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Communicating to Readers
June 5, 2002

Paper or Screen, Mother Tongue or English: Which Is Better?A Randomized Trial

Author Affiliations

Author Affiliations:Journal of the Norwegian Medical Association, Oslo, Norway (Drs Gulbrandsen and Nylenna); Journal of the Danish Medical Association, Copenhagen, Denmark (Dr Schroeder); and Journal of the Swedish Medical Association, Stockholm, Sweden (Dr Milerad). Dr Gulbrandsen is now with the Center for Health Services Research, Nordbyhagen, Norway.

JAMA. 2002;287(21):2851-2853. doi:10.1001/jama.287.21.2851

Context To compare family physicians' ability to retain information when reading a review article on paper vs on screen, and in their mother tongue vs in English.

Methods Randomized trial of 114 Scandinavian family physicians who read a review article in October or November 2000 from the Journal of Trauma for 10 minutes either on paper and in English, on screen and in English, on paper in their mother tongue, or on screen in their mother tongue. To assess comprehension, they immediately completed a questionnaire with 6 open questions about 13 key facts from the review article. Sum score was on a scale from 0 (no correct answers) to 13 points (all questions answered correctly).

Results There was no significant difference between readers of paper vs screen versions, with a median (interquartile range [IQR]) of 4 (2-6) vs 4 (2-5), respectively (P = .97). Physicians who read in their mother tongue scored significantly higher than those who read in English, with a median (IQR) of 4 (3-6) vs 3 (2-4) (P = .01).

Conclusion The medium (paper vs screen) did not influence the ability of family physicians to retain medical information. They best retained medical information when reading in their mother tongue.

Two features are characteristic for the developments in medical publishing recently; a trend toward English as the leading language of publication1 and the introduction of the Internet. Concern has been raised over the future of national and paper journals.24 No comparisons of the effect of reading the same medical text in different media and languages have been made. The objective of this study was to assess whether the medium (paper vs screen) or the language (English vs mother tongue) influenced the ability of Scandinavian family physicians to retain information from a review article.


A review article from the Journal of Trauma5 on how to handle mild and moderate head injuries was selected. A questionnaire with 6 open questions about 13 key facts of the article was prepared. A total score ranging from 0 (no correct answers) to 13 points (all questions answered correctly) could be achieved. Given a difference of 2 points between means, a significance level of .05, a power of 80%, and an estimated SD of 3, we needed at least 96 physicians in the analysis (48 in each group). In addition, the questionnaire included questions about the frequency and preference of reading on paper vs screen, as well as in mother tongue vs English on a 5-point Likert scale. Year of birth, sex, and nationality of the physician were reported.

The review article was translated into 3 Scandinavian languages. Paper and screen versions were prepared pairwise, so that the English and mother tongue versions had the same layout in each country, equal to the regular layout of the national medical journal (eg, prepared paper and screen versions [in Danish and English] of the article in Denmark had the same layout as the paper or Internet version of the Journal of the Danish Medical Association). We used laptops with 13-in LCD display and pdf format in Denmark, and personal computers with 17-in screens and html format in Norway and Sweden.

Family physicians passing the study room during breaks at the annual assemblies of the national societies of family medicine in October or November 2000 were asked to participate. Those 122 physicians who agreed were informed about the aims of the study. Eight declined after having received this information: 114 were included.

By drawing opaque, closed envelopes from a box, the participants were randomized into 4 groups: to read in their mother tongue on paper vs screen, or to read in English on paper vs screen. Each participant was given exactly 10 minutes to read the article. The questionnaire was completed immediately afterward. We used 2-tailed Mann-Whitney U (Wilcoxon) tests for comparison among groups. The statistical package SPSS version 10.0 (SPSS Inc, Chicago, Ill) was used.


Of the 114 respondents, 2 were non-Scandinavian physicians and 1 did not complete the questionnaire, leaving 111 physicians (32 Danes, 36 Norwegians, and 43 Swedes) for the analyses. Age, sex, nationality, and reading habits are summarized in Table 1.

Table 1. Characteristics of Study Physicians (N = 111)
Table 1. Characteristics of Study Physicians (N = 111)
Image description not available.

Table 2 presents the main results. We found no significant differences in retaining information between those who had been presented the article on paper vs those who had read it on screen (median [interquartile range (IQR)], 4 [2-6] vs 4 [2-5]; P = .97). Those who had read the paper in their mother tongue scored higher than those who had read in English (median [IQR], 4 [3-6] vs 3 [2-4]; P = .01). The tendency to score higher with the mother tongue applied to all subgroups.

Table 2. Median Score and Interquartile Range (IQR) (Scale 0-13) After Reading a Review Paper for 10 Minutes
Table 2. Median Score and Interquartile Range (IQR) (Scale 0-13) After Reading a Review Paper for 10 Minutes
Image description not available.

The physicians younger than 40 years scored higher than physicians aged 40 years or older (median [IQR], 6 [3.75-8] vs 3 [2-5]; P = .001). The men physicians scored higher than the women physicians (median [IQR], 4 [3-6] vs 3 [1.5-5]; P = .05).


We deliberately chose a review article and a short period of reading because it is thought that paper articles are easier to browse than computer screen articles. The only indication that paper may be easier to read was observed among the Danish physicians. The quality of the computer screen and the format of the text may explain the difference because we used pdf versions on laptops in Denmark. Reading on a computer screen compared with reading paper does not seem to influence the ability to retain information.

A large proportion of the physicians claimed to read medical information in English at least weekly. Nevertheless, we found that more of the medical information was retained if it was read in the mother tongue than in English. The median difference on our scale represents 25% less retention of information, which is of practical relevance. Scientific publication in the mother tongue of the readers offers obvious advantages.

We have not found support in the literature for the sex difference.6,7 The subject of the review article could possibly have interested the men readers more than the women readers. The relevance of the information to the reader must be taken into account when assessing the ability to retain information.

Physicians who attend national assemblies are likely to read more and be more proficient in English. The difference between reading in the mother tongue and in English might have been even larger in a representative sample of family physicians.

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