The imperative voice in medical journal editorials

I’ve long wanted to do a little study – though in my experience no study is ever “little” – which is available to anyone in the entire world to do if they have the time and inclination (and resources)

Essentially I wished take a year or so of editorials from various medical journals and assess how much imperative language used. The seemingly endless “musts” and “shoulds” and “needs” that tend to be as inescapable a feature as the words “more research is needed.” I would like to assess exactly who “must” do this-or-that, and what the this-or-that tends to be. Often the subjects of this imperative language are those old standbys “stakeholders” or “policymakers”, adding to their holding of stakes and making of policy duties. Often it is rather specific bodies, often it is more generalised groups (“doctors”, “consultants”, “junior doctors”) It would be interesting to have the benefit of some kind of empirical study of this phenomenon.

For all the status of the medical profession, doctors do not seem to be a terribly happy bunch.   In the piece I just linked to I originally had a section in the opening paragraphs more explicitly exploring how much of this was contextual – related to working patterns, social attitudes, etc. – and how much was something inherent in the profession of medicine itself, either in the practitioners or in the practice. As I wrote in that review:

Lewis Terman’s classic study of “gifted” individuals, published in 1954, found that physicians tended to feel inferior relative to those of comparable attainment in other fields, and the Grant Study, George Vaillant’s epic survey of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects.

In Myers and Gabbard’s highly readable The Physician as Patient we read of the physicians ultimate impotence in the face of death and much disease, and discussion of the defence mechanisms used to manage this. There is also a tendency to conscientiousness that can easily tip over into obsessionality.

Of course, there are non-conscientious doctors, and no doubt plenty of very happy doctors, and doctors who lack of the feelings of inferiority identified by Terman and Valliant (although Myers and Gabbard write that to a certain degree the oft-purported medical narcissism is a defence against the unknown and uncontrollable)

The essential point remains however. It has always struck me that – admirable as it is – the culture of audit and of quality improvement can all too easily tip into a kind of self-flagellation. There is no end to the potential improvements would could  make to one’s own practice. It can be difficult to separate out the individual from the role, especially the role of the individual within a system, and to over-personalise the findings of an audit.

I wonder too about the endless imperative language of editorials feeding into this tendency. With a certain amount of irony, a recent Lancet editorial “When the doctor is sick too” illustrates the style perfectly in its closing paragraph:

The Academy, the RCP, NHS England, NHS Employers, and Health Education England need to work together to provide solutions without stifling individual actions. Junior doctors need to lead on actions, supported by their organisations. But overall, family structures and small groups work better than huge multidisciplinary teams in supporting the health of junior doctors. Consultants and managers, please take note.

I am not disputing anything that is being said – indeed (perhaps more than most editorials) I would fully support what is being said, especially about the relative benefit of “family structures and small groups.” Yet it is more the tone of the imperative language used that struck me as typical of a certain kind of editorial.
It can be easy to spot the point in an editorial where the author switches from descriptive or evaluative language into something-must-be-done mode.

I find the issue most acute in papers with an educational bent. Surveys of the degree to which topic A is taught in medical schools will almost always find that topic A isn’t taught enough, or taught properly, or taught in a way that students feel emboldened to fill out a Likert scale self-assessing their competence with “Very Competent.” Topic A therefore needs to be, must be, or should be more integrated or even included in the curriculum. In papers on medical education published outside the specialist medical educational literature, rarely if ever is there much discussion beyond a few cursory words on that fact that curricula are already quite overloaded as it is, and while Topic A is no doubt wonderful if not life-saving, not all goods are reconcilable.


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