whodunit? theydunit…

Posted on Thursday 29 December 2016

    The active voice is usually more direct and vigorous than the passive:
         I shall always remember my first visit to Boston.
    This is much better than
         My first visit to Boston will always be remembered by me.
    The latter sentence is less direct, less bold, and less concise. If the writer tries to make it more concise by omitting "by me,"
         My first visit to Boston will always be remembered,
    it becomes indefinite: is it the writer, or some person undisclosed, or the world at large, that will always remember this visit?

I come from a generation schooled in the ways of Strunk and White, though the only suggestion I really remember is Don’t use the passive voice as my take-away [in case I forget, the grammar-checker in Microsoft Word is there to remind me]. As a kid, I could see that the active voice sounded better. But later, I saw that the passive voice was often used to obscure agency – a way of avoiding saying directly whodunit?. So writing "The primary outcome variables were changed in the published version of Paxil Study 329" just isn’t the same as writing "Martin Keller and his coauthors changed the primary outcome variables in the published version of Paxil Study 329."

One encounters patients who appear to live their lives in the domain of the passive voice. Things just happen in the world. Things happen to them [usually bad or disappointing things], but there’s no agent causing them. And invariably, they leave out their own participation in the things that happen. This was once known as the Fate Neurosis. While it may keep them from blaming others, or keep them from shouldering blame themselves, it’s part of a long-suffering view of life that has a sticky persistence that maintains their dysphoria [and often drives their therapists and acquaintances to distraction]. One of the goals of their psychotherapy is to help them see their own part in making things happen, even if it’s negative – to help them see a world in which they are actors rather than victims of obscure forces like fate, destiny, or bad luck. Whodunit? is of major importance in understanding anything that happens to these people [often times theydunit].

Oddly, my mind goes down this path when reading some of the language used to describe the various sources of bias in Clinical Trial reporting. There’s a long-suffering quality to the lamentations, as if we are victims of a maleficant  universe. It’s in the language we use. Publication Bias refers to trials with unfavorable outcomes that don’t get published. That italicized phrase happens to be an example of the use of the passive voice in that the actor who didn’t publish the study is missing in action – literally. Selective Reporting? Somebody did the selecting. And so it goes. The culprit isn’t in the language. All these sheenanigans that have so garbled our Clinical Trial literature aren’t mistakes, or sloppiness, or something overlooked, or random acts of a perverse deity. They’re not coming from incompetent or poorly trained statisticians. They’re the conscious, motivated acts of a person or persons who’ve got something very specific in mind. And again, the important question is whodunit?

We all know that these distorted trial reports are motivated actions. The goal is to exaggerate efficacy and downplay toxicity, to sell these drugs, but that knowledge doesn’t make it into our descriptive language or our policies. We routinely relate to them in the passive voice, but then wrack our brains trying to think up things that might respond to their happening rather than stopping people from doing them in the first place. We request minimal information and give industry a long time to provide it. Then we don’t levy fines when the required information doesn’t show up. We lament the things that are happening and rarely go after the agents except to extract inadequate fines long after the fact. Many say it won’t stop until we start sending people to prison, but that just hasn’t happened, in part because it’s so difficult to prosecute and often impossible to prove.

Instead of chasing instances where various biases have colored  the reported results after the fact, we could face the reality that distortion and non-compliance are the the expected response. The a priori protocol and declared outcome variables are unlikely to be available a priori. So we could say that no trial can begin until the outcome variables are posted in the registration section on ClinicalTrials.gov. Why not? They’re already available from the Institutional Review Board submission. Similarly, we could say no FDA review of an NDA will be initiated until the Results Database is publicly available filled out on ClinicalTrials.gov for all submitted trials. Why not? They’re being submitted to the FDA so they’re available. Why not submit them to the rest of us?

So no more it happened to us. We need to act on they do it. We already know whodunit!
    December 29, 2016 | 2:53 PM

    Another thoughtful analysis of the deliberate actions of the drug companies to obscure the truth of how ineffective and/or toxic their products are.

    Bernard Carroll
    December 29, 2016 | 7:39 PM

    The style you describe is sometimes termed, sarcastically, the Divine Passive voice. Things just happen through no stated agency, as though they were acts of God. Nobody can be held accountable for those, right? The DP style has been honed in direct-to-consumer advertising of drugs: “serious side effects such as cancers, overwhelming infections, and immune system suppression HAVE HAPPENED.” But we’re not saying that our product caused them, no sirree!

    James OBrien, M.D.
    December 29, 2016 | 10:14 PM

    The divine passive voice bothered me from the moment I started charting in third year medical school rotations, and naturally I had the temerity to voice my disgust and I specifically cited Strunk and White. Example:

    The patient was informed of the risks of the procedure and agreed to proceed. The patient’s abdomen was prepared using a …., the patient was anesthetized…a three inch incision was made at the…

    Why not:

    Dr. Smith the resident, informed the patient of the risks. Dr Jones did this and that, Dr. Johnson the anesthesiologist did blah blah…

    The passive voice is a pathological mind set in medicine. I think it has a lot to do with why we accept garbage like MOC and EHR.

    If we accepted agency for MOC and EHR, it would be like that glorious scene in Network.

    Dan Abshear
    December 29, 2016 | 10:38 PM


    I’ve wrote more essays on this website.

    December 30, 2016 | 6:54 AM
    The Divine Passive Voice! What a great term. I hadn’t heard that before. Psychoanalyst Roy Shafer proposed something he called “Action Language.” His point was that Freudian and other metapsychology, in an attempt to deconstruct mental phenomena into “agencies” had removed overall agency in the process – placing the patient in the position of being a victim to things like feelings, egos, ids, etc. While it didn’t catch on generally, it was a useful idea that many of us incorporated into our way of talking to patients [One could make a similar point about Dx’s like MDD or TRD]…
    James OBrien, M.D.
    December 30, 2016 | 8:24 AM

    The divine passive voice in all operative reports contradicts the active temperament of surgeons especially orthopedists.

    On a related subject, what the hell is a SONT-ameter?


    I guess CENT-ameter is “INAPPROPRIATE”, which is medicalese means “wrong but we don’t have to tell you why.”

    Peter C Dwyer
    December 30, 2016 | 12:01 PM

    This is related to “professionalism” among all medical and “mental health” professions. I could never stop the social workers I supervised from referring to themselves as “this writer,” or “social worker.” Like Occam’s razor, the simpler wording is usually better – and shorter words are usually better than longer ones.

    Not just because a spade needs to be a spade, but because fancy impersonal language helps professionals minimize the fact that each of their “interventions” is, more fundamentally, an INTERACTION between two humans. And each human influences the other. It’s easy to lose sight of how much the influence is two way.

    “I” needs to be put into our writing and our thinking about patients/clients. Theory and professionalism aren’t all bad, but they should be things you carry in your pocket as tools, not wear on your entire body as armour.

    I’d rather have a mensch help me than an “expert.”

    James OBrien, M.D.
    December 30, 2016 | 7:36 PM

    My analysis is that it’s basically a secret fraternity code that signals membership and a mind set. Kind of like when Obama says POHKistan or ISIL. Saying CENTimeter actually got you wicked stares in medical training back in the day. I don’t know if it’s true anymore. Certainly any operative report not in the passive voice would get you called out.

    Yes, I agree the professional speak directly, accurately, succinctly and actively.

    Rachel Goldberg
    December 30, 2016 | 9:29 PM

    Of note, “distancing language” in clinical documentation is associated with increased suicide risk (pilot work at VAMC).
    Evaluation of Veterans’ Suicide Risk With the Use of Linguistic Detection Methods

    James OBrien, M.D.
    December 30, 2016 | 10:08 PM

    Passive voice isn’t just a grammatical offense as Dr. Goldberg just pointed out. The mind-set that denies agency forgoes accountability and this leads to the excessive use of passive voice as the perma-alibi. Hence the famous phrase, “the knife went in” instead of “I stabbed him” referenced by Dr. Anthony Daniels. I just read Life at the Bottom under the pen name Theodore Dalyrimple so this ties in nicely to this discussion.

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