Grammar Points on
Medical Writing
Dr Steve Wallace
Introduction and outline of speech
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- Active and passive voice in
medical writing
- “Hedging” in medical writing
- Dangling modifiers
- Misplaced modifiers
- Latin and Greek plurals
- Other Grammar points
Active and passive
voice
What Is Active Voice?
The active voice emphasizes the
performer of the action:
 Wind disperses plant seeds.
 Smith et al. investigated the
relationship.
 We have analyzed the results.
The active voice is direct (performer–
verb–receiver), clear, and concise.
What Is Passive Voice?
The passive voice, emphasizes the
receiver of the action:
 Plant seeds are dispersed [by wind].
 The relationship was investigated [by
Smith et al].
 The results have been analyzed [by
us].
 The passive voice is indirect and
can be weak, awkward, and wordy.
Tradition and the Passive Voice
More than a century ago, scientists
wrote in the first-person pronouns
I and we.
Example: Charles Darwin
“I have called this principle by the
term of Natural Selection, in order to
mark its relation to man's power of
selection.”
Beginning in the 1920s scientists
adopted a passive writing style.
The passive voice was thought to be
objective, impersonal, and well
suited to science writing.
Exception

“We wish to suggest a structure for
the salt of deoxyribose nucleic acid
(D.N.A.).”
Watson and Crick's classic article is simple, direct,
and clear.
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“In this paper, a structure is
suggested for the salt of deoxyribose
nucleic acid (D.N.A.).”
Emphasize the Active Voice
Currently, most medical and scientific
style manuals prefer active voice
 Some journals ask authors to limit
first-person pronouns or restrict
them to certain sections.
 Other journals prefer authors to use
first-person pronouns over passive
voice.
AMA Manual of Style
recommends that:
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“In general, authors should use the
active voice, except in instances in
which the author is unknown or the
interest focuses on what is acted
upon.“
AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford
University Press; 2007.
The Journal of Trauma and
Dissociation:
"Use the active voice whenever
possible: We will ask authors
that rely heavily on use of the
passive voice to re-write
manuscripts in the active voice.“
Guidelines for authors. International Society for the Study of Trauma Web site: The
Journal of Trauma & Dissociation. http://www.isst-d.org/jtd/journal-traumadissociation-info-for-authors.htm. Accessed March 5, 2009.
Ophthalmology
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"Active voice is much preferred to passive
voice, which should be used
sparingly....Passive voice...does not
relieve the author of direct responsibility
for observations, opinions, or conclusions
(e.g., 'The problem of blood flow was
investigated...' vs. 'We investigated the
problem of blood flow...').“
Guide for authors. Elsevier Web site: Ophthalmology: Journal of the American Academy of
Ophthalmology.
http://www.elsevier.com/wps/find/journaldescription.cws_home/620418/authorinstructions.
Accessed March 5, 2009.
The Journal of Neuroscience
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"Overuse of the passive voice is a
common problem in writing. Although the
passive has its place—for example, in the
Methods section—in many instances it
makes the manuscript dull by failing to
identify the author's role in the
research....Use direct, active-voice
sentences.“
Westbrook G, Cooper L. Writing tips: Techniques for clear scientific writing and editing. The Society
for Neuroscience Web site:The Journal of Neuroscience. http://www.jneurosci.org. Accessed March
5, 2009.
British Medical Journal
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"Please write in a clear, direct, and
active style....Write in the active
[voice] and use the first person
where necessary.“
The essentials of BMJ style. BMJ Publishing Group Web site: British Medical Journal.
http://resources.bmj.com/bmj/authors/bmj-house-style. Accessed March 5, 2009.
The Publication Manual of the American Psychological
Association (APA) has similar advice:
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"Prefer the active voice....The
passive voice is acceptable in
expository writing and when you
want to focus on the object or
recipient of the action rather than on
the actor.“
American Psychological Association. (2001). Publication Manual of the
American Psychological Association (5th ed.). Washington, DC: Author.
Behavioral Ecology

“Active voice is preferable to
the impersonal passive
voice.“
Instructions to authors. Oxford Journals Web site: Behavioral Ecology.
http://www.oxfordjournals.org/our_journals/beheco/for_authors/general.html. Accessed March
5, 2009.
Science
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"Use active voice when suitable,
particularly when necessary for
correct syntax (e.g., 'To address this
possibility, we constructed a lZap
library ...,' not 'To address this
possibility, a lZap library was
constructed...').“
http://www.sciencemag.org/about/authors/prep/res/style.dtl. Accessed March 4, 2009.
Nature
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"Nature journals like authors to
write in the active voice as
experience has shown that readers
find concepts and results to be
conveyed more clearly if written
directly.“
How to write a paper: writing for a Nature journal. Nature Publishing Group Web site:
Nature. http://www.nature.com/authors/author_services/how_write.html.
Accessed March 4, 2009.
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When should an author choose
the passive voice?
1. If the performer is unknown,
unimportant, or obvious
“Up to 90% of the energy in light
bulbs is wasted in the form of heat.”
“The first edition of Freud's earliest
writings on dreams was published in
1899.”
“Drosophila melanogaster has been
one of the most extensively studied
species in genetics research.”
2. If the performer is less
important than the action
“The honey bees were kept in a humidified
chamber at room temperature overnight.”
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“The solution was heated to 90°C for
approximately 30 minutes and then allowed to
cool.”
If active:
“We kept the honey bees in a humidified chamber
at room temperature overnight.”
“We heated the solution to 90°C for
approximately 30 minutes and then allowed it to
cool.”
3. Put important information at
the beginning of the sentence
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Green plants produce carbohydrates
in the presence of light and
chlorophyll.
If, "carbohydrates" (the receiver of the action) is the
opening topic, passive is better:
Carbohydrates are produced by
green plants in the presence of light
and chlorophyll.
Watson and Crick (1953)
“We wish to suggest a structure for the
salt of deoxyribose nucleic acid (D.N.A.).
This structure has novel features which
are of considerable biological interest. A
structure for nucleic acid has already been
proposed by Pauling and Corey.”
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The authors used the active voice in the first and second
sentences, but the passive in the third. If the third sentence
is changed to active voice, it becomes:
Pauling and Corey have already proposed
a structure for nucleic acid.
Summary on Passive Voice
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Choose the active voice whenever
possible.
Choose the passive voice when:
1) The performer is unknown, irrelevant,
or obvious.
2) The performer is less important than
the action.
3) The recipient is the main topic.
You can also use the passive voice to
hedge (i.e., to be noncommittal).
Not recommended
Hedging in
Scientific Writing
"Hedging" in Scientific Writing
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Report the limits of their findings
Protect themselves from the risk of error
Show humility
Cautious language is important, but not use too
much
3 hedging techniques:
Qualifiers (modifiers)
Passive voice
Apologetic quotation marks
1. Word choice: Unnecessary
qualifiers
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Qualifiers modify or limit the meaning of other
words.
Qualifiers are added to scientific writing to
express:
approximation
probability
doubt
limit the scope of a statement
Examples of qualifiers
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Adjectives: apparent, certain, consistent with,
few, many, most, possible, presumed, probable,
putative, several, some, supposed
Adverbs: about, apparently, arguably, fairly, in
general, largely, likely, more or less, mostly,
often, perhaps, possibly, presumably, probably,
quite, rather, somewhat, unlikely, usually
Nouns: appearance, indication, inference,
likelihood, possibility, probability, suggestion,
tendency, to my knowledge
Verbs: aim, appear, assume, can, could,
estimate, indicate, infer, intend, may, might,
presume, propose, seem, seen as, should,
speculate, suggest, suppose, tend
Unnecessary qualifiers (continued)
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Qualifiers reduce a researcher's certainty about a
method or observation
Double, triple, and quadruple synonyms are
unnecessary
Example:
may be possible
seems to suggest
rather likely to indicate
may be seen as rather likely
How would you modify
this sentence?
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“A possible cause is likely the
apparent tendency of a certain
number of patients with diabetes to
develop indications of retinopathy.”
“A possible cause is the tendency of
patients with diabetes to develop
retinopathy.”
2. Point of view: Unnecessary
passive voice
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A noncommittal form of the passive voice occurs
when authors fail to name themselves (with the
personal pronouns I, we)
Often begins with the word It
Example:
It was apparent...
It has been noted...
It was decided...
It is known to be...
Who reported the results? To whom was it
apparent?
The reader is forced to guess who holds the view
Passive in the Methods Section
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“It was concluded that sleep deprivation
has three effects on cognitive
performance.”
The passive voice protects the authors from the
risk of uncertainty. However, who concluded?.
The reader may find it difficult to determine who
did the action when authors use the passive voice
to describe their own work other researcher’s
work.
Unless you have good reason to write in the
passive voice, use the active voice to identify the
performer (e.g., We concluded that...).
3. Punctuation: Unnecessary
quotation marks
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Some authors add quotation marks to
emphasize expressions that are being used for
irony or in a nonstandard sense:
“Many patent "medicines" in the 1800s
contained little more than alcohol and
water.”
Apologetic quotation marks tell the reader
that an expression is not being used in the usual
way.
The author hedges by adding quotation marks
rather than trusting readers to draw their own
conclusions or to recognize the irony or special
use.
Many style guides consider them unnecessary.
Summary on Hedging
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1) Eliminate unnecessary qualifiers
2) Use the active voice when
necessary
3) Seldom apply apologetic quotation
marks
Dangling Modifiers
A dangling modifier is a word or phrase
that modifies the wrong subject in a
sentence. This occurs because the
implied subject is missing.
Most are verbal phrases:
Participles (verbs used as adjectives)
Gerunds (verbs used as nouns)
Infinitives (verbs used as nouns adjectives,
or adverbs)
Dangling Participles
(end in “ing” or “ed”)
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Example
Using the survey data, the effects of
education on job satisfaction were
examined.
(Who is using the data? Implied subject =
we/researchers; grammatical subject =
the effects)
Correction
Using the survey data, we examined the
effects of education on job satisfaction.
Dangling Gerunds (end
in “ing”)
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Example
After preparing the samples, our focus
was on collecting the data.
(Who did the preparing? Implied subject =
we/ researchers; grammatical subject =
our focus)
Correction
After preparing the samples, we focused
on collecting the data.
Dangling Infinitives
(include the word “to”)
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Example
To investigate the relationship, a series of
experiments were designed.
(Who is going to investigate? Implied
subject = we/researchers; grammatical
subject = a series)
Correction
We designed a series of experiments to
investigate the relationship.
Quick Tips: Dangling Modifiers
Watch for dangling modifiers at the
beginning of sentences.
 Ask who or what is doing the action
and make sure the implied subject is
doing it.
 Write in the active voice whenever
possible.
 The passive voice "encourages"
dangling modifiers to appear.
Misplaced Modifiers
Misplaced modifiers are an error in
sentence structure involving the
order of words
 A misplaced modifier has been
incorrectly placed in a sentence,
describing the wrong word or phrase
 Adjectives and adverbs are easily
misplaced, producing unclear results
The word only modifies the word that
directly follows it.
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Example
Only eradication of this disease can be achieved
through immunization. (Eradication, but no other
outcome, can be achieved.)
Alternative 1
Eradication of only this disease can be achieved
through immunization. (Eradication of this
disease, but not of any other, can be achieved.)
Alternative 2
Eradication of this disease can only be achieved
through immunization. (Eradication can be
achieved, but no other action can occur.)
Alternative 3
Eradication of this disease can be achieved only
through immunization. (Eradication can be
achieved through immunization but not by any
other means.)
Quick Tips: Misplaced Modifiers
Place words and groups of words as
close as possible to the words that
they are describing.
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Place words such as only, almost,
and even just before the word that
you want them to describe.
Pronoun Errors
The Ambiguous Antecedent
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A pronoun (e.g., you, ours, she, this,
whom, which, himself) takes the place of
a noun.
The noun, pronoun, or clause that a
pronoun refers to, called an antecedent,
usually appears earlier in the sentence.
A pronoun should refer to one specific
antecedent.
An ambiguous pronoun antecedent occurs
when a pronoun has two or more
possible antecedents.
Example: Does the pronoun it refer to the first
study or to the second study?
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“The second study was designed to enroll 2000
more participants than the first study. It tested
three dose levels of the study drug.”
Correction 1
The second study, which tested three dose levels
of the study drug, was designed to enroll 2000
more participants than the first study.
Correction 2
The second study, designed to enroll 2000 more
participants than the first study, tested three
dose levels of the study drug.
Example of an unclear
antecedent
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Smith et al. compared their study results
with those of previous researchers and
presented them at the conference.
At the conference, Smith et al. presented
their study results, which they had
compared with those of previous
researchers.
Quick Tips: The Ambiguous
Antecedent
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Make sure that each pronoun refers
to only one antecedent.
To correct:
remove the pronoun,
shorten the sentence, or
rearrange sentence elements.
You may need to do all three.
The Missing Antecedent
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A missing pronoun antecedent is
when the author implies an
antecedent but does not include it
in the sentence.
The true antecedent, or reference, is
missing.
How can we modify this
sentence?
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After reading the nursing professor's recent
publication on patient care, the students
contacted her to obtain more information.
Correction 1 After reading the recent publication
on patient care by their nursing professor, the
students contacted her to obtain more
information.
Correction 2
After reading the recent publication on patient
care by Johnson, the students contacted her to
obtain more information.
Correction 3
The students contacted the nursing professor to
obtain more information after reading her recent
publication on patient care.
Quick Tips: The Missing
Antecedent
Look for missing antecedents when
the implied antecedent of a pronoun
is in possessive case (and thus an
adjective).
 To correct a missing antecedent
 1) Replace antecedent adjectives
with nouns or noun phrases; or
 2) Replace pronouns with nouns or
noun phrases.
The Vague Antecedent
Sometimes authors use the pronouns this,
that, it, or which to refer to a noun or
clause (called an antecedent) in the
previous sentence.
 If the reference is not obvious readers
may not review the previous sentence to
understand what the author is saying.
 A vague pronoun antecedent occurs when
a pronoun refers to one or more groups
of words and the reference is not clear.
The Vague Antecedent
Example 1
Patients with a latent infection may need
to be monitored for several months
because they are at risk of developing the
active form of the disease. This diminishes
over time.
or
Example 2
 Patients with a latent infection may need
to be monitored for several months
because they are at risk of developing the
active form of the disease, which
diminishes over time.
The Vague Antecedent
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Correction 1
Patients with a latent infection may need to be
monitored for several months because they are
at risk of developing the active form of the
disease. This risk diminishes over time.
Correction 1
Patients with a latent infection may need to be
monitored for several months because they are
at risk of developing the active form of the
disease. The need to monitor these patients
diminishes over time.
Correction 1
Patients with a latent infection may need to be
monitored for several months because they are
at risk of developing the active form of the
disease. As the risk diminishes over time, so too
does the need to monitor these patients.
Quick Tips: The Vague
Antecedent
Be careful with the pronouns this,
that, it, and which.
 Correct vague pronoun antecedents
by:
 changing the pronoun into an
adjective,
 replacing the pronoun with a noun
or noun phrase, or
 revising the sentence more
extensively.
Other Grammar Errors
Latin and Greek Plurals
Common in scientific and medical writing.
 The preferred plural form of many of
these words is the same as in the original
language. But for other plurals, the usual
English rules of adding "s" or "es" now
apply.
 The acceptability of an English plural form
may differ by journal
 Caution: Read the dictionary entry
carefully. Sometimes the English plural is
used for only a narrow definition of the
term.
Common traditional endings for Latin or
Greek singular nouns and their
corresponding plural endings
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Singular ending
Plural ending
-a →
-ae
-en→
-ina
-ex→
-ices
-is →
-es
-itis→
-itides
-ix →
-ices
-on→
-a
-um→
-a
-us→
-i
Singular and Plural Nouns Derived From
Latin and Greek
Singular form
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alga
analysis
bacterium
basis
criterion
datum
focus
foramen
formula
fungus
genus
hypothesis
index
Plural form
algae or algas
analyses
bacteria
bases
criteria or criterions
data
foci or focuses
foramina or foramens
formulae or formulas
fungi or funguses
genera
hypotheses
indices (math) or indexes
Singular and Plural Nouns Derived From
Latin and Greek (continued)
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Singular form
larva
matrix
medium
nephritis
nucleus
parenthesis
phenomenon
radius
stimulus
stratum
synthesis
vertebra
Plural form
larvae or larvas
matrices or matrixes
media
nephritides
nuclei or nucleuses
parentheses
phenomena
radii or radiuses
stimuli
strata
syntheses
vertebrae or vertebrasa
Do not insert a comma before but also in a
sentence with not only...but also
Correlative conjunctions are pairs
(not only...but also, either...or,
neither...nor, and both...and).
These conjunctive pairs are used when
there is a continuous flow of ideas.
A comma signifies a pause in the line
of thinking so no comma should be
used to separate the elements joined
by correlative conjunctions.
 Do not insert a comma before but
also.
How would you change
this sentence?
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We observed that poor drug
efficiency was due to not only lack
of absorption, but also increased
clearance.
We observed that poor drug
efficiency was due to not only lack
of absorption but also increased
clearance.
How would you change
this sentence?
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Radiotherapy is valuable not only in
reducing the number of courses of
chemotherapy, but also in
producing superior overall survival.
Radiotherapy is valuable not only in
reducing the number of courses of
chemotherapy but also in producing
superior overall survival.
Avoid double negatives
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Double negatives are used in English
to make a very positive statement,
but this is not appropriate for a
scientific paper.
In Chinese a double negative can
actually strengthen the negativeness
of a statement, which does not
translate into English.
How would you change
this sentence?
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"No background staining was not
seen..."
"No background staining was
seen..."
Do not use the same or similar
word/phrase in quick succession in two
consecutive sentences
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The baseline characteristics are shown in
Table 1. Table 2 shows the body
temperature of all female subjects.
The baseline characteristics are shown in
Table 1, and the body temperature of all
female subjects are shown in Table 2.
Table 1 and Table 2 show the baseline
characteristics and body temperature of
all female subjects, respectively.
How would you change
these sentences?
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Percutaneous RF ablation of the lung
tumors was approved by our
institutional review board. The
institutional review board also
approved tumor biopsy and specimen
analysis with the novel approach.
Our institutional review board
approved percutaneous RF ablation of
the lung tumors as well as tumor biopsy
and specimen analysis with the novel
approach.
Asian Fonts
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Asian fonts such as MS Mincho and
SimSum possess characters with different
widths from those of Latin fonts
Do not use Asian fonts in your
manuscripts
Frequently encountered problems include
those caused by Asian-font brackets, plus
and minus signs and other mathematical
symbols, and units of temperature
“temperature was increased （1 ° C/min”)
Use the present tense
for in-text reference to
figures and tables
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The vital signs upon presentation
were summarized in Table 1.
The vital signs upon presentation are
summarized in Table 1.
How would you change
this sentence?
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Figure 1 showed the relationship
between age and incidence of
dementia.
Figure 1 shows the relationship
between age and incidence of
dementia.
Do not use a period at the end of
the title of a manuscript
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Title and subtitles are not full
sentences and do not need a
period at the end.
Do not insert a period after the
title
How would you change
this title?

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Prespondylosis and some Pain
Syndromes following Denervation
Supersensitivity.
Prespondylosis and some Pain
Syndromes following Denervation
Supersensitivity
How would you change
this title?
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Acupuncture and the Peripheral
Nervous System: A Radiculopathy
Model.
Acupuncture and the Peripheral
Nervous System: A Radiculopathy
Model
Do not use a comma after a salutation in
a formal letter written in the American
style
In American English, the salutation
ends in a colon in a formal letter and
ends in a comma in an informal
letter.
In the British style of writing, a
salutation is followed by a comma in
both formal and informal letters.
How would you change
this salutation?

Dear Editor,

Dear Editor:
How would you change
this salutation?
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Dear Dr. Thomson,
Dear Dr. Thomson:
Sources
Zeiger M. Essentials of Writing Biomedical Research Papers. 2nd ed. New
York, NY: McGraw-Hill; 2000.

Gopen GD, Swan JA. The science of scientific writing. Am Scientist.
1990;78:550-558.

Watson JD, Crick FHC. Molecular structure of nucleic acids. Nature.
1953;171:737-738.



Iverson C, Christiansen S, Flanagin A, et al. AMA Manual of Style: A Guide
for Authors and Editors. 10th ed. New York, NY: Oxford University Press;
2007.
American Psychological Association. (2009). Publication Manual of the
American Psychological Association (6th ed.). Washington, DC: Author.
Instructions to authors. Oxford Journals Web site: Behavioral Ecology.
http://www.oxfordjournals.org/our_journals/beheco/for_authors/general.h
tml. Accessed March 5, 2009. Accessed March 4, 2009.
Sources (continued)
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The essentials of BMJ style. BMJ Publishing Group Web site: British Medical Journal.
http://resources.bmj.com/bmj/authors/bmj-house-style. Accessed March 5, 2009.
Westbrook G, Cooper L. Writing tips: Techniques for clear scientific writing and
editing. The Society for Neuroscience Web site:The Journal of Neuroscience.
http://www.jneurosci.org. Accessed March 5, 2009.
Guidelines for authors. International Society for the Study of Trauma Web site: The
Journal of Trauma & Dissociation. http://www.isst-d.org/jtd/journal-traumadissociation-info-for-authors.htm. Accessed March 5, 2009.
How to write a paper: writing for a Nature journal. Nature Publishing Group Web site:
Nature. http://www.nature.com/authors/author_services/how_write.html. Accessed
March 4, 2009.
Guide for authors. Elsevier Web site: Ophthalmology: Journal of the American
Academy of Ophthalmology.
http://www.elsevier.com/wps/find/journaldescription.cws_home/620418/authorinstr
uctions. Accessed March 5, 2009.
Some notes on Science style. American Association for the Advancement of Science
Web site: Science. http://www.sciencemag.org/about/authors/prep/res/style.dtl
Sources (continued)

Merriam-Webster's Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster,
Inc.; 2007.

Sternberg RJ. The Psychologist's Companion: A Guide to Scientific Writing for
Students and Researchers. 4th ed. New York, NY: Cambridge University Press; 2005.
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