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©2023 American Medical Writers Association. All rights reserved.  
ISSN 2163-5315

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Bad writers write badly for 2 simple reasons: they choose 
the wrong words and put them in the wrong order. As a 
result, they write bad sentences. Then, they usually put 
those bad sentences in an order that makes no sense. A 
good writer writes good sentences and puts them in a 
meaningful order, so that the writer’s ideas flow smoothly 
from the page into the reader’s mind (see Key Points). Good 
writers also break up their text into manageable chunks, 
called paragraphs.
 Writing guides often tell you to use the paragraph as the 
unit of composition. Each paragraph can focus on a particu-
lar topic or idea. The break between paragraphs gives read-
ers a chance to rest, to think about what they have just read. 
The break also alerts the reader that there may be some shift 
of focus.

WHAT IS A PARAGRAPH?
The word paragraph came from the roots para- (meaning 
beside) and graphein (literally, “to write”). In ancient Greek 
punctuation, a paragraphos was a punctuation mark, derived 
from the letter gamma (Γ), that was used to mark a division 
in text (such as between speakers in a dialogue). The paragra-
phos was the only punctuation mark that the Greek philoso-
pher Aristotle mentioned, and he took a dim view of it. In his 
Rhetoric, Aristotle argued, “A sentence should break off with 
the long syllable: the fact that it is over should be indicated 
not by the scribe, or by his period-mark in the margin, but 
by the rhythm itself.”1 This advice may have made sense in 
ancient Greek, but it is utterly useless in English.
 By the Middle Ages, scribes were using a paragraphus 
(the Latinized version of paragraphos) to mark the begin-
ning of a new section in a discourse. They often used a 
capital C, which stood for capitus (head). For clarity, they 
started putting a single vertical line through the C, then 2. 
Eventually, the sign developed into our modern pilcrow 
symbol (¶), which word processing programs still use to 
indicate the end of a paragraph.2 (The word pilcrow is a 
corrupted version of the word paragraphus.) Meanwhile, 
the word paragraph started to mean the block of text that 
was set off in some way, such as by adding a line of space 
between paragraphs by indenting the first line of the new 

paragraph, or by adding a large initial capital letter to the 
beginning of the new paragraph. In typeset text, you can 
use a dingbat (eg, ) to signal a paragraph break that occurs 
when you cannot use a line return.

PARAGRAPH STRUCTURES
You probably learned in school that every paragraph should 
have a topic sentence, and that the rest of the sentences in 
the paragraph should support or build on that topic sen-
tence. Plenty of paragraphs do have that structure, but many 
well-written paragraphs do not. I don’t worry about whether 
each of my paragraphs has a topic sentence. Instead, I try  
to put my sentences in a logical order and then make 
sure that I put in paragraph breaks wherever there is a big 
enough change of topic or focus. Nevertheless, I find that 
many of my paragraphs do have a topic sentence. Instead of 
worrying about how to generate a topic sentence for each 
paragraph, think about the purpose of the paragraph. If a 
paragraph is well written, its structure will generally reflect 
its purpose.

To Tell Part of a Story
A narrative is a story, an account of a series of related 
events. Events are facts that have some restriction related to 
time: events have a before, a during, and an after. Each para-
graph can tell a portion of the story. A narrative might not 
have a topic sentence in each paragraph. Instead, a para-
graph may contain a series of sentences of equal impor-
tance, each describing a particular event: this happened, 
this happened, this happened, and so on. Each of these sen-
tences may be equally important. However, you might find 
some places in which there is a natural break in the action 
(eg, “On the following day, …”). Those are good places to 
insert a paragraph break.
 In a narrative, you may need to add some sentences that 
provide commentary to explain the context or meaning of a 
particular event. The sentence that recounts the event and 
the sentences that provide commentary about that event 
can be set apart as a separate paragraph.
 In a simple narrative, you can recount a series of events 
that happened one right after another. But to tell some  

Laurie Endicott Thomas, MA, ELS / Freelance writer, Madison, NJ

Paragraph Structures

IN THE SERVICE OF GOOD WRITING

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AMWAJournal.org     57Paragraph Structures

stories, you need to use a nonlinear timeline. For example, 
you may have to recount the events in the order that you 
learned about them instead of the order in which they hap-
pened. You may have to describe events that overlap each 
other, or events that happened simultaneously in 2 different 
places (“meanwhile, back at the ranch…”). You may have to 
describe the same event as seen from several points of view 
(as in the famous movie Rashōmon). Thus, you may have to 
depart from a simple chronological account. Instead, you 
may have to write subnarratives that you must then weave 
into the larger narrative.
 When writing a simple or complicated narrative, you 
can use a paragraph break whenever you need to signal a 
discontinuity in the action or a shift in topic, setting, or per-
spective. If you need to make a larger break in the narrative, 
you can use a text break (signaled by white space and per-
haps a printer’s ornament) or start a new chapter.

To Give Instructions
Instructions are a series of commands, sometimes inter-
spersed with explanations. You can usually put the com-
mands in the order in which they are to be followed. 
However, in an ordinary recipe, you may need to refer to a 
separate recipe for how to prepare one of the ingredients. 
For example, a recipe for sourdough bread would call for 
sourdough starter. Thus, there is generally a separate recipe 
for how to make and maintain the starter. For this reason, 
the timeline in a recipe might not be strictly linear.
 In a recipe or any other set of instructions, you can use 
paragraph breaks to separate major steps in the process. For 
example, when writing about how to perform a surgical pro-
cedure, you might devote the first paragraph to the options 
for anesthesia, the second to patient positioning, the third 
to the initial incision, etc. You might also need to write a 
separate set of instructions for the anesthesiologist.

To Describe or Explain Something
A paragraph that describes or explains something may have 
a topic sentence that defines what the thing is and sev-
eral other sentences that give more information about that 
thing. When you need to shift topic or emphasis, add a para-
graph break. Note that in the passage below, there is a clear 
topic sentence in the first and third paragraphs, but not in 
the second paragraph:

Insulin is the hormone that allows the body to react 
to a meal [topic sentence]. Insulin is a peptide hor-
mone that is secreted by the beta cells in the islets of 
Langerhans in the pancreas. During fasting, these cells 
release only a small trickle of insulin (basal or consti-
tutive insulin secretion). Various stimuli that are asso-
ciated with a meal cause a burst of insulin secretion. 

These stimuli include hormones released by the gas-
trointestinal tract in response to feeding, as well as the 
rise in blood glucose that occurs after a meal. Insulin 
then acts on cells throughout the body, to stimulate 
them to react to the meal.
      Insulin’s most familiar actions are on blood glu-
cose levels. Insulin stimulates liver and muscle cells 
to convert glucose to glycogen for storage. Insulin also 
stimulates heart and muscle cells to express GLUT4 
transporters, thus allowing those cells to take in more 
glucose to use as an energy substrate. These two 
effects cause a reduction in blood glucose. However, 
insulin also stimulates adipose cells to store the fat 
that is being absorbed from the meal. It also stimulates 
cells throughout the body to use amino acids to syn-
thesize proteins. Thus, insulin is an anabolic (growth 
promoting) hormone. Insulin also crosses the blood–
brain barrier to enter the brain, where it has effects on 
cognition and behavior. Crucially, insulin also acts on 
the alpha cells of the pancreas, to suppress the release 
of glucagon.
      Glucagon is the hormone that opposes the actions 
of insulin, promoting mobilization of stored nutri-
ents as opposed to the storage of circulating nutrients 
[topic sentence]. Thus, it allows the body to survive a 
fast. Like insulin, glucagon is a peptide hormone….

 The second paragraph does not have a topic sentence. 
Instead, it provides more commentary on the topic sentence 
from the first paragraph. The paragraph break is useful 
because the first paragraph focuses on insulin secretion, 
whereas the second paragraph focuses on insulin’s effects. 
The third paragraph does more than shift focus. It changes 
the topic to a different hormone: glucagon. Depending on 
the overall structure of the piece, you might insert a new 
heading before the third paragraph.

To Explain How Parts Make Up a Whole
You can use a paragraph to give an overview of a structure. 
The topic sentence will say that the whole consists of several 
parts. Other sentences may address each individual part. If 
you have a series of parallel sentences, you might want to 
present them as a bulleted list. Note that the bulleted list 
makes a long paragraph easier for your reader to digest:

The pancreas has exocrine and endocrine func-
tions [topic sentence]. An exocrine gland is one that 
secretes products through a duct [definition]. The 
pancreas secretes digestive enzymes (e.g., amylase, 
lipase, and proteases) through a duct that empties into 
the duodenum, which is the first few inches of small 
intestine. In contrast, endocrine glands release their 

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AMWAJournal.org     58Paragraph Structures

products directly to the bloodstream [definition]. The 
endocrine functions of the pancreas are performed by 
the islets of Langerhans, which are small clusters of 
hormone-producing cells that are scattered through-
out the pancreas. Although these islets make up only 
about 1% to 2% of the mass of the pancreas, they 
receive 10% to 15% of its blood flow. Several different 
kinds of cells are found in the islets, each producing a 
different hormone or hormones:

• Alpha cells produce glucagon

• Beta cells produce insulin and amylin

• Delta cells produce somatostatin

• Epsilon cells produce ghrelin

• Gamma cells, also called F or PP cells, produce 

pancreatic polypeptide.

To Say That Something Is True
According to the Greek philosopher Plato, knowledge is jus-
tified true belief.3 Suppose that you want your paragraph to 
persuade someone to accept a claim as truth. You can state 
the claim in a topic sentence, which often ends up at the 
beginning or the end of the sentence. You can then add a 
sentence or 2 to define your terms or clarify what you mean 
by the claim. Then, you write one or more sentences that 
provide evidence to support the claim. You might also add 
a sentence or 2 to explain why the evidence justifies your 
claim. In the following paragraph, the claim is the  
final sentence:

Pre-eclampsia is defined as hypertension that starts 
after week 20 of gestation [definition]. All of the fea-
tures of pre-eclampsia represent either the effects of 
poor circulation (e.g., poor placental development, 
intrauterine growth restriction, and the HELLP syn-
drome [hemolysis, elevated liver enzyme levels, and 
low platelet levels]) or the body’s attempt to compen-
sate for or correct low blood volume (e.g., robust acti-
vation of the renin-angiotensin-aldosterone system, 
leading to hypertension and edema) [evidence]. 
Aldosterone promotes retention of salt and water; but 
if the woman does not have enough plasma protein to 
hold the extra fluid within the vascular space, it will 
migrate to the intracellular space. Thus, the extra fluid 
will produce edema instead of expanding intravascu-
lar volume. Pre-eclampsia is most common among 
women who are prone to hypoproteinemia and thus 
to hypovolemia (e.g., undernourished women and 
women with gestational diabetes) and among women 
who are carrying more than one fetus (and thus need 
a greater expansion of blood volume) [evidence]. Pre-
eclampsia can be managed with careful use of intra-
venous colloids (albumin or hetastarch) to expand 

blood volume [evidence]. All of this evidence sup-
ports the same conclusion: pre-eclampsia results 
when the woman does not have enough plasma pro-
tein to expand her blood volume enough to meet the 
demands of pregnancy [claim].

 This is a long and dense paragraph. You might be 
tempted to split it into 2 paragraphs, just to give the reader a 
break. But if you do that, then the reader might not be sure 
what you mean by “all of this evidence.” To solve this prob-
lem, you might put the claim after the definition and then 
offer the evidence. If so, you will have to reword the claim, 
“Pre-eclampsia occurs when a pregnant woman does not 
have enough plasma protein to expand blood volume suffi-
ciently to meet the demands of pregnancy.”

To Offer Advice
Whether you are expounding truth or offering advice, your 
argument may follow a similar structure. The difference is 
the mood of the verb in the topic sentence: to state what is 
true, you use the indicative mood, which is a realis modal-
ity. But to give advice or commands, you use an irrealis 
modality. The advice may be in the form of a command 
(imperative mood) or a deontological statement (what 
should or must be done or what you think is needed). The 
advice could be implied by a conditional statement, which 
is a statement about what would or can happen, if a condi-
tion is met. (For more information on linguistic modality, 
see Shoulda, Woulda, Coulda!4). The topic sentence that 
offers the advice could come at the beginning or the end of 
the paragraph, or even somewhere in the middle. Some of 
the other sentences could clarify the advice or explain why 
the advice is sound:

To prevent pre-eclampsia, we must provide nutritional 
support for undernourished women and nutritional 
counseling for overnourished women [topic sentence: 
advice]. Pregnant women with protein-energy mal-
nutrition are at risk for pre-eclampsia because they 
convert too much of their blood proteins to glucose, 
for use as an energy substrate [explanation]. These 
women simply need more food [advice]. In contrast, 
overnourished women are at risk for pre-eclampsia 
because a high-calorie, high-fat diet promotes insulin 
resistance, which leads to oversecretion of glucagon, 
which promotes the excessive conversion of plasma 
protein to yield excess blood glucose [explanation]. 
When added to the physiologic insulin resistance of 
pregnancy, the insulin resistance resulting from over-
nutrition can lead to gestational diabetes, which is a 
temporary form of type 2 diabetes during pregnancy 
[explanation]. Fortunately, the insulin resistance from 

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overnutrition can be rapidly corrected by a change to a 
low-fat, high-fiber, high-carbohydrate diet [advice].

 Notice that the paragraph has the same basic struc-
ture as the topic sentence: we must do A and B. The other 
sentences in the paragraph provide clarification and justi-
fication for A and then B. This is the order that the reader 
expects from having read the topic sentence.

RELEVANCE AND ORDER
To use the paragraph as your unit of composition, you need 
to do more than add hard returns every so often. You must 
analyze how the sentences in the paragraph fit together. 
Thus, you might ask yourself the following questions:

• Does the paragraph contain all of the information that 

I need to make this particular point? If not, what must 

I add (eg, a definition of an uncommon word)?

• Does the paragraph contain any sentences that are 

not relevant to the point that I want the paragraph 

to make? If so, do I move those sentences to another 

paragraph or delete them?

• Are the sentences within my paragraph in the right 

order? Would the writing make more sense if I put the 

sentences in a different order?

• Are my paragraphs in the right order? How does each 

paragraph fit into the overall structure of the piece?

COHERENCE
When you study grammar, you focus on individual sentences. 
When you study writing composition, you learn to pay atten-
tion to the relationships between sentences. The goal is to 
learn how to achieve coherence in your writing: a logical, 
orderly, and aesthetically consistent relationship of parts. 
Even if you put your sentences in the right order, you need 
to pay attention to words that provide connections between 
sentences and that clarify the relationships between ideas. 
These include repeated words, demonstratives, pronouns 
and possessive adjectives, and conjunctive adverbs.

• The infection produces inflammation. This inflamma-

tion then…. (repeated word and a demonstrative [this])

• Elizabeth Blackwell was the first woman to receive a 

medical degree in the United States. Her acceptance 

letter to Geneva College was intended as a practi-

cal joke; but she earned the respect of professors and 

classmates, graduating first in her class. (She is a pro-

noun, and her is a possessive adjective.)

• All men are mortal. Socrates is a man. Therefore, 

Socrates is mortal. (Therefore is a conjunctive adverb. 

For more information on conjunctive adverbs, see 

Meanwhile, Back at the Ranch5).

IGNORE BAD ADVICE
If you read about how to write good paragraphs, you will 
find some pieces of advice that I never follow.

Primer Language
Many writing guides tell you to avoid “primer language” (ie, 
short, simple sentences). Ignore that advice. Instead, we 
must struggle to keep our sentences as short as possible. 
As medical writers, we must explain complex ideas. To do 
that, we must often write complex sentences, which are long 
and hard to read. Meanwhile, everyone wants us to produce 
readable text. Writers for federal government agencies must 
follow the Federal Plain Language Guidelines.6 Likewise, 
corporations also want us to produce text in plain language. 
Readable text appeals to consumers and ranks higher in 
search engine results.7

Sentence Variety
Some writing guides say that it is bad to have a string of sen-
tences that all have the same grammatical structure. For this 
reason, they urge you to alter the structure of some of your 
sentences, for the sake of variety. Yet that method leads to 
madness. The structure of a sentence should be based on 

KEY POINTS
•   Write good sentences.
•   Put your sentences in an order that makes sense.
•   Use paragraph breaks to signal a shift in topic, emphasis, 

or point of view.
•   You don’t have to have a topic sentence in each paragraph.
•   Paragraphs that serve a particular purpose will tend to 

have a corresponding structure (eg, a topic sentence that 
expresses a claim and other sentences that provide  
supporting evidence).

•   If you cannot see the whole paragraph at once on your 
computer screen, it is probably way too long. Look for  
reasonable places to break it up.

•   To indicate a paragraph break, you can use a space 
between lines or an indentation of the first line of the  
new paragraph.

•   In a typeset piece, if you cannot use a line return to signal 
the end of a paragraph, use a dingbat (eg, ).

•   To indicate a larger break in a narrative, such as in a  
work of fiction, you can use white space and perhaps a 
printer’s ornament.

•   You can also break your text into sections, each of which 
contains a series of paragraphs.

•   Section headings will help your readers navigate within 
the piece and may even help your readers find your  
piece online.

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AMWAJournal.org     60Paragraph Structures

the structure of the underlying idea. If your ideas vary  
naturally in structure, your sentences will also vary natu-
rally in structure. By fixing the grammatical problems (eg, 
problems with modifier placement) that occur in so many 
sentences, you will automatically create variety in sentence 
structure. Conversely, if you have a series of ideas that are 
parallel in structure, the sentences that express them will 
naturally be grammatically parallel. When that happens, 
you can set those parallel sentences out in a bulleted list. 
The items in a list are supposed to be grammatically parallel!

Author declaration and disclosures: The author notes no  
commercial associations that may pose a conflict of interest in 
relation to this article. 

Author contact: Lthomas521@verizon.net

References
1.   Aristotle. Rhetoric. 3. 8. 6 (238-239). 
2.   Stamp J. The origin of the pilcrow, aka the strange paragraph 

symbol. Smithsonian Magazine. Published July 10, 2013. Accessed 
January 7, 2023.  https://www.smithsonianmag.com/arts-
culture/the-origin-of-the-pilcrow-aka-the-strange-paragraph-
symbol-8610683 

3.   Plato. Meno. 
4.   Thomas LE. Shoulda, woulda, coulda! AMWA J. 2016;31(4): 

184-185.
5.   Thomas LE. Meanwhile, back at the ranch. AMWA J. 2014; 

29(3):140-141.
6.   Federal plain language guidelines. Plain Language Action and 

Information Network. Accessed January 7, 2023. https://www.
plainlanguage.gov/guidelines/

7.   Readability and SEO: how are they related? Screpy. Published 
June 29, 2021. Accessed January 7, 2023. https://screpy.com/
readability-and-seo/ 

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https://www.smithsonianmag.com/arts-culture/the-origin-of-the-pilcrow-aka-the-strange-paragraph-symbol-8610683
https://www.smithsonianmag.com/arts-culture/the-origin-of-the-pilcrow-aka-the-strange-paragraph-symbol-8610683
https://www.smithsonianmag.com/arts-culture/the-origin-of-the-pilcrow-aka-the-strange-paragraph-symbol-8610683
https://www.plainlanguage.gov/guidelines/
https://www.plainlanguage.gov/guidelines/
https://screpy.com/readability-and-seo/
https://screpy.com/readability-and-seo/



