Dr. Lawrence I. Bonchek Fall 2012 - Vol. 7, No. 3

How's That Again?
Good and Bad Medical Writing and the Dizzy Awards

Lawrence I. Bonchek, M.D., F.A.C.S., F.A.C.C.

It is an Editor’s job to help authors with phrasing, grammar, and syntax. As those who have written for this Journal know, this Editor doesn’t shirk that responsibility, and I review every submitted article carefully; some would say too carefully! My principal goal in editing manuscripts is to enhance readability. I want to ensure that the reader doesn’t have to stop repeatedly in order to figure out what the writer is trying to say – a problem that is sadly common in medical writing.

I also insist that the Journal’s articles adhere to fundamental principles of grammar, not only because incorrect grammar distracts the reader and usually – though admittedly not always – decreases clarity, but because if we don’t maintain high standards our magnificent language will deteriorate into muddiness and ambiguity.

The English language has a special need for detailed rules because it is such an enormous structure comprised of an extraordinarily large number of the words that give it unique richness, versatility, scope, and power. The world has some 2700 languages, but as explained in The Story of English, the PBS television series of the 1980s hosted by Robert MacNeil, and in its companion volume,1 none of the others has nearly as rich a vocabulary as English does because it heartily welcomes foreign words while many languages (most notably French) stubbornly resist them. The Oxford English Dictionary lists about 500,000 words, and there are probably another half million scientific and technical terms that are not even catalogued. By comparison, German has a vocabulary of about 185,000 words and xenophobic French has substantially fewer than 100,000, unless one includes Franglais such as le snaque-barre and le hit-parade,1 which the French Academy officially discourages despite their popularity.

And though it is demographically obvious that more people speak Chinese as a mother tongue than any other language, that is only true among its native-speakers; Chinese has no influence as a national language outside its home country. English, by contrast, is the one truly international language, thanks to the heritage of the British Empire. One can find someone who speaks English almost everywhere. In countries as disparate in culture and size as India and Israel, English is spoken by all the educated classes, and appears on almost all street signs, public notices, etc. The city-state of Singapore, with its multicultural society comprised mostly of Chinese, Indians, and Malays, has four official languages, but uses English as the principal language of instruction in schools, and English is the language of government and the lingua franca of daily life.

For such an international language, rules and standards are crucial or it will degrade rapidly.

During the six years since this Journal began publication in the Spring of 2006, my efforts to maintain high editorial standards have required more attention to confusing syntax than to grammatical errors. Because the former are not as obviously wrong, they are far more common and also easier to overlook. Still, even grammatical errors can be quite obscure, usually because incorrect forms have come into such common use that they are accepted as part of everyday technical jargon.

My favorite example of an error hiding in plain sight is the standard and seemingly unexceptionable:

“The patient has kidney failure.”

Most people see nothing wrong with this sentence, but “failure” is a noun, and nouns should be modified by adjectives. “Kidney” is also a noun, which should not be used to modify another noun. The grammatically correct form uses an adjective: “The patient has renal failure.”

The phrase “kidney failure” is ubiquitous, and it would be bizarrely pedantic and pointlessly quixotic to attempt to banish it from common use, so we do not attempt to do so in this Journal. But though I generally give a pass to vernacular forms like “kidney failure” unless I’m feeling crotchety, I still insist on revising phrases such as "process documentation" and "workflow analysis" into "documentation of processes" and "analysis of workflow."

I trust we can all agree that those are examples of obvious but simple problems with simple solutions. Unfortunately, the tendency to use nouns as adjectives is one of those errors that build from relatively harmless forms up to more egregious ones. And the tendency is spreading widely, so the battle against grammatical impropriety never ends. An unfortunate practice that is much more troublesome is the habit of stringing together two, three, or even four nouns and adjectives as modifiers. The reader is left to search for the object of all the modifiers. An example is: "electronic prescription refill process" rather than "the process for refilling prescriptions electronically." In the first version, the reader must wait till the end of the sentence to find out that the central concept is the "process" and everything else merely describes it.

Another example from a paper submitted to this journal is “an eleven professional organization consensus committee,” rather than “a consensus committee representing eleven professional organizations.”

Repetitive use of inverted and complex arrangements of words impairs comprehension, obscures meaning, and makes the reader cry out “How’s that again?”


I recently was gratified and simultaneously amused to find evidence that – thankfully – I am not alone in my concerns. The Texas Heart Institute Journal recently published the 11th in a series of their "Dizzy Awards" that began 29 years ago.2 The authors inform us (with tongues planted firmly in cheek) that the awards are given for “excellence in unintentionally comical, bewildering, or downright terrible medical writing… [and] poor editing.”

They honor Jay Hanna “Dizzy” Dean (1910–1974), who was a National League pitching immortal for the St. Louis Cardinals during the team’s “Gashouse Gang” era of the Depression-scarred 1930s.

His mother died of Tb when he was 8. As the son of a tenant farmer in Arkansas, he had little education after the 4th grade, and he joined the Army at age sixteen, where he was known to throw potatoes against the lids of garbage cans, presumably as an approximation of the strike zone? (Some think this was the origin of his nickname.) Dean left the Army in 1929, played semi-pro and then minor-league ball, and emerged as a star for the St. Louis Cardinals in 1933 when he won twenty games and set what was then a record for strikeouts by fanning 17 batters in a nine-inning game.

In 1934 he won 30 games, a National League pitching record that still stands, and he lost only 7. His stellar career was abbreviated when a line drive off the bat of the last hitter he would have faced in that game broke his left great toe in 1937. His attempt to keep pitching despite the pain altered his pitching motion and injured his shoulder. After several unsuccessful seasons with the Chicago Cubs, he retired in 1941 and began a legendary career broadcasting the home games of the St. Louis Cardinals and the American League’s St. Louis Browns.

As part of the first generation of former players to use their profound first-hand knowledge of the game, his poor schooling became an asset that injected a refreshing note of humor into his broadcasts. According to his online biography,3 he used “baseball slang, the vocabulary of rural America, Dean’s own word inventions, and his mispronunciations of players’ names.”

For Dean, runners “slud” into bases, players “throwed” the ball, a batter strode to the plate “confidentiality” and looked “mighty hitterish” in the batter’s box. If a batter “swang” at the pitch mightily, he “had quite a ripple” at the ball. If runners were on base and a foul ball was hit, the runners had to return to their “respectable” bases. (I can’t help noting that if he had lived in our era he might have been elected President.)

When teachers expressed concern about his influence on school children’s grammar, he responded “I ain’t never met anybody that didn’t know what ain’t means.”*

The winners of the Dizzy Awards published in the Texas Heart Institute Journal are excerpts from prominent medical journals. The authors offer to provide references upon request, but as an editor myself, I am sure these are authentic and references need not be checked for accuracy! I present herein some selections from their article, with their unexpurgated comments4 in the plaintive hope that study of these errors may prevent future errors in articles submitted to the Journal of LGH.

The Batty Title Awards

"Non-Traumatic Gram-Negative Bacillary Meningitis in the Detroit Medical Center"
- Did the Center have a stiff neck?

"Treatment of Alcoholic Hepatitis with Encephalopathy"
- What dose of encephalopathy is most effective?

"Food-Dependent Exercise-Induced Anaphylaxis: A Case Related to Chickpea Ingestion and Review"
- Wow! A case of anaphylaxis related to review!

"Primary Kaposi's Sarcoma of an Intraparotid Lymph Node with AIDS"
- Was the lymph node drug dependent, hemophiliac, or homosexual?

"Deaths Attributed to X-Ray Contrast Media on U.S. Death Certificates"
- Ink is safer on death certificates.

The Batted Out of Order Awards

"Upon being admitted to the geriatric service for persistent symptoms, a review of systems .... "
- We reserve our beds for patients, not reviews.

"On admission to the hospital, the vital signs were stable, ... "
- What were the signs complaining of?

"Discovered as a pathogen in 1939, Hellerstrom first described M. marinum . ... "
- True. Some people are pathogenic.

"On standing the color rapidly changed to reddish brown."
- What happened when the color sat down?

The Best Defensive Play Award

"Preventing active tuberculosis (TB) in nursing homes is a high priority."
- Vaccinating the nursing home or having it wear a mask might help.

The High Heater Award

"Six hours after arrival, the temperature rose to 40.9 °C"
- Did the temperature arrive by ambulance?

The Wrong Ballpark Award (4-way tie)

"Numerous outbreaks of infection and colonization by multidrug-resistant organisms (MDROs) have been reported in LTC facilities .... " "To our knowledge, Legionnaires disease in cannabis smokers has never been reported in humans." "It is an unusual and rare infection, previously recorded in only five humans." "Various curved, gram-negative bacilli have been periodically reported in the stomach for over a century, ... "
- Remember, you always report in journals, not in LTC facilities, in humans, or in stomachs.

The Word Series Award

"The development of Goodpasture's disease may be considered an autoimmune 'conformeropathy' that involves perturbation of the quaternary structure of the A345NC1 hexamer, inducing a pathogenic conformational change in the A3NC1 and u5NCl subunits, which in turn elicits an autoimmune response."
- We'll put that one out to pasture-for good!

The Umpires Are Conferring Award

"The patient was also referred to a psychiatrist who diagnosed depression related to the recent death of his mother."
- Oedipus complex by proxy?

The Cases at the Bat Award

"All cases had swollen bursae."
- Did the cases complain of pain?

The Bag of Soda Pop Award

"Because they are much more common, this review focuses on patients presenting with nonmassive PE."
- This and they doesn't fit together all that good.

The Preseason Rankings Award

"Considering that 76% of the control group was correctly predicted, it was concluded that the predictor variables were able to correctly predict membership of the control group, but not able to correctly predict the presently or formerly injured sufferers of plantar fasciitis. "
- Sounds prediculous to us!

The Adjusting the Lineup Award

"Survivors of unexpected deaths were found to be at high risk for poor subsequent adjustment."
- Surviving death is, in itself, a very good adjustment, don't you think?

The Game-Ending Award

"Sudden death is a prominent and lethal feature of coronary heart disease (CHD), ... "
- Agreed! Death is lethal, sudden or otherwise.

The Fog on the Playing Field Award

"Our understanding of the natural history of silent ischemic episodes is poorly understood."
- We don't understand why your understanding is poorly understood.

The Blooper Award

"His vital signs were normal except for dullness to percussion and decreased breath sounds over the left hemithorax."
- When did percussion and auscultation become vital signs?

The Removed from the Lineup Award

"Treatment of an asymptomatic nodule which has been removed surgically is controversial."
- We usually pickle it, throw it away, put it back where we found it, or give it an antibiotic.

The Breakout Inning Award

"Other potential complications of bed bug bites are emerging in the literature."
- Warning: a literature search might cause a rash.


Please note that in the vast majority of these amusing quotes (other than those that simply are characterized by mangled syntax), the error is the omission of the word or words “the patient(s)” or “in the patient(s).” Medical writing that ignores the patient and reads as if the problem is the disease rather than the patient with a disease, reflects an attitude that is not a laughing matter.


1 McCrum R, Cran W, MacNeil R. The Story of English.. Penguin Viking books. New York 1986.

2 Fred HL, Robie P. Dizzy medical writing. South Med J 1983;76(9):1165-6.

3 encyclopediaofarkansas.net/encyclopedia/entry-detail.aspx?entryID=13

4 Fred HL and Scheid MS. Dizzy Medical Writing and Editing; Time for a Lockout?. Texas Ht Inst J. 2012;39:471-479


An amusing sidebar is that my Microsoft Word grammar/spell checker flagged this sentence because “ain’t never” is a double negative. Apparently, the “correct” form is “ain’t ever!” We can be thankful, I guess, that Dizzy didn’t hit a triple by saying “I ain’t never met nobody…”