity is a specific measurement of one aspect of the sensation of vision assessed by an examiner.

A patient describing symptoms of his or her visual sensation would be describing the overall visual performance of the eye(s) and would use the term vision: “My vision is improved [or worse].”

A practitioner reporting the examination findings at one specific time would describe visual acuity (20/30, 20/15, etc). However, the practitioner might also refer to the general visual function as vision: “As the vitreous hemorrhage cleared, the vision improved and visual acuity returned to 20/20.” It is possible to have normal visual acuity despite marked vision impairment (eg, when the peripheral visual field is abnormal).

This parrot is no more. It has ceased to be. It’s expired and gone to meet its maker. This is a late parrot. It’s a stiff. Bereft of life, it rests in peace. If you hadn’t nailed it to the perch, it would be pushing up the daisies. It’s rung down the curtain and joined the choir invisible. This is an ex-parrot.

John Cleese, “Monty Python’s Flying Circus”²⁰

A redundancy is a term or phrase that unnecessarily repeats words or meanings. Below are some common redundancies that can usually be avoided (redundant words are italicized):

Some words and phrases can usually be omitted without affecting meaning, and omitting them often improves the readability of a sentence:

Quite, very, and rather are often overused and misused and can be deleted in many instances (see 11.1, Correct and Preferred Usage, Correct and Preferred Usage of Common Words and Phrases).

Avoid roundabout and wordy expressions:

Some words are regarded as “absolute” adjectives, those not possessing a comparative or superlative form (eg, young, younger, youngest or loud, louder, loudest). Words considered incomparable that need no superlative or comparative modifier are listed below:

Note: In general, superlatives should be avoided in scientific writing.

ante mortem/antemortem—Both forms are used depending on placement before or after the noun. Ante mortem means occurring before death and is used after the noun. Antemortem means before death and precedes a noun.

The antemortem injuries were not the cause of death.

The injuries were discovered ante mortem.

bloodstream/blood stream—Bloodstream is preferred.

brainstem/brain stem—Brainstem is preferred.

caregiver/care giver—Caregiver is preferred.

caseload/case load—Caseload is preferred.

dataset/data set—Dataset is preferred.

email/e-mail—Email (email) is preferred.

end point/endpoint—End point is preferred

fiberoptic(s)/fiber optic(s)—Fiberoptic(s) is preferred.

flowchart/flow chart—Flowchart is preferred but use flow diagram over flowdiagram.

gallbladder/gall bladder—Gallbladder is preferred.

healthcare/health care—Health care is preferred.

heartbeat/heart beat—Heartbeat is preferred.

needlestick/needle stick—Needlestick is preferred.

postmortem/post mortem—Both forms are used depending on placement before or after the noun. Postmortem means after death and precedes a noun. Post mortem means occurring or performed after death or pertaining to the period after death and is used after a noun.

A postmortem clot formed in the heart.

The clot formed in the heart post mortem.

postpartum/post partum—Both forms are used depending on placement before or after the noun. Postpartum means after childbirth and precedes a noun. Post partum means occurring after childbirth with reference to the mother and is used after a noun.

The new mother experienced postpartum depression.

The new mother’s depression began post partum.

radiofrequency/radio frequency—Radiofrequency is preferred.

radioguided/radio guided—Radioguided is preferred.

skinfold/skin fold—Skinfold is preferred.

slitlamp/slit lamp—Slitlamp is preferred.

waveform/wave form—Waveform is preferred.

website/Web site—web (lowercase “w”) and website (1 word, lowercase “w”) are preferred, but retain initial caps on the full name the World Wide Web.

The transformation of a noun into a verb is a back-formation, often seen in technical as well as informal writing. Diagnose, for example, is a mid–19th-century back-formation, from diagnosis. Back-formations in use include dialyze (from dialysis) and anesthetize (from anesthesia). A back-formation that is not widely accepted is diurese (from diuresis). Any use of back-formations should be checked in a dictionary.

Many words have found their way into medical vocabularies with unusual meanings that are not recognized even by medical dictionaries. Such writings may be characterized as medical jargon or medical slang. When these words appear in medical manuscripts or in medical conversation, they are unintelligible to other scientists.

Morris Fishbein, MD²¹

Jargon is . . . a language exquisitely precise, using terms in a highly specific sense. It is highly rational, addressed to the intellect and not the emotions; a technical language, intended for a particular group engaged in a particular activity. . . . Jargon has a specificity and precision of meaning, intelligible to a limited group but more or less baffling to other groups.

Lester S. King, MD²²

Words and phrases that can be understood in conversation but are vague, confusing, or depersonalizing are generally inappropriate in formal scientific writing (see 7.7, Diction; 11.1, Correct and Preferred Usage of Common Words and Phrases; and 19.5, Glossary of Statistical Terms).

The following terms and euphemisms should be changed to preferred forms:

Avoid trivializing or dehumanizing disciplines or specialties. For example:

Osteopathic physician and osteopathic medicine, not osteopath and osteopathy

Cardiologic consultant or cardiology consultation, not cardiology [for the person]

Orthopedic surgeon, not orthopod

Colloquialisms, idioms, and vulgarisms should be avoided in formal scientific writing. Exceptions may be made in editorials and informal articles.

When describing the administration of drugs, buccal, cutaneous, dermal, inhalational, intra-articular, intracardiac, intramuscular, intrathecal, intravenous, intraventricular, intravitreal, nasal, ocular, oral, otic, parenteral, rectal, subconjunctival, subcutaneous, sublingual, topical, transdermal, and vaginal are acceptable terms when these are the usual or intended routes of administration. Except for systemic chemotherapy, however, drugs are usually neither systemic nor local but are given for systemic or local effect.

Some topical corticosteroid ointments produce systemic effects.

Oral penicillin is often preferred to parenteral penicillin.

Intravenously injected heroin may be contaminated.

Exceptions: Local anesthetics are a class of drug. Techniques for delivering anesthesia are general, local, and regional.

Use specific terms to refer to a person’s age.

Neonates or newborns are persons from birth to 1 month of age.

Infants are children aged 1 month to 1 year (12 months).

Children are persons aged 1 to 12 years. Sometimes, children may be used more broadly to encompass persons from birth to 12 years of age. They may also be referred to as boys or girls.

Adolescents are persons aged 13 through 17 years. They may also be referred to as teenagers or as adolescent boys or adolescent girls, depending on context.

Adults are persons 18 years or older and should be referred to as men or women. Persons 18 to 24 years of age may also be referred to as young adults.

Note: If the age of an individual patient is given, it may be expressed as a mixed fraction (eg, 6½ years) or as “6 years 6 months.” However, when age is presented as a mean, use the decimal form: 6.5 years (see 19.4.1, Study Design and Statistics, Significant Digits and Rounding Numbers, Significant Digits).

Whenever possible, a patient should be referred to as a man, woman, boy, girl, or infant. Occasionally, however, a study group may comprise children and adults of both sexes. Then, the use of male and female as nouns is appropriate. Male and female are also appropriate adjectives.

See 11.12.4, Inclusive Language, Age.

Authors often err in referring to anatomical regions or structures as the “right heart,” “left chest,” “left neck,” and “right brain.” Generally, these terms can be corrected by inserting a phrase such as “part of the” or “side of the.”

right side of the heart, right atrium, right ventricle

left side of the chest, left hemithorax

left aspect of the neck

right hemisphere

ascending [not right] and descending [not left] colon

Where appropriate, use specific anatomical descriptors:

proximal jejunum, distal esophagus, distal radius, distal ureter, femoral neck

The upper extremity comprises the arm (extending from the shoulder to the elbow), the forearm (from the elbow to the wrist), and the hand. The lower extremity comprises the thigh (extending from the hip to the knee), the leg (from the knee to the ankle), and the foot. Therefore, references to upper and lower arm and upper and lower leg are often redundant or ambiguous. When such references appear in a manuscript, the author should be queried.

Occasionally, reference to a locus of insertion, position, or attitude is given in terms of a clock-face orientation, as seen by the viewer (see 18.1.4, Numbers and Percentages, Use of Numerals, Measures of Time).

Note: The terms clockwise and counterclockwise can also be confusing. The point of reference (eg, that of observer vs subject) should be specified if the usage is ambiguous.

Usually, in reports of clinical or laboratory data, the substance per se is not reported; rather, a value is given that was obtained by measuring a substance or some function or constituent of it. For example, one does not report hemoglobin but hemoglobin level. Some other correct forms are as follows:

agglutination titer

antinuclear antibody titer

creatinine level

creatinine clearance

differential white blood cell count

erythrocyte sedimentation rate

hemagglutination inhibition titer

high-density lipoprotein fraction

increase in antibody level

increase in bilirubin level

mean corpuscular volume

platelet count

prothrombin time

pulse rate

serum phosphorus concentration

total serum cholesterol value or level or concentration

24-hour urine output or volume

urinary placental growth factor concentration

urinary protein excretion

In reports of findings from clinical examinations or laboratory values, data may be enumerated without repeating value, level, etc, in accordance with the following example:

Laboratory values were as follows: white blood cells, 19.5×10³/μL; hemoglobin, 12.9 g/dL; hematocrit, 38.5%; platelets, 203×10³/μL; and international normalized ratio, 1.1.

The article a is used before the aspirate h (eg, a historic occasion) and nonvocalic y (eg, a ubiquitous organism). Abbreviations and acronyms are preceded by a or an according to the sound following (eg, a UN resolution, an HMO plan) (see 13.8, Agencies, Organizations, Foundations, Funding Bodies, and Others and 7.0, Grammar).

Any classification according to a singular identity polarizes people in a particular way, but if we take note of the fact that we have many different identities . . . we can see that the polarization of one can be resisted by a fuller picture. So knowledge and understanding are extremely important to fight against singular polarization.

Amartya Sen²³

Avoid the use of language that imparts bias against persons or groups on the basis of gender or sex, race or ethnicity, age, sexual orientation, socioeconomic status, or disability or disorder. Avoid generalizations without context (such as minorities) and stereotypes and be specific when choosing words to describe people.

Note: Researchers should avoid using study designs and statistical comparisons of “non-” (eg, “White and non-White participants”), which is a nonspecific “convenience” grouping and label. Such a category may be oversimplified and misleading, even incorrect. If comparing racial and ethnic groups, specify the racial and ethnic groups included and conduct analyses comparing the specific groups. If such a binary comparison is justified. authors should explain the rationale and specify what categories are included in the “non-” group. If a collective term is needed to address the heterogeneous racial and ethnic background of many people, consider using racial and ethnic minority groups or marginalized racial and ethnic groups.

Sex refers to the biological characteristics of males and females. Gender includes more than sex and serves as a cultural indicator of a person’s personal and social identity. An important consideration when referring to sex is the level of specificity required: specify sex when it is relevant. In research articles, sex/gender should be reported and defined, and how sex/gender was assessed should be described.¹⁵ In nonresearch reports, choose sex-neutral terms that avoid bias, suit the material under discussion, and do not intrude on the reader’s attention (see 11.7, Age and Sex Referents).

Note: Use man or men when referring to a specific man or group of men and woman or women when referring to a specific woman or a group of women. Similarly, chairman or spokesman might be used if the person under discussion is a man and chairwoman or spokeswoman if the person is a woman. Any of these might be used in an official title, for example, Michele Smith, alderman of the 43rd Ward, City of Chicago.

Do not attempt to change all words with man to person (eg, manhole). If possible, choose a sex-neutral equivalent such as sewer hole or utility access hole.

Terms such as physician, nurse, and scientist are sex-neutral and do not require modification (eg, female physician, male nurse) unless the sex of the person or persons described is relevant to the discussion (eg, a study of only female physicians or male nurses).

After completing internship, the physician specialized in emergency medicine and worked at several hospitals in California. She was selected as an astronaut candidate by NASA in 2007.

When reporting the sex of participants in a table, include both sexes, as defined in the study, regardless of ratio. Do not use “White” and “male” as the default. When reporting on racial and ethnic differences, be as specific as possible (even if these comprise a small percentage of participants). Define the participants who are in the “other” category (see 4.1.2, Organizing Information in Tables).

Avoid sex-specific pronouns in cases in which sex specificity is irrelevant. Do not use common-gender “pronouns” (eg, “s/he,” “shem,” “shim”). Reword the sentence to use a singular or plural non–sex-specific pronoun, neutral noun equivalent, or change of voice; or use “he or she” (“him or her,” “his or her[s],” “they or their[s]”). The use of the “singular they” construction is permitted when rewriting would be awkward or unclear (see 7.2.3.2, Pronoun-Pronoun Agreement).

This section addresses race and ethnicity. Other subchapters address sex and gender, sexual orientation, personal pronouns, age, socioeconomic status, and terms for persons with diseases, disabilities, and disorders.

Race and ethnicity are social constructs, without scientific or biological meaning. The indistinct construct of racial and ethnic categories has been increasingly acknowledged, and concerns about use of these terms in medical and health research, education, and practice have been progressively recognized. Accordingly, for content published in medical and science journals, language and terminology must be accurate, clear, and precise and must reflect fairness, equity, and consistency in use and reporting of race and ethnicity. (Note: historically, although inappropriately, race may have been considered a biological construct; thus, older content may characterize race as having biological significance.)

One of the goals of this guidance is to encourage the use of language to reduce unintentional bias in medical and science literature. The reporting of race and ethnicity should not be considered in isolation but should be accompanied by reporting of other sociodemographic factors and social determinants, including concerns about racism, disparities, and inequities, and the intersectionality of race and ethnicity with these other factors.

When reporting the results of research that includes racial and ethnic disparities and inequities, authors are encouraged to provide a balanced, evidence-based discussion of the implications of the findings for addressing institutional racism and structural racism as these affect the study population, disease or disorder studied, and the relevant health care systems. For example, Introduction and Discussion sections of manuscripts could include implications of historical injustices when describing the differences observed by race and ethnicity. Such discussion of implications can use specific words, such as racism, structural racism, racial equity, or racial inequity, when appropriate.

The definitions provided herein focus on reporting race and ethnicity. Definitions of broader terms (eg, disparity, inequity, intersectionality, and others) will be included in the overarching Inclusive Language section that contains this subsection.

“Race and ethnicity are dynamic, shaped by geographic, cultural, and sociopolitical forces.”²⁴ Race and ethnicity are social constructs and with limited utility in understanding medical research, practice, and policy. However, the terms may be useful as a lens through which to study and view racism and disparities and inequities in health, health care, and medical practice, education, and research.^24,25,26 Terms and categories used to define and describe race and ethnicity have changed with time based on sociocultural shifts and greater awareness of the role of racism in society. This guidance is presented with that understanding, and updates have been and will continue to be provided as needed.

The terms race (first usage dating back to the 1500s) and ethnicity (first usage dating back to the late 1700s)²⁷ have changed and continue to evolve semantically. The Oxford English Dictionary currently defines race as “a group of people connected by common descent or origin” or “any of the (putative) major groupings of mankind, usually defined in terms of distinct physical features or shared ethnicity” and ethnicity as “membership of a group regarded as ultimately of common descent, or having a common national or cultural tradition.”²⁸ For example, in the US, ethnicity has referred to Hispanic or Latino, Latina, or Latinx people. Outside of the US, other terms of ethnicity may apply within specific nations or ancestry groups. As noted in a lexicographer’s post on the Conscious Style Guide, race and ethnicity are difficult to untangle.²⁷ In general, ethnicity has historically referred to a person’s cultural identity (eg, language, customs, religion) and race to broad categories of people that are divided arbitrarily but based on ancestral origin and physical characteristics.²⁷ Definitions that rely on external determinations of physical characteristics are problematic and may perpetuate racism. In addition, there is concern about whether these and other definitions are appropriate or out-of-date²⁹ and whether separation of subcategories of race from subcategories of ethnicity could be discriminatory, especially when used by governmental agencies and institutions to guide policy, funding allocations, budgets, and data-driven business and research decisions.³⁰ Thus, proposals have been made that these terms be unified into an aggregate, mutually exclusive set of categories as in “race and ethnicity.”³¹ (See Additional Guidance for Use of Racial and Ethnic Collective Terms.)

The term ancestry refers to a person’s country or region of origin or an individual’s lineage of descent. Another important characteristic of many populations is genetic admixture, which refers to genetic exchange among people from different ancestries and may correlate with an individual’s risk for certain genetic diseases.²⁴ Ancestry and genetic admixture may provide more useful information about health, population health, and genetic variants and risk for disease or disorders than do racial and ethnic categories.²⁴

Although race and ethnicity have no biological meaning, the terms have important, albeit contested, social meanings. Neglecting to report race and ethnicity in health and medical research disregards the reality of social stratification, injustices, and inequities and implications for population health,^24,25 and removing race and ethnicity from research may conceal health disparities. Thus, inclusion of race and ethnicity in reports of medical research to address and further elucidate health disparities and inequities remains important at this time.

According to the “Health Equity Style Guide for the COVID-19 Response: Principles and Preferred Terms for Non-Stigmatizing, Bias-Free Language” of the Centers for Disease Control and Prevention (CDC), racism is defined as a “system of structuring opportunity and assigning value based on the social interpretation of how one looks...(“race”), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and undermines realization of the full potential of our whole society through the waste of human resources.” Note that racism and prejudice can occur without phenotypic discrimination.

Jones³² and the CDC style guide³³ have defined 3 levels of racism:

Systemic, institutionalized, and structural racism: “Structures, policies, practices, and norms resulting in differential access to the goods, services, and opportunities of society by ‘race’ (eg, how major systems—the economy, politics, education, criminal justice, health, etc—perpetuate unfair advantage).”³³ The Associated Press (AP) Stylebook advises to not shorten these terms to “racism,” to avoid confusion with the other definitions.³⁴

Interpersonal and personally mediated racism: “Prejudice and discrimination, where prejudice is differential assumptions about the abilities, motives, and intents of others by ‘race,’ and discrimination is differential actions towards others by ‘race.’ These can be either intentional or unintentional.”³³

Internalized racism: “Acceptance by members of the stigmatized ‘races’ of negative messages about their own abilities and intrinsic worth.”³³

There are many examples of reported associations between race and ethnicity and health outcomes, but these outcomes may also be intertwined with ancestry and heritage, social determinants of health, as well as socioeconomic, structural, institutional, cultural, demographic, or other factors.^24,25,35 Thus, discerning the roles of these factors is difficult. For example, a person’s ancestral heritage may convey certain health-related predispositions (eg, cystic fibrosis in persons of Northern European descent and sickle cell disease reported among people whose ancestors were from sub-Saharan Africa, India, Saudi Arabia, and Mediterranean countries); however, such perceptions have resulted in underdiagnosis of these conditions in other populations.³⁶

Also, certain groups may bear a disproportionate burden of disease compared with other groups, but this may reflect individual and systemic disparities and inequities in health care and social determinants of health. For example, according to the US National Cancer Institute, the rates of cervical cancer are higher among Hispanic/Latina women and Black/African American women than among women of other racial or ethnic groups, with Black/African American women having the highest rates of death from the disease, but social determinants of health and inequities are also associated with a high prevalence of cervical cancer among these women.³⁷ The American Heart Association summarizes similar disparities in cardiovascular disease among Black individuals in the US compared with those from other racial and ethnic groups.³⁸

Identifying the race or ethnicity of a person or group of participants, along with other sociodemographic variables, may provide information about participants included in a study and the potential generalizability of the results of a study and may identify important disparities and inequities. Researchers should aim for inclusivity by providing comprehensive categories and subcategories where applicable. Many people may identify with more than 1 race and ethnicity; therefore, categories should not be considered absolute or viewed in isolation.

However, there is concern about the use of race in clinical algorithms and some health-based risk scores and databases because of inapplicability to some groups and the potential for discrimination and inappropriate clinical decisions. For example, the use of race to estimate glomerular filtration rates among Black adults has become controversial for several reasons.^39,40,41,42 Oversimplification of racial dichotomies can be harmful, such as in calculating kidney function, especially with racial inequities in kidney care. In this context, health inequities among populations should be addressed rather than focusing solely on differences in racial categories (eg, Black vs White adults with kidney disease).⁴² Another example is the Framingham Risk Score, which was originally developed from a cohort of White, middle-class participants in the US included in the Framingham Heart Study and may not accurately estimate risk in other racial and ethnic populations. Similar concerns have been raised about genetic risk studies based on specific populations or that do not include participants from other groups (eg, a genome-wide association study that reports a genetic association with a specific disease or disorder based solely on a population of European descent).⁴³ Use caution in interpreting or generalizing findings from studies of risk based on populations of individuals representing specific or limited racial and ethnic categories.

The JAMA Network journals include the following guidance for reporting race and ethnicity and other demographic information in research articles in the Instructions for Authors.⁴⁴

Demographic Information: Aggregate, deidentified demographic information (eg, age, sex, race and ethnicity, and socioeconomic indicators) should be reported for research reports along with all prespecified outcomes. Demographic variables collected for a specific study should be indicated in the Methods section. Demographic information assessed should be reported in the Results section, either in the main article or in an online supplement or both. If any demographic characteristics that were collected are not reported, the reason should be stated. Summary demographic information (eg, baseline characteristics of study participants) should be reported in the first line of the Results section of the Abstract.

With regard to the collection and reporting of demographic data on race and ethnicity:

Reporting race and ethnicity in this study was mandated by the US National Institutes of Health (NIH), consistent with the Inclusion of Women, Minorities, and Children policy. Individuals participating in the poststudy survey were categorized as American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, Native Hawaiian or Other Pacific Islander, or White based on the NIH Policy on Reporting Race and Ethnicity Data. Children’s race and ethnicity were based on the parents’ report.

Race was self-reported by study participants, and race categories (Black and White) were defined by investigators based on the US Office of Management and Budget’s Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. Given that racial residential segregation is distinctively experienced by Black individuals in the US, the analytical sample was restricted to participants who self-identified as Black.

In this genome-wide association study, participants were from 8 African countries (ie, Kenya, Mozambique, Namibia, Nigeria, South Africa, Sudan, Uganda, and Zambia). Any Black African group from any of the 8 African countries (mostly of Bantu descent) was included in the Black African cohort. The South African group composed primarily of multiple racial categories, comprising any admixture combination of individuals of European, Southeast Asian, South Asian, Bantu-speaking African, and/or indigenous Southern African hunter-gatherer ancestries (Khoikhoi, San, or Bushmen), was renamed admixed African individuals. The race and ethnicity of an individual was self-reported.

Data for this study included US adults who self-reported as non-Hispanic Black (hereafter, Black), Hispanic or Latino, and non-Hispanic White (hereafter, White) individuals. We excluded individuals who self-reported being Asian or of other race and ethnicity (which included those who were American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander) because of small sample sizes.

Specific racial and ethnic terms are preferred over collective terms, when possible. Authors should report the specific categories used in their studies and recognize that these categories will differ based on the databases or surveys used, the requirements of funders, and the geographic location of data collection or study participants.

When collective terms are used, merging of race and ethnicity with a virgule as “race/ethnicity” is no longer recommended. Instead, “race and ethnicity” is preferred, with the understanding that there are numerous subcategories within race and ethnicity. Given that a virgule often means “and/or,” which can be confusing, do not use the virgule construction in this context (see also 8.4, Forward Slash [Virgule, Solidus]).

The general term minorities should not be used when describing groups or populations because it is overly vague and implies a hierarchy among groups. Instead, include a modifier when using the word “minority” and do not use the term as a stand-alone noun, for example, racial and ethnic minority groups and racial and ethnic minority individuals.^33,45 However, even this umbrella term may not be appropriate in some settings. Other terms such as underserved populations (eg, when referring to health disparities among groups) or underrepresented populations (eg, when referring to a disproportionately low number of individuals in a workforce or educational program) may be used provided the categories of individuals included are defined at first mention.⁴⁶ The term minoritized may be acceptable as an adjective provided that the noun(s) that it is modifying is included (eg, “racial and ethnic minoritized group”). Groups that have been historically marginalized could be suitable in certain contexts if the rationale for this designation is provided and the categories of those included are defined or described at first mention.³³

The nonspecific group label “other” for categorizing race and ethnicity is uninformative and may be considered pejorative. However, the term is sometimes used for comparison in data analysis when the numbers of those in some subgroups are too small for meaningful analyses. The term should not be used as a “convenience” grouping or label unless it was a prespecified formal category in a database or research instrument. In such cases, the categories included in “other” groups should be defined and reported. Authors are advised to be as specific as possible when reporting on racial and ethnic categories (even if these categories contain small numbers). If the numbers in some categories are so small as to potentially identify study participants, the specific numbers and percentages do not need to be reported provided this is noted. For cases in which the group “other” is used but not defined, the author should be queried for further explanation.

The terms multiracial and multiethnic are acceptable in reports of studies if the specific categories these terms comprise are defined or if the terms were predefined in a study or database to which participants self-selected. If the criteria for data quality and confidentiality are met, at a minimum, the number of individuals identifying with more than 1 race should be reported. Authors are encouraged to provide greater detail about the distribution of multiple racial and ethnic categories if known. In general, the term mixed race may carry negative connotations³⁴ and should be avoided, unless it was specifically used in data collection; in this case, the term should be defined, if possible. To the extent possible, the specific type of multiracial and multiethnic groups should be delineated.

In this study, 140 participants (25%) self-reported as multiracial, which included 100 (18%) identifying as Asian and White and 40 (7%) as Black and White.

Other terms may enter the lexicon as descriptors or modifiers for racial and ethnic categories of people. For example, the term people of color was introduced to mean all racial and ethnic groups that are not considered White or of European ancestry and as an indication of antiracist, multiracial solidarity. However, there is concern that the term may be “too inclusive,” to the point that it erases differences among specific groups.^34,47,48,49 There are similar concerns about use of the collective and abbreviated terms for Black, Indigenous, and people of color (BIPOC) and Black, Asian, and minority ethnic (BAME) (commonly used in the UK). Criticism of these terms has noted that they disregard individuals’ identities, do not include all underrepresented groups, eliminate differences among groups, and imply a hierarchy among them.^34,47,48,49 Although these terms may be used colloquially (eg, within an opinion article), preference is to describe or define the specific racial or ethnic categories included or intended to be addressed. These terms should not be used in reports of research, unless the terms are included in a database on which a study is based or specified in a research data collection instrument (eg, survey questionnaire).

In agreement with other guides,^34,45 other terms related to colors, such as brown and yellow, should not be used to describe individuals or groups. These terms may be less inclusive than intended or considered pejorative or a racial slur.

In addition, avoid collective reference to racial and ethnic minority groups as “non-White.” If comparing racial and ethnic groups, indicate the specific groups. Researchers should avoid study designs and statistical comparisons of White groups vs “non-White” groups and should specify racial and ethnic groups included and conduct analyses comparing the specific groups. If such a comparison is justified, authors should explain the rationale and specify what categories are included in the “non-White” group.

The names of races, ethnicities, and tribes should be capitalized, such as African American, Alaska Native, American Indian, Asian, Black, Cherokee Nation, Hispanic, Kamba, Kikuyu, Latino, and White. There may be sociopolitical instances in which context may merit exception to this guidance, for example, in an opinion piece for which capitalization could be perceived as inflammatory or inappropriate (eg, “white supremacy”).

Racial and ethnic terms should not be used in noun form (eg, avoid Asians, Blacks, Hispanics, or Whites); the adjectival form is preferred (eg, Asian women, Black patients, Hispanic children, or White participants) because this follows AMA style regarding person-first language. The adjectival form may be used as a predicate adjective to modify the subject of a phrase (eg, “the patients self-identified as Asian, Black, Hispanic, or White”).³³

Most combinations of proper adjectives derived from geographic entities are not hyphenated when used as racial or ethnic descriptors. Therefore, do not hyphenate terms such as Asian American, African American, and Mexican American, and similar combinations, and in compound modifiers (eg, African American patient).

Awareness of the relevance of geographic origin and regionalization associated with racial and ethnic designations is important. In addition, preferred usage may change about the most appropriate designation. For example, the term Caucasian had historically been used to indicate the term White, but it is technically specific to people from the Caucasus region in Eurasia and thus should not be used except when referring to people from this region.

The terms African American or Black may be used to describe participants in studies involving populations in the US, following how such information was recorded or collected for the study. However, the 2 terms should not be used interchangeably in reports of research unless both terms were formally used in the study, and the terms should be used consistently within a specific article. For example, among Black people residing in the US, those from the Caribbean may identify as Black but not as African American, whereas Black people whose families have been in the US for several generations may identify as Black and African American. When a study includes individuals of African ancestry in the diaspora, the term Black may be appropriate because it does not obscure cultural and linguistic nuances and national origins, such as Dominican, Haitian, and those of African sovereign states (eg, Kenyan, Nigerian, Sudanese), provided that the term was used in the study.

The term Asian is a broad category that can include numerous countries of origin (eg, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, Vietnam, and others) and regions (eg, East Asia, South Asia, Southeast Asia).⁴⁴ The term may be combined with those from the Pacific Islands as in Asian or Pacific Islander. The term Asian American is acceptable when describing those who identify with Asian descent among the US population. However, reporting of individuals’ self-identified countries of origin is preferred when known. As with other categories, the formal terms used in research collection should be used in reports of studies.

In reference to persons indigenous to North America (and their descendants), American Indian or Alaska Native is generally preferred to the broader term Native American. However, the term Indigenous is also acceptable. There are also other specific designations for people from other locations, such as Native Hawaiian and Pacific Islander.^50,51 If appropriate, specify the nation or peoples (eg, Inuit, Iroquois, Mayan, Navajo, Nez Perce, Samoan). Many countries have specific categories for Indigenous peoples (eg, First Nations in Canada and Aboriginal in Australia). Capitalize the first word and use lowercase for people when describing persons who are Indigenous or Aboriginal (eg, Indigenous people, Indigenous peoples of Canada, Aboriginal people). Lowercase indigenous when referring to objects, such as indigenous plants.

Hispanic, Latino or Latina, Latinx, and Latine are terms that have been used for people living in the US of Spanish-speaking or Latin American descent or heritage, but as with other terms, they can include people from other geographic locations.^50,51  Hispanic historically has been associated with people from Spain or other Spanish-speaking countries in the Western hemisphere (eg, Cuba, Central and South America, Mexico, Puerto Rico); however, individuals and some government agencies may prefer to specify country of origin.^50,51,52  Latino or Latina are broad terms that have been used for people of origin or descent from Cuba, Mexico, Puerto Rico, and some countries in Central America, South America, and the Caribbean, but again, individuals may prefer to specify their country of origin.^50,51,52 When possible, a more specific term (eg, Cuban, Cuban American, Guatemalan, Latin American, Mexican, Mexican American, Puerto Rican) should be used. However, as with other categories, the formal terms used in research collection should be used for reports of studies. For example, some US agencies also include Spanish origin when listing Hispanic and Latino. The terms Latinx and Latine are acceptable as gender-inclusive or nonbinary terms for people of Latin American cultural or ethnic identity in the US. However, editors should avoid reflexively changing Latino and Latina to Latinx or vice versa and should follow author preference. Authors of research reports, in turn, should use the terms that were prespecified in their study (eg, via participant self-report or selection, investigator observed, database, electronic health record, survey instrument).

Description of people as being of a regional descent (eg, of African, Asian, European, or Middle Eastern or North African descent) is acceptable if those terms were used in formal research. However, it is preferable to identify a specific country or region of origin when known and pertinent to the study.

For the GWAS discovery stage, study participants of African ancestry were recruited from Ghana, Nigeria, South Africa, and the US, where the same phenotype definition was applied to diagnose primary open-angle glaucoma. The second validation meta-analysis included individuals with primary open-angle glaucoma and matched control individuals from Mali, Cameroon, Nigeria (Lagos, Kaduna, and Enugu), Brazil, Saudi Arabia, the Democratic Republic of the Congo, Morocco, and Peru.

For example, it is generally preferable to describe persons of Asian ancestry according to their country or regional area of origin (eg, Cambodian, Chinese, Indian, Japanese, Korean, Sri Lankan, East Asian, Southeast Asian). Similarly, study participants from the Middle Eastern and North African region should be described using their nation of origin (eg, Egyptian, Iranian, Iraqi, Israeli, Lebanese) when possible. Individuals of Middle Eastern and North African descent who identify with Arab ancestry and reside in the US may be referred to as Arab American. In such cases, researchers should report how categories were determined (eg, self-reported or selected by study participants or from demographic data in databases or other sources).

Note that Arab and Arab American, Asian and Asian American, Chinese and Chinese American, Mexican and Mexican American, and so on are not equivalent or interchangeable.

For studies that use national databases or include participants in a single country, a term for country of origin can be included if the term was provided at data collection (eg, Chinese American and Korean American for a study performed in the US, or Han Chinese and Zhuang Chinese for a study conducted in China). Again, how these designations were determined (eg, self-reported or selected or by other means) should be reported.

Generally, abbreviations of categories for race and ethnicity should be avoided unless necessary because of space constraints (eg, in tables and figures) or to avoid long, repetitive strings of descriptors. If used, any abbreviations should be clearly explained parenthetically in text or in table and figure footnotes or legends.

Journals and publishers that collect race and ethnicity data on editors, editorial board members, authors, and peer reviewers should follow principles of confidentiality, privacy, and inclusivity and should permit individuals to self-identify or opt out of such identification. The Joint Commitment on Action for Inclusion and Diversity in Publishing is developing an international list of terms for journals and publishers that collect information on race and ethnicity.⁵³

Journals that collect information on race and ethnicity should not permit editorial decisions to be influenced by the demographic characteristics of authors, peer reviewers, editorial board members, or editors. In addition, the collection and use of such data should respect privacy regulations and be secured to prevent disclosure of personally identifiable information. Individual personally identifiable information of authors and peer reviewers should not be accessible to anyone involved in editorial decisions. Such data may be used in aggregate to benchmark and monitor strategies to promote and improve the diversity of journals.

Discrimination based on age (young or old) is ageism. Because terms like seniors, elderly, the aged, aging dependents, old-old, young-old, and similar "other-ing" terms connote a stereotype, avoid using them. Terms such as older persons, older people, older adults, older patients, older individuals, persons 65 years and older, or the older population are preferred. Use older adults, a term less likely to connote discrimination and negative stereotypes, when describing individuals 65 years old and older.

Note: In studies that involve human beings, age should always be given specifically (eg, “older people aged 75 to 84 years” or “children younger than 12 years”) (see 11.7, Age and Sex Referents).

Adultism is a form of ageism in which children and adolescents are discounted.^54,55

Avoid labeling people with their socioeconomic status, such as the poor or the unemployed. Instead, terms such as low income and no income are preferred. See also limited-income, low-income, resource-limited, resource poor, transitional.

Avoid labeling (and thus equating) people with their disabilities or diseases (eg, the blind, schizophrenics, epileptics). Instead, put the person first. Avoid describing persons as victims or with other emotional terms that suggest helplessness (afflicted with, suffering from, stricken with, maimed). Avoid euphemistic descriptors, such as physically challenged, special, or special needs.

Avoid metaphors that may be inappropriate or insensitive and do not translate well (blind to the truth, deaf to the request). For similar reasons, some publications avoid the term double-blind when referring to a study’s methods.

Note: Some manuscripts use certain phrases many times, and changing, for example, “AIDS patients” to “persons with AIDS” at every occurrence may result in awkward and stilted text. In such cases, the adjectival form may be used, although this is not preferred.

Sexual orientation should be indicated in a manuscript only when scientifically relevant. The term sexual preference should be avoided because it implies a voluntary choice of sexual orientation not supported by the scientific literature. In some contexts, reference to specific sexual behaviors (eg, men who have sex with men) may be more relevant than sexual orientation.

The nouns lesbians and gay men are preferred to the broader term homosexuals when referring to specific groups. Avoid using gay or gays as a noun. Heterosexual, homosexual, bisexual, asexual, and intersex may be used as adjectives (eg, heterosexual men).

A member of a heterosexual or homosexual couple may be referred to as spouse, companion, partner, or life partner. Same-sex couple and same-sex marriage are appropriate terms.

See also LGBTQAI in 13.11 Clinical, Technical, and Other Common Terms, the GLAAD Reference Guide-Transgender Issues website,¹⁶ and the Gender Equity Resource Center website.¹⁷

Principal Authors: Tracy Frey, BA, and Roxanne K. Young, ELS

Thanks to the following for reviewing and providing comments to improve the manuscript: Helene M. Cole, MD, formerly of JAMA; Gabriel Dietz, MA, JAMA Network; Barbara Gastel, MD, MPH, Texas A&M University, College Station; Julie Gerke, ELS, IQVIA, Parsippany, New Jersey; Carissa Gilman, MA, American Cancer Society, Atlanta, Georgia; Emily A. Greenhow, JAMA; Trevor Lane, MA, DPhil, Edanz Group, Fukuoka, Japan; and Peter J. Olson, ELS, Sheridan Journal Services, Waterbury, Vermont.

We thank the following individuals for their thoughtful review and comments that helped shape the updated guidance on race and ethnicity: Nadia N. Abuelezam, ScD, Boston College William F. Connell School of Nursing; Adewole S. Adamson, MD, MPP, Associate Editor, JAMA Dermatology, University of Texas at Austin, Internal Medicine, Division of Dermatology; Dewesh Agrawal, MD, Children’s National Hospital, and Departments of Pediatrics and Emergency Medicine, George Washington University School of Medicine and Health Sciences; Kristine J. Ajrouch, PhD, Department of Sociology, Eastern Michigan University; Germine H. Awad, PhD, University of Texas at Austin; Maria Baquero, PhD, MPH, senior social epidemiologist, Research and Evaluation Unit, Bureau of Epidemiology Services, Division of Epidemiology, New York City Department of Health and Mental Hygiene; Aisha Barber, MD, MEd, Children’s National Hospital, and Department of Pediatrics, George Washington University School of Medicine and Health Sciences; Ashley Bennett, MD, Children’s Hospital Los Angeles; Howard Bauchner, MD, former editor in chief, JAMA and JAMA Network; Khadijah Breathett, MD, MS, Department of Medicine, University of Arizona; Thuy D. Bui, MD, Department of Medicine, Global Health/Underserved Populations Track, University of Pittsburgh School of Medicine; Kim Campbell, BS, senior manuscript editor, JAMA; Jessica Castner, PhD, RN-BC, editor in chief, Journal of Emergency Nursing; Linh Hồng Chương, MPH, Department of Health Policy & Management, UCLA Fielding School of Public Health; Francisco Cigarroa, MD, Department of Surgery, Director, Transplant Center, UT Health, San Antonio, and JAMA editorial board member; Desiree M. de la Torre, MPH, MBA, Community Affairs & Population Health Improvement, Children’s National Hospital; Christopher P. Duggan, MD, MPH, Center for Nutrition at Boston Children’s Hospital and Harvard Medical School; Torian Easterling, MD, New York City Department of Health and Mental Hygiene; Enrique Escalante, MD, MSHS, director of Diversity Recruitment and Inclusion, Children’s National Hospital, and Department of Pediatrics, George Washington University School of Medicine and Health Sciences; Lisa Evans, JD, Scientific Workforce Diversity Officer, National Institutes of Health; Olanrewaju O. Falusi, MD, Children’s National Hospital; Stephanie E. Farquhar, PhD, MHS, New York City Department of Health and Mental Hygiene; Glenn Flores, MD, Department of Pediatrics, University of Miami Miller School of Medicine, Holtz Children’s Hospital, Jackson Health System; Barbara Gastel, MD, MPH, Texas A&M College of Medicine, Humanities in Medicine; L. Hannah Gould, PhD, New York City Department of Health and Mental Hygiene; Carmen E. Guerra, MD, MSCE, vice chair of Diversity and Inclusion, Department of Medicine, Perelman School of Medicine, University of Pennsylvania; P. Michael Ho, MD, PhD, University of Colorado, Aurora; Said Ibrahim, MD, MPH, MBA, Division of Healthcare Delivery Science & Innovation, Weill Cornell Medicine; Omer Ilahi, MD, Southwest Orthopedic Group; Alireza Hamidian Jahromi, MD, Rush University Medical Center; Quita Highsmith, MBA, chief diversity officer, Genentech; Renee M. Johnson, PhD, MPH, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health; Kamlesh Khunti, PhD, MD, University of Leicester; Trevor Lane, MA, DPhil, AsiaEdit; Cara Lichtenstein, MD, MPH, Children’s National Hospital; Francie Likis, DrPh, editor in chief, Journal of Midwifery & Women’s Health; Preeti N. Malani, MD, MSJ, associate editor, JAMA, and Department of Medicine, Division of Infectious Disease, University of Michigan; Jacqueline McGrath, PhD, RN, School of Nursing, UT Health San Antonio; Michelle Morse, MD, New York City Department of Health and Mental Hygiene; Brahmajee K. Nallamothu, MD, MPH, University of Michigan, Ann Arbor; Peter Olson, MA, manuscript editing coordinator, JAMA Network; Manish Pareek, MD, University of Leicester; Monica Peek, MD, MPH, Department of Medicine, Chicago Center for Diabetes Translational Research, University of Chicago; Jose S. Pulido, MD, MS, MPH, MBA, Wills Eye Hospital, and Departments of Ophthalmology and Molecular Medicine, Mayo Clinic; Zudin Puthucheary, MBBS, PhD, BMedSci, William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, Royal London Hospital, Barts Health NHS Trust; Sanjay Ramakrishnan, MBBS, Nuffield Department of Medicine, University of Oxford; Jeanne M. Regnante, chief health equity and diversity officer, LUNGevity Foundation; Allie Reynolds, Princeton University; Ash Routen, PhD, University of Leicester; James B. Ruben, MD, Folsom, California (retired); Randall L. Rutta, National Health Council; Deborah Salerno, PhD, senior medical writer, Salerno Scientific; Kanade Shinkai, MD, editor, JAMA Dermatology, and Department of Dermatology, University of California San Francisco; Erica S. Spatz, MD, MHS, Yale School of Medicine; Jenna Rose Stoehr, BA, Northwestern University Feinberg School of Medicine; L. Tantay, MA, New York City Department of Health and Mental Hygiene; Ayanna Vasquez, MD, MS, New York City Department of Health and Mental Hygiene; Jason H. Wasfy, MD, MPhil, Massachusetts General Hospital.