Read a medical journal, guideline or progress note and most often you will find yourself reading sentences in the passive voice. “The infant is placed in the lateral decubitus position.” “The catheter should be removed as soon as it is no longer necessary.” “The treatment options were explained to the patient.” These snippets are typical examples of how the medical community has been taught to write, purportedly serving to protect anonymity and set an impassive, professional tone.
While this stylistic standard may have its role in formal medical writing, it introduces a host of concerns at the bedside. Compared to the active voice, the passive voice tends to be less interesting, less forceful and most importantly for patient safety and quality of care, less clear.
The purpose of the passive voice is to eliminate the subject of the sentence and thereby hide the agent and remove accountability. In politics, this might sound like “taxes were raised,” instead of “I raised taxes.”
In medicine this might sound like “The ultrasound was ordered incorrectly and therefore had to be repeated,” rather than, “I ordered the ultrasound, but didn’t understand it had to be after the LP, so I had to order a repeat study after I did the LP.”
Clear speaking both requires and supports clear thinking, which is critical for all of us to practice safe medicine. Recently on morning rounds, I heard a colleague say, “The J tube insertion has been added onto the central line placement.” With this sentence, the speaker left two critical questions unanswered: Who asked to have the procedure added? And who was going to perform the procedure?
Consider that communication errors are one of the major sources of medical errors. The passive voice removes accountability, and accountability lies at the heart of safety.
As the day unfolded, we learned the answer to both of those questions was…no one. Had my colleague really captured the facts, he would have said:
“Someone was going to ask Dr. A to insert a J tube after Dr. B finished placing the central line. But it is not clear to me whether anyone actually asked either of them, or, if someone did, if both Drs. A and B know about the plan.”
Though the sentence is slightly longer, those seconds would have been well invested. As it was, we spent more time teasing out all the confusion and frustration that resulted directly from his use of the passive voice.
Unlike the world of academic writing, in the real world of medical practice the passive voice is not a characteristic of good scholarship. Rather, it is a source of inaccuracy, confusion and, potentially, medical error. Consider that communication errors are one of the major sources of medical errors. The passive voice removes accountability, and accountability lies at the heart of safety.
As much as our mentors, teachers and peers may have trained us to communicate in medical writing with the passive voice, we need to rid ourselves of this habit when communicating about patient care, and bring back the subject — the agent. Language matters, and we should welcome the active voice back into our spoken medical communications.
Anne Hansen, MD, MPH, is the medical director of the Neonatal Intensive Care Unit at Boston Children’s Hospital and an associate professor of pediatrics at Harvard Medical School.