V38 N1 / 2023 ©2023 American Medical Writers Association. All rights reserved. ISSN 2163-5315 AMWAJournal.org 56 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 http://www.amwajournal.org 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 http://www.amwajournal.org 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 http://www.amwajournal.org https://cdn.ymaws.com/www.amwa.org/resource/resmgr/journal/Issues/2016/2016v31n4_online.pdf AMWAJournal.org 59Article Title 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. http://www.amwajournal.org https://cdn.ymaws.com/www.amwa.org/resource/resmgr/journal/Issues/2014/2014v29n3_online.pdf 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/ Get FIT with AMWA F AST I NTERACTIVE T RAINING AMWA’s FIT Series helps medical communicators stay healthy. In only 15 minutes—jog your memory, tone your writing muscles, build your core skills, and stretch your knowledge. www.amwa.org/fit Only $15 each / Approved for .5 CE Topics in the series include: } Misplaced Modifiers } Mean, Median, and Mode } Dangling Participles } Measures of Variability http://www.amwajournal.org 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/