The strength of verbs in important in medical writing and should correspond to the level of evidence or better, level of causality

1. Strength of verbs in medical
writing should correspond to the
level of evidence (or degree of
causality): A plea for accuracy
Abe Fingerhut, MD, FACS (hon), FRCPS (g), FRCS (Ed) hona
and
Michael G. Sarr MD, FACS (hon), FRCPS (g), FRCS (Ed) hon,b
Graz, Austria, and Rochester, MN
From the University Hospital,a
Medical University of Graz, Graz, Austria; and the Department of Surgery,b
Mayo Clinic and Mayo Foundation, Rochester, MN
When I use a word, it means exactly what I choose
it to mean---nothing more, nor less
---Lewis Carroll, Through the Looking Glass
THE MAIN GOAL of scientific writing both in sci-
ence and in surgery is to convey methodologically
sound, accurate, and thereby credible information
to the reader, who can then use this published in-
formation with confidence for patient care.
Various levels of “evidence” have been con-
structed with the goal of hierarchizing the credi-
bility of published information; the higher the level
of evidence, the greater credibility and the greater
the probability of causality (or cause and effect)
between what has been observed as outcome and
the intervention or purported cause.
When reporting the outcome of one’s work or
when citing the outcomes of other papers, the
writer must weigh carefully the meaning of words
used---the verbs, in particular---with a conscious
goal being to distinguish between a potentially
per-chance association on one hand, and causality
on the other. The choice of verbs should depend
on the degree of causality.
Verbs can be descriptive or declaratory. Descriptive
verbs are used to describe an action; they should be
neutral, without any connotation or even suggestion
of inference, and should not specifically claim a
causal relationship. Descriptive verbs have their
place, for instance, in an observational, nonrandom-
ized, retrospective, or prospective data collection or
in analytic studies, when the comparison of interven-
tions or outcomes between 2 groups cannot claim
causalitybecauseofpotential bias.Severaldescriptive
verbs or verbal phrases can be used, including “are in
favor,are associatedwith, believe,bring(forward),carry,
find, get, give, have, highlight, hold, identify, look, main-
tain, make, observe, place, provide, put, report, suggest, sup-
port, think, underline, or underscore”, just to name some
of the most commonly used.
Declaratory verbs are stronger and are used specif-
ically to make a claim or to assert. They should only
be used to denote causality and, in clinical surgery,
derived only from well-designed, adequately pow-
ered, randomized, blinded, controlled trials. These
include show, demonstrate, prove, establish, cause, deter-
mine, and result in, which are the most frequently
used. These verbs should never be used for uncon-
trolled (noncomparative) findings, observations, or
comparisons where causality is neither inferred nor
established. The verb show, however, can be used in
both a descriptive (as in “the data in Figure X
show”) or a declarative manner (denoting causal-
ity). To avoid any ambiguity, however, depict, exhibit,
display, expose, and reveal may be preferred instead of
the descriptive sense of show.
Verbs have 3 distinct functions in medical
writing: to compare, to theorize, or to define a
fact.1
Verbs used for comparisons indicate the
writer’s representation or placing of one work in
relation to another, for instance, a cited author’s
work as being similar to or different from that under
scrutiny; the verbs can be descriptive (“our findings
are in accordance with, contrast with, differ from.” or
“we found.”) or declarative (“our findings show
that the intervention decreased, increased.”).
Accepted for publication December 22, 2016.
Reprint requests: Abe Fingerhut, MD, FACS (hon), FRCPS (g),
FRCS (Ed) hon, University Hospital, Medical University of Graz,
Graz 8036, Austria. E-mail: abefingerhut@aol.com.
Surgery 2017;j:j-j.
0039-6060/$ - see front matter
Ó 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.surg.2016.12.026
SURGERY 1
ARTICLE IN PRESS

2. Theorizing verbs indicate the use made by the
writer of another author’s work in the writer’s own
developing argument or having putative impor-
tance, for example, “This may account for, seems,
appears to explain, suggests, could support or indicate
the theory that..” Such verbs, also called modal,
speculative, or hedging verbs,2,3
should be used for
potential but as yet unproven statements, as in
experimental studies, and can lead the way to
transform speculative assertions into workable hy-
potheses for further validation. These verbs or
phrases should not be used to imply or define cau-
sality. Verbs used for defining facts are straightfor-
ward and can be either descriptive or declarative
(implying causality).
Several verbs or associated words have specific
meanings in scientific writing and, therefore,
should be used preferentially. For example, the
word significant should be used only to designate
an estimate of statistical likelihood (and always
be preceded by statistically significant to avoid
any ambiguity). Thus, when there has been no
formal statistical analysis, a phrase such as “a signif-
icant increase or decrease” is ambiguous and not
appropriate for a scientific article; either the in-
crease or decrease was statistically significant as
shown by a statistical test, or the adjectives substan-
tial or substantive would be more appropriate to
suggest a change of magnitude or potential impor-
tance. When a statistically significant difference is
found in a randomized trial, the verb should be
declaratory. Otherwise, only descriptive verbs may
be used, such as “a statistically significant differ-
ence was found,” or “X is associated with a statisti-
cally significant increase (or decrease).”
The verb trend and its corresponding noun refer
to situations in which the P value is > .05 but < .10;
however, the use of the word trend by authors does
not and should not imply or claim statistical signif-
icance. By providing the P value, the readers can
draw their own conclusions. The verb correlate re-
fers to the outcome of the Pearson r or Spearman
rank correlation coefficient (r) and should not be
used otherwise. Likewise, stating that “X was in
agreement with Y” should be avoided, because this
statement may be ambiguous with the result of
the Cohen “agreement” kappa statistic.
Finally, the tense of verbs has importance. By
convention, all experiments or observations that
have already occurred are expressed in some form
of the past tense. The present tense is used for
general knowledge or for widely admitted or uni-
versally accepted facts; however, when used for the
results of an experiment or trial or in the title, the
present tense is strong and declarative and there-
fore implies and denotes causality. A statement
such as “X (intervention) decreased mortality” is
descriptive, whereas “X decreases mortality” is
declaratory and implies causality.
In conclusion, in scientific writing, the strength
of the verb should correspond to the level of
evidence or, even better and more specifically, the
degree of causality. Declaratory verbs should be
used only for results where causality can be
supported without reasonable doubt, such as with
level 1, randomized, controlled trials or with meta-
analyses of well-designed, adequately powered,
randomized, controlled trials without bias or het-
erogeneity. All other comparisons are the results of
observational or some degree of biased findings or
unproven working hypotheses; they should be
expressed with descriptive verbs only.
As others have reported,2,4
we maintain that
verbs should be used selectively and accurately ac-
cording to the type of the study and need to be
used strictly consistently with the level of evidence.
Misuse of verbs in scientific writing leads to misun-
derstanding and can be used as a source of “SPIN”5
to try to embellish the writer’s work either pur-
posely or unknowingly; this misuse of the verb
can be a very real danger when applied to clinical
practice.
We hereby make a plea that these “rules” be
followed by all scientific writers and journal
editors.6
REFERENCES
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2. Horton R. The rhetoric of research. BMJ 1995;310:985-7.
3. Malhotra A, Younesi E, Gurulingappa H, Hofmann-
Apitius M. ‘Hypothesis finder:’ a strategy for the detection
of speculative statements in scientific text. PLoS Comput
Biol 2013;9:e1003117.
4. Kohli P, Cannon CP. The importance of matching language
to type of evidence: avoiding the pitfalls of reporting out-
comes data. Clin Cardiol 2012;35:714-7.
5. Fingerhut A, Lacaine F, Cuschieri A. Medical SPIN: misinfor-
mation by another name. Surg Endosc 2015;29:1257-8.
6. Greenwaugh T. Commentary: scientific heads are not turned
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2 Fingerhut and Sarr