What ho, Book of Style!

Follow me down the rabbit hole here…

It all apparently started with this article at Advance for HIM, Big Transcription… which got picked up and posted at the AHDI Lounge… which generated a lot of comments… which got Chad Sines thinking, so he wrote a blog post, Style Over Substance… which again got linked at AHDI Lounge.

Whew! And now, of course, I'm going to write a blog about it, because it seems my comments at AHDI Lounge never quite make it to publication – plus, I am going to be a bit long-winded.

So what's the big deal?

The big deal is the English errors made in the original Advance for HIM article. Chad Sines seems to think MTs need to cool off a bit and pay more attention to the substance of what's said and stop picking on the errors.

What struck me as off was that the comments seemed to suggest that since this MT made “glaring” errors, the substance of the article was not worthy of reading. The author apparently was to be shamed and discarded as seemingly irrelevant simply because of “mute” versus “moot” and other simple oopsies. While reading the comments I was almost yelling “WHO CARES??? Get off your pedestal and listen to the message!!”

Here's the thing for me: there's a reason for those big fat books on the shelf called “dictionary” and “Gregg Reference Manual” and that slim but oh-so-potent “Strunk & White.”

Errors such as mute instead of moot can certainly be overlooked – but as is obvious from the discussions at these websites, they're distracting. It's the equivalent of watching a period movie set in the 1800s and seeing an airplane fly across the sky in the background. Suddenly, you can't pay attention to anything but the airplane, in spite of the fact that it's a few seconds of a 90-minute film and a relatively minor event. And if you've ever watched TV or a movie with someone in the TV/movie business, you'd know that these types of errors are very obvious to them. Errors in spelling, grammar and punctuation are distracting and detracting for most readers, whether it's a fiction novel or a professional journal – or a medical record.

If the Big Transcription article had been a blog post or a post in a forum or some other type of casual venue, errors could be written off – the author was tired, in a hurry, etc., whatever. But this isn't a blog or a forum post, it's an article in a professional publication that is widely read by everyone in the health information management chain. Is Advance for HIM no longer running articles past an editor? Or are the editors no better than the author?

Moving on, Chad compares this to the medical transcriptionist's obsession with grammar and punctuation while overlooking glaring errors in the medical record.

The article in question isn't a medical report. It's a regular column published in a professional online magazine. By any publishing standard, the grammar and punctuation should be correct. Asking a group of people whose daily bread is the written word to ignore them is like asking a production assistant to ignore the airplane flying across the sky in a movie set in the 1800s.

The discussion at AHDI Lounge takes a turn in that direction, which then raises the question about Book of Style Bootcamps. Lea Sims defends the BOS as something other than a grammar and punctuation manual.

We can't raise a fist at the use of a contraction and turn a blind eye to the clinical inaccuracy in the record that may impact care decisions. Both are necessary, but of the two, clinical accuracy can't be sacrificed for style.

This really isn't an either/or. There are few – very few – instances where clinical accuracy would even have to be sacrificed for style. Correct me if I'm wrong, but proper grammar, punctuation and spelling  are not exclusive of accuracy of medical terms and terminology. I can think of many instances, however, where improper punctuation, grammar and spelling have impacted the clinical accuracy of a record.

Feel the need to defend the BOS a bit (I'm biased, I know), but there is ONE chapter on grammar in the entire BOS and ONE chapter on punctuation.

The BOS is not about clinical accuracy of the medical record. It is about style. No big surprise there, given the title of the publication. As part of the MT Desk online style guide wiki project, I've been through the Book of Style for Medical Transcription with a fine-tooth comb. It's a style guide, not a laboratory values reference or a word list or an anatomy guide, or anything else that would guide a medical transcriptionist to recognize accurate clinical documentation. Let me just open this book at random in some of the sections  and give you some examples – you tell me if this helps medical transcriptionists identify clinically accurate documentation. I'm going to identify Section 2, Chapter 4 (Grammar) as the ONE chapter Lea identifies as being devoted to grammar and Section 2, Chapter 6 (Punctuation) as the ONE chapter devoted to punctuation – everything else is fair game.

Section 3 is devoted to Measurement & Quantitation; i.e., numbers, percents, proportions, ratios and ranges, units of measure. I see how to decide when to use arabic numerals, Roman numerals and ordinal numbers. I don't see any explanation of the clinical use of these numbers or how to determine whether or not what's being dictated is within the accurate range. And oh look – there's an entire section on punctuation when expressing numeric values in the record, covering days and times, among other things. Lots of clinical significance there. There's another section on how to form plurals, use of numbers in proper names, use of numbers at the beginning of a sentence….

Section 4 is devoted to Specialty Standards. Surely, there's something in this section that would help a transcriptionist make decisions about a clinically accurate document. Let's see… commonly encountered elements in the periodic table and their symbols, how to write chemical compounds, how to write chemical names and concentrations… nothing there that would help me make decisions about whether or not the dictation was clinically accurate. The Pharmacology section devotes an entire page to the FDA approval process; while interesting, not especially helpful from either style or clinical accuracy point of view. As long as we're being obsessive-compulsive about the little things, we could start a discussion about the clinical importance of capitalizing brand name drugs and not capitalizing generic drug names. There's a section on the different DEA drug classes, but there's only a short list, given as an example, of some of the drugs in that class. And while I would say it's useful for an MT to know the forms of administration of a drug, as outlined on page 302, what would be helpful insofar as the clinical accuracy is knowing which drugs are administered by each method – but that information is missing.

I could go on and on, but you get the idea.

The Book of Style for Medical Transcription is a style guide. It may have only one chapter devoted solely to grammar and one chapter devoted solely to punctuation, but that doesn't mean the rest of the book isn't full of instructions for grammar and punctuation and (gasp again!) style as applied to the medical record. What it is not about is what drugs are administered by inhalation and what drugs are tablets, or what laboratory ranges are normal, or what diagnostic studies might be performed on specific parts of the body, or to rule out a specific diagnosis. In other words, it has nothing whatsoever to do with clinical accuracy. As the self-claimed author of the BOS, Lea Sims surely knows that.

The Book of Style does what it's supposed to do – other than general grammar and punctuation, it provides a framework for how to format the terms found in medical records. The terms themselves, the anatomy, the physiology, the pharmacology, the diagnostic studies – in other words, the clinical aspect of the medical record – are not the purview of a style guide. For one thing, it would take several volumes to cover the amount of information required to ensure the clinical accuracy of a document. The medical transcription school an MT attends, subsequent training, reference manuals, quality assurance, etc. – those are the appropriate venues for ensuring that a medical transcriptionist has the information to assess the clinical accuracy of the document. And I'm not even going to climb on my soapbox (again) about the dangers of attempting to make medical transcription more important by claiming that MTs are or should be responsible for the accuracy of the medically relevant portions of the record.

As far as I'm concerned, the bottom line concerning the errors in the Big Transcription article is that this is an article by a transcriptionist, in a professional publication for health information management professionals, and therefore it represents – or should represent – the standards of the industry. Starting with the transcriptionist who made the mistakes and ending with the editor who didn't correct them, it's a poor reflection of the kind of skills a medical transcriptionist brings to the table. Really, if MTs can't demonstrate that they know the difference between they're/their/there, moot/mute, or any number of other common English language errors, how can anyone be confident that they have the ability to protect the clinical accuracy of the document? I recognize that nobody is saying the English language component isn't as important as the clinical accuracy of the document; however, my opinion is that we have to view this in the broad spectrum. You don't trust someone with advanced skills – and the clinical accuracy of a document is certainly an advanced skill – when they can't even demonstrate mastery of their native language.

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