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.