Patrick J. Skerrett

Medical journals: Stop being so passive

Reading medical journals is the main occupational hazard I face as editor of the Harvard Heart Letter. This task is like parachuting into a desert at high noon—I drop into a barren, colorless landscape and then struggle across dry, soporific terrain. The content isn’t to blame; it is usually interesting, and is sometimes even compelling. It’s the style, especially use of the passive voice, that makes my brain drift and my eyelids droop.

BRIEF GRAMMAR LESSON AHEAD: The connection between verb and subject determines the “voice” of a sentence. In active voice, the subject performs the verb, as in “I made mistakes.” In passive voice, the subject is acted on, or doesn’t appear at all, as in “Mistakes were made.”

In her book Breathing Life into Medical Writing, author Anitra Sheen described overuse of the passive voice as “the bane of medical writing. It pervades medical literature with the haze and heaviness of stagnant air.” Yet even though journal editors encourage authors to use the active voice, few of them fight the passive. Leaf through any medical journal and you will immediately see this construction: It was observed… Subjects were instructed to… Data were collected…

Although pundits occasionally rail against this construction, no one has ever quantified its use in medical writing. Until now. Dr. Robert Amdur and colleagues from the University of Florida College of Medicine classified the voice of every sentence in 30 articles from each of three leading journals—The New England Journal of Medicine, JAMA, and The Lancet. They did the same thing for 30 articles from the Wall Street Journal. The averages were telling. In the medical journals, 20% to 26% of the sentences were in the passive voice, compared to just 3% in the Wall Street Journal.

Dr. Amdur sent the article to several top-tier medical journals. Editors found the paper interesting, important, and useful, but passed on publishing it. “I don’t want to open up this subject for debate,” one medical journal editor told Dr. Amdur. “We are not ready to deal with it.” The paper finally found a home in the American Medical Writers Association Journal, where you can read it for free.

In the scheme of things, medical journals’ overuse of the passive voice doesn’t rate up there with health care reform or identifying effective treatments for heart disease or cancer. But it gets in the way of effective communication, which should be the whole point of medical writing. It generates dreary, convoluted sentences that make medical research—much of it done with our tax dollars—even more inaccessible to most folks.

Thirty-five years ago, Dr. Michael Crichton took medical writers to task. “Medical writing is weak,” he wrote in a blunt essay in The New England Journal of Medicine. “The general tone is one of utmost timidity, going far beyond sensible caution.” The late Dr. Crichton, now better known for his popular writing (The Andromeda Strain, Jurassic Park, the television show ER, and more) argued that dense and forbidding medical prose is designed as a “display of scientific profundity, and not as an attempt to communicate experience.”

Everyone seeking medical information—researchers, doctors, and folks trying to learn about a disease or ways to stay healthy—deserve better, like the straightforward language of Michael Crichton.

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  5. Leslie Nolen - The Radial Group

    Treating this topic as strictly a readability issue trivializes it (and I wish I had seen the original post at the time!).

    Sure, poorly-written, dry, tedious articles prevent effective communication. No argument, that’s bad.

    Much more important, however: passive voice and many of the other most annoying writing tics we see in journal articles allow the writers to hedge what they’re saying, avoid taking clear accountability and responsibility for their observations, and avoid stating strong conclusions.

    The result: watered-down, soft-soaped articles for reasons that have nothing to do with the quality of supporting data.

    Statements like “Mistakes were made” avoid assigning specific accountability for actions or their absence. Far more meaningful and actionable to say: “The attending did not….” or “The charge nurse should have…” or “The patient decided to…”

    Statements like “It was observed” distance researchers from the design and results of their work, positioning them as folks watching from a distance rather than the key decisionmakers. Who observed? Was it the lead researcher? A graduate student? An unpaid undergrad required to provide lab assistance as part of a class?

    And weasel-worded mushy-middle statements like “It may be said” should make us ask: “Really? Should it in fact be said, or not? To what extent did the data support this? If the data didn’t strongly support this, why are you coyly hinting at it without appropriate caveats?”

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  7. Paul

    Communication is only effective if the other person receives and understands it in the way you intended, so just writing your information without paying attention to its readability defeats the purpose of your writing.

  8. Mary Albert

    I like to write just as if I was sitting across from the table from you.
    [URL removed by moderator]

  9. Bob Freeman (www.MedicalAlertSystems-Reviews.com)

    Information exists to be shared. When it’s written so dry no one wants to read it. It’s a tough balance, you can’t make it too relaxed, however we are far from there. We need information to be interesting so it’s spreads and people can share ideas.

  10. Michael Field-Dodgson

    Excellent article – having been trained as a scientist and undertook scientific research for more than a decade before turning to commerce I understand both sides of the fence.

    On the one hand when you write up a research paper for inclusion in a peer reveiwed scienticic journal, it is refereed so that the prose is as definitive as it can be and any ambiguity is removed. That is, a statement like: “The temperature increased ……” is incorrect because the word temperature cannot increase, so we write:”The temperature value increased…….”

    The result to the non-scientist is dry, rather staccato like prose with wierd words making the article unintelligible.

    If scientists are writing for public consumption in popular article format then there is no need for the prose to be dry etc. They need to become story tellers in the active voice, informing the public of what they found and the significance of this in adult, but non-scientific prose.

    I think it is lazy on their part for scientists to not relate to the sort of prose the public expect to read.

  11. R Moss

    I was a psychology major for three years back in the 70′s and a mandatory course was in scientific writing. We were taught to write in this manner and, to be honest, it’s one of the reasons I changed majors. There is no reason why scientific and medical studies can’t be made more people-friendly.

  12. Maria Esposito

    There’s more than just the issue of passive voice. Writings in peer-review journals have convoluted sentence structure and insider jargon/abbreviations, too.

    All of that is fine when you’re talking peer-to-peer; the issue of readability comes into the picture when the layperson goes online to read one of those journals. As a medical journalist, I’ve become immune to the problem, but it took a long time.

    What compounds the problem even more is that the medical profession has told us we have a right to understand what is being done to us. Many savvy consumers want to know not only the present, but also what may happen in the future.

    Some medical journals have tried to compensate for the problem by publishing patient summaries of select research. However, the summaries are written as though they were aimed at children just learning to read their first “chapter book”.

    The best solution, in my opinion, is to have an intermediary between the researchers and the layperson – someone to explain the trial using readable sentence structure and without the insider language.

    I have started doing that in my blog and the results have been amazing. I have a number of people reading it and my posts are translated into other languages. Why, because all the average person wants to do is exercise the right to know that you (the medical profession) told us we have.

  13. Tracy Allison Altman (EvidenceSoup.com)

    Excellent piece. The ‘plain language’ movement – which mandates the use of plain language in government publications – must be extended to writing in medical journals. As you explain so well, our tax dollars are supporting publication of research that is cryptic and difficult to understand.

    Besides making the research/evidence more accessible, better writing can reduce the need for others to translate findings into plain language, streamlining the process and hopefully reducing the likelihood of errors or misinterpretation.

    Well done. I wrote about your article on EvidenceSoup.com today in “Hey you, the one with the scientific evidence. Enough with the passive writing already!”

    -Tracy Allison Altman, PhD
    Editor @ Evidence Soup