EDITORIAL
What’s In a Word?
MICHAEL W. STEWART, SARAH L. DUNCAN POWERS, STEVEN J. FLIESLER, AND RICHARD K. PARRISH II
O
N DECEMBER 15, 2017, THE WASHINGTON POST
reported that policy analysts at the Centers for
Disease Control and Prevention (CDC) were
given a list of forbidden words by senior CDC officials
who oversee the budget.1,2 The Post claimed that the
United States Department of Health and Human
Services (DHHS) was prohibiting the use of 7 words or
phrases—‘‘vulnerable,’’ ‘‘entitlement,’’ ‘‘diversity,’’
‘‘transgender,’’ ‘‘fetus,’’ ‘‘evidence-based,’’ and ‘‘science-
based’’—from appearing in proposed budget documents
for 2019. In some instances, the analysts were given
alternative phrases to use in budget documents. Instead
of ‘‘science-based’’ or ‘‘evidence-based,’’ the suggested
phrase has become ‘‘CDC bases its recommendations on
science in consideration with community standards and
wishes.’’1
During the ensuing literary firestorm, other journalists
claimed that these words have not actually been banned,
that general use of the words is still allowed at the CDC
outside of the budgetary process, and that the ‘‘forbidden’’
list merely represents ‘‘guidelines’’ for the analysts to use
when preparing the Centers’ budget for presentation to
current authorities.3
Although the origin and political implications of this
ban remain indeterminate, the limitation of ‘‘science-
based’’ and ‘‘evidence-based’’ phrases is particularly
notable.3,4 This discussion takes place as these widely
accepted concepts are being increasingly used both by
peer-reviewed journals, to judge the value of submis-
sions, and by physicians, to make patient care deci-
sions.5-8
Evidence-based medicine is more than just a definition;
it is a classification system used to qualify the strength of
medical evidence and to instill the appropriate degree of
Accepted for publication Jan 17, 2018.
From the Department of Ophthalmology, Mayo Clinic, Jacksonville,
Florida (M.W.S.); American Journal of Ophthalmology, Saint
Augustine, Florida (S.L.D.P.); Department Ophthalmology, Jacobs
School of Medicine and Biomedical Sciences, University at Buffalo, and
Research Service, VA Western New York Healthcare System, Buffalo,
New York (S.J.F.); and Bascom Palmer Eye Institute, Miller College of
Medicine, University of Miami, Miami, Florida (R.K.P.).
Inquiries to Michael W. Stewart, Department of Ophthalmology, Mayo
Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; e-mail: stewart.
michael@mayo.edu
0002-9394/$36.00 © 2018 ELSEVIER INC. ALL
https://doi.org/10.1016/j.ajo.2018.01.019
confidence in the validity of data. ‘‘Evidence-based medi-
cine,’’ as originally described, is ‘‘the conscientious,
explicit, and judicious use of current best evidence in mak-
ing decisions about the care of individual patients.’’8 The
hierarchical consensus based on the ‘‘strength of the evi-
dence’’ was described over 20 years ago (1996) by Sackett8
(Figure),9-11 and the journal Evidence Based Medicine has
been continuously published since 1995.
These phrases have appeared in the American Journal of
Ophthalmology many times over the last 20 years.6 On April
15, 2005, a PubMed Central search of the terms ‘‘evidence-
based medicine’’ and ‘‘ophthalmology’’ yielded 27 citations,
whereas on December 21, 2017, the same search
yielded 164 results. On December 20, 2017, a Google
Scholar–based search produced about 334 000 articles
and citations. A PubMed Journal Database search for ‘‘ev-
idence based medicine’’ identified 47 journals.
The American Journal of Ophthalmology vigorously
supports the underlying principles of evidence-based
science and medicine. Returning to reporting anecdotal
experiences dependent upon the reputation of the se-
nior author and the sheer number of procedures
performed or patients treated would mark a retreat to
the darker and less informed days of medicine.12
Limiting the use of ‘‘evidence-based medicine,’’ even
by editing suggestions and word replacements, so as
not to offend government officials or to filter out by
an ideology, raises the specter of an Orwellian shift at
the DHHS and the legislative branch of government.
It is not coincidental that these concepts are discour-
aged at the point of determination for further funding,
leaving the value, strength, and merit of scientific goals
up for ideologically based interpretation and debate.
The suggestion that banning, or in any way discour-
aging the use of, the linguistic bedrock of evidentiary
support for new ideas that spawn improvements
of our diagnostic and therapeutic capabilities is para-
doxical to the notion of sound science and human prog-
ress.
This globally embraced dictum demands accuracy, valid-
ity, reproducibility, and transparency; and we encourage
the most rigorous application of commonly used, unambig-
uous words and phrases to facilitate frank medical, scienti-
fic, and sociological discussions and to maintain the
positive progress of humankind.
RIGHTS RESERVED. 1
FIGURE. Commonly accepted hierarchy of medical evidence that is obtained from different types of studies.

FUNDING/SUPPORT: NO FUNDING OR GRANT SUPPORT. FINANCIAL DISCLOSURES: MICHAEL W. STEWART: ALLERGAN: ADVI-
sory Board, Institutional Research Support; Alkahest: Consultant; Bayer: Consultant; Regeneron: Advisory Board, Research Support. The following au-
thors have no financial disclosures: Sarah L. Duncan Powers, Steven J. Fliesler, and Richard K. Parrish II. The authors attest that they meet the current
ICMJE criteria for authorship.

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