Dr. Crichton never practiced medicine, and while his novels were carefully researched and detailed with scientific precision, to my knowledge he published only one article in the scientific literature. This was a short article, published in 1975, discussing the topic of “medical obfuscation”. I remember reading it then, and as with most of Crichton’s writing, it found very perceptive. The point of his short “op-ed” piece was that scientists write poorly, and that scientific articles are needlessly difficult to read.

The Merriam-Webster dictionary describes “to obfuscate” as an intransitive verb that means “to be evasive, unclear, or confusing”. In analyzing several articles published the New England Journal of Medicine (his comments were not directed only to that journal), Dr. Crichton pointed out a number of recurring problems in writing, including excessive verbiage, redundancy, poor syntax, and needless complexity as well as excessive compression. He observed, “Medical writing in general is weak. Voices are passive, verbs are transitive, modifiers are abstract, and qualifying clauses abound.” He also noted that “the general consequence of all these writing errors is to make medical prose as dense, impressive and forbidding as possible,” and came to the conclusion that “what they (authors) are communicating is their profound scientific-ness , not whatever the title of their paper may be.”

We medical professionals certainly do speak a strange language! I suppose this is not entirely a surprise—on my first day of medical school, I remember being told that I would learn 6,000 new words in the next year. I found this quite unexpected. I was already a college graduate, and I thought that my command of the English language was pretty good. It turns out that many of the “new words” were not English at all—at least not the English language that normal people speak in everyday interaction. Perhaps this explains why our patients sometimes find our descriptions and discussions and summaries to be so hard to understand.

I share Crichton’s perspective that perhaps we like to use big and important sounding words so that we can sound big and important ourselves. I am not sure. But why else would we say, for example, “a collection of edema is observed in the bilateral legs” when “both legs are swollen” would do just fine? Or “a cardiac murmur was able to be auscultated over the lateral precordium” instead of “I heard a murmur over the left chest”? Even echocardiographic reports often use cumbersome phrases when simpler ones could be used. For example, noting that “evidence of left ventricular enlargement is observed” is really just saying “the left ventricle is large”. Patients would probably understand the simpler terminology better, and if we used real English they might even follow our instructions more faithfully. It is even conceivable that other doctors and health care providers would also understand us better, too.

Of course, while we health care professionals like to use big words, we also like to use “shorthand”— perhaps this allows us to think that “we are in on the secret, and you are not!— neener, neener”. Let’s consider abbreviations and in particular, acronyms. Strictly speaking, an abbreviation is a shortened form or a word or phrase. An obvious example is the term “auto” which we might use as shorthand for “automobile” or “automatic”. Some would consider that an acronym is a type of abbreviation, but instead of shortening the actual word (“echo” instead of “echocardiography”), an acronym is a word made up of letters from a series of words. The word “radar” is an acronym— during World War II, the Navy developed a technique for detecting ships at sea and planes in the air that was based on reflected radio waves and was known as RAdio Ranging And Detection, or RADAR. I fact, this technique has many similarities to SONAR, which is Sound Navigation And Ranging and forms the basis for echocardiography. The use of acronyms has achieved high visibility in the contemporary cardiology literature; it seems that every large multi-center trial is known by a clever acronym. This can be effective if it allows readers to remember a long and somewhat cumbersome title by using a simple acronym that illustrates the focus of the trial. A good example, published recently in this Journal , is the CLOTS trial; the acronym is shorthand for “Comprehensive Left atrial appendage Optimization of Thrombus using Surface echocardiography” and makes clear to the reader what the article is about. Sometimes, however, it seems that the acronym by which a study is known was chosen largely because it was “catchy” and not because it provided a sense of the purpose of the study.

One major problem with acronyms is that a given acronym may mean something totally different to one person than to another. One of my favorites is “MS”. A psychiatrist knows that MS stands for “mental status”, while a neurologist might take it to mean “multiple sclerosis”. I am interested in valvular heart disease and am certain that MS stands for “mitral stenosis”. My cardiac pharmacologist reminds me, however, that MS really stands for “morphine sulfate”, while my neighbor, who works in the computer industry, tells me that it stands for “MicroSoft”. MS is also used for “medical student”, “metabolic syndrome”, “mass spectroscopy”, “manuscript”, and even “Marge Simpson”.

We echocardiographers often use another common acronym— PE. Just think of all the things that the acronym PE might be taken to mean. “Pericardial effusion”, of course. Or perhaps “pleural effusion”, or “pulmonary embolism”, or “physical examination”, or “phenlyepherine”, or “performance evaluation”, or “phase encoding”, or even “premature ejaculation”. Of course, it is often— not always, but often— possible to guess what the acronym means by considering the context in which it is used. But readers of clinical summaries and diagnostic exam reports should not have to guess— and neither should readers of medical journals.

In fact, why should the authors of scientific articles in a medical journal use abbreviations or acronyms? A few good reasons do come to mind— every journal has a finite number of editorial pages available for publishing articles, and every reader has a finite attention span. No journal editor can publish an article the length of War and Peace , and most readers do not have the time or patience to read very long articles. Abbreviations and acronyms do save space, and using them may make it easier for a reader to wade through an article that would otherwise be complex. Our own journal title is an example; “Journal of the American Society of Echocardiography” is easy to understand, but it includes 20 syllables, and takes a long time to say or even read. “JASE” is so much easier. If a given author has a lot of important material to cover and must use some complex notation, it may make sense to use clearly defined and unambiguous acronyms to make the article easier to read and understand. The key word is “unambiguous”. I wish, for example, that authors would not use “LAD” for “left atrial diameter” when most cardiologists use this same term to mean “left anterior descending” coronary artery. Similarly, AMI would be a poor choice for “augmented myocardial index” since most cardiologists will take this to mean “acute myocardial infarction”. Even if the new use of an old acronym is defined precisely, many readers will have trouble remembering how it is being used. Better the author should choose a different method for abbreviating and avoid the potential for confusion.

If we are going to use acronyms, let’s use them correctly. I often see ECHO used to refer to “echocardiography”. Of course, if you have read this Editor’s Page carefully, you will realize that ECHO, when written in capital letters, is really an acronym. The proper abbreviation for “echocardiography” is “echo”. The acronym ECHO stands for a variety of interesting things. A little online investigation will reveal that the acronym ECHO has been used to refer to the Extended Care Health Option (a supplemental coverage program offered to dependents of members of the military), the Evangelical Christian Humanitarian Outreach, the Eastern Co-operative Health Organization, the Egyptian Cultural Heritage Organization, and the Escherischia Coli Help Organization, among many others. All worthy groups, but not related to the field of echocardiography as best as I can tell.

The echocardiography community also commonly uses the acronym PEDOF incorrectly. I have seen this described as “the name of the guy who invented continuous wave Doppler”, and I often see it spelled (incorrectly) as Pedoff. I have been told that some have used the term Peedoff, which is what the people who invented this acronym might be if they saw how it has been misused. A very reliable source (Liv K. Hatle, MD; personal communication, 26 July 2009) reminds me that PEDOF is indeed an acronym that was derived from the phrase “Pulsed Echo DOppler Flow velocity meter”. It is a fine acronym, but if you are going to use it, please use it correctly.

Of course, I have nothing against big words or small abbreviations. Used appropriately, both can be effective. I do wish, however, that those of us in the medical profession sometimes thought a little bit more about “how we say it” and not exclusively about “what we say”. Often, how we say (or write) something is at least as important as what is said— and has a lot to do with whether others understand our point. Most writers would agree that it is harder to say something succinctly and clearly than to describe it in a roundabout and complicated manner; I suspect that even Shakespeare may have found it easier to write a play than a sonnet. Whether what we have to describe is a short summary of a test result or a long discussion of a new scientific discovery, language that is clear, direct, and familiar to the audience is more effective than complicated words and acronyms that require the reader to sit with the article on one knee and a dictionary on the other. As Crichton wrote many years ago, “if the authors of these scientific papers really wanted to be understood in a straightforward way, they would write simply and express their ideas in the clearest, most unambiguous form they could manage”. I would hope that we do want to be understood, and would like to think that with a bit of extra effort, all of us could learn to write better and to communicate more clearly.

As always, if you have comments or suggestions, I can be reached at jaseeditor@asecho.org .