Acronyms Confuse Everyone: Combating the use of acronyms to describe paediatric research studies
- Conflict of interest: Nil to declare.
As medical ethicists and members of the Acronym Suppression Society (ASS), the authors have observed a practice among researchers to entitle their research proposals with acronyms. Our attention to this was stimulated by a recent review paper on paediatric asthma that referenced several studies described by acronyms including SMART, PEAK and BEST.
We call attention to three aspects of the pervasive use of acronyms to describe clinical research trials. Two of these are trivial and include an amusement or tongue-in-cheek factor and that an acronym can be a concise way of describing a study. There is, however, a third issue that we believe has the potential to improperly influence parents to volunteer their children for research. We believe this has significant ethical implications. This paper reviews the role of acronyms for research trials, particularly positive-sounding acronyms, which by their nature imply likely benefit, to describe paediatric research.
AAA – Acronyms as Amusing Adjectives
With the use of acronyms in clinical trials, now so pervasive there is a challenge, if not a compulsion, for researchers to create an apposite acronym for the title of their research project. We suspect that the title of the research project is often chosen with the acronym in mind. As one might expect, there is now a web-based acronym generator available. Charlton and Schmidt have also published a guideline for the development of research proposals using a Structured Holistic Approach to Research Planning (SHARP).
The explosion in the use of acronyms has led to new words entering the lexicon including acronym madness, acromania, acronymania, acronymophilia and acronymophobia. Isaacs and Fitzgerald described acronymophilia as ‘an epidemic infection and a sinister scourge of modern medicine’. Depressingly, they observed there was no known cure and 10 years of further research have not given further palliation. Nevertheless, they did propose, using a series of acronyms (of course), a method of treatment for the sufferers of acronymophilia. Among their important acronymic recommendations was Y-not; Yield not unto the temptation to abbreviate. Despite their treatment suggestions for sufferers, the use of acronyms has continued to proliferate at an exponential rate. We believe that Isaacs and Fitzgerald may have underestimated the true infectivity of acronymophilia. Indeed, acronymophilia is now a treatment resistant acronym syndrome in humans (TRASH).
Other examples abound. The preliminary results of the DEVIL study in children – Determining the Efficacy and Value of Immunotherapy on the Likelihood of peanut tolerance – have recently been reported as to have the results of the CHAT study (Childhood Adeno-tonsillectomy Trial). Abbott, using acronyms from the cardiac literature, has published two one-act plays constructed solely from research trial names.[4, 9] It is not at all uncommon for the same acronym to be used to describe different studies. The aforementioned CHAT acronym has also been used to describe a Checklist for Autism in Toddlers, which we suggest is an oxymoron as children with autism are not renowned for their ability to ‘chat’. A similar oxymoronic acronym, AWAKE, was used to describe an anaesthesia study.
Cheng has observed that there is no correlation between positively named acronym trials in cardiology and their hoped-for beneficial outcomes with I-PRESERVE, ALIVE, SAVED and SUCCESS trials all had negative outcomes. Similarly, the enticingly named study, NICE-SUGAR, compared mortality rates in intensive care patients receiving intensive blood glucose control with conventional treatment. Despite the seductive name for the study, the mortality in the intensive treatment group was significantly higher, the opposite to what was expected.
There is a growing resistance to the use of acronyms in some circles. Lowe described DUCTS – Down with Useless Clinical Trial AcronymS, while Oranksy nominated HALT: Help Acronyms Leave (medical) Trails.
There are benefits, both practical and scientific, which accrue from the use of acronyms. Acronyms can simplify and facilitate communication, enhance recall, as well as save time, space and effort. These benefits are particularly advantageous for studies with long, unwieldy names. At a scientific level, there is good evidence to suggest that a well-chosen acronym is seductive for both medical researchers and research subjects. Stanbrook et al. showed in a study of 173 reviews completed by the Cochrane Heart Group that acronym-named studies enrolled five times the number of subjects and were cited at twice the rate of trials not identified by an acronym.
BUT – Bioethical Uncertainties of Treatment
Despite the sometimes irreverent approach to the subject of acronyms in clinical research, there is a serious aspect to this subject. Positive sounding acronyms for research trials may contribute to the therapeutic misconception (the authors resisted including the acronym TM).
The therapeutic misconception was first described in 1982 and Applebaum, one of the original authors on this subject, recently defined this term:
A therapeutic misconception occurs when a subject transfers to the research setting the presumption that obtains in ordinary clinical treatment that the physician will always act only with the patient's interests in mind. In the research study, in contrast, the physician's actions … may be undertaken because they advance the scientific validity of the research study, rather than because they serve the subject.
Applebaum reported that as many as 70% of research subjects may suffer from the therapeutic misconception.
The consequences of the therapeutic misconception are that research subjects, or parents of children who may be research subjects, overestimate of the potential benefits of the research study and underestimate the potential risks. Any influences that artificially lead to an overemphasis on the potential benefits or place the risks in a muted light are inappropriate and unethical. For this reason, the ethics committee of which we are executives does not permit the use of positive acronyms and has a preference for acronyms not being included at all in patient/parent information material and consent forms (Fig. 1).
We argue that human research ethics committees, or their equivalent, have an important role in minimising the therapeutic misconception. The role of such committees in regulating research can be challenging, particularly with regard to research on children. Grodin and Glantz observed ‘Such research presents a powerful tension between two sometimes conflicting social goals: protecting individual children from harm or exploitation while at the same time expanding our knowledge’.
Stanbrook et al. suggested that the influence of acronyms may be subliminal because specific acronyms may invoke subconscious, value-laden associations that have the potential to provoke positive perceptions of the studies they name. This process is described by Fazio et al. as automatic attitude activation in which key positive words trigger positive attitudes. Thus, a subject would be more likely to enrol in the BEST or the CURE study than the RISK study. An extension of this is that a subject might think they would be viewed as less intelligent if they did not enrol in the SMART study.
Orlowski and Christensen analysed 2383 acronyms in the behavioural and social psychology literature and found 6.5% of acronyms to be possibly, probably or almost certainly coercive. They also gave consideration to the context in which a patient or parent may be confronted with the choice to enter themselves or their child into a clinical trial and observed that a patient or parent of a child with a life-threatening illness who is offered participation in a research trial with an acronym of CURE, HOPE, or HELP, etc. has the potential of being coerced by the acronym into enrolling in the study.
DORA – Discussion of Research Acronyms
Ethical best practice in clinical research requires that consent for participation be freely given by the research subject. Anything that inappropriately entices participation is prohibited by guidelines including the first principle of the Nuremberg Code, which requires consent to be free from coercion. In this context, we believe that coercion includes subtle psychological influence.
The Council for International Organisations of Medical Sciences International Ethical Guidelines involving Human Subjects, in relation to the obligations of investigators regarding informed consent, states that the investigator has a duty ‘… to exclude the possibility of unjustified deception undue influence and intimidation’.
Orlowski and Christensen observed that:
Words can be very powerful, evoking emotional responses in the recipient. These acronyms can be clever, amusing, nonsensical or enticing. The acronyms cross the line of propriety and become coercive when they trigger emotions, memories or hopes that might subliminally sway a potential research subject to participate in a research trial.
Our human research ethics committee is conservative in this area. It prohibits wording in parent/patient information or consent material such as ‘this is an important study …’ and other grammatical or intellectual inducements that may sway parental decision-making in regard to their child's potential participation in a research study.
We believe that acronyms have some utility for researchers in oral and written communication about their clinical research study. In contrast, acronyms with a positive outcome connotation for all who might volunteer have no place in patient or parent information packages or consent forms. We believe that researchers themselves and human research ethics committees must be vigilant about this trend and adhere to best-practice conservatism to protect the autonomy of the patient.