Maura Taaffe

Dr. Dale Sullivan

HU521 - Technical Communication

May 19, 1998

Initially, I was interested in looking at medical writing handbooks and at the different kinds of journals in which academic and nonacademics published articles about medical writing, a subfield in technical communication. I wanted to see if there was any crossover, how the issues of practitioner professionals complement or conflict with the issues of academics focused on the writing of these nonacademic professionals. I quickly discovered that the lines between disciplines are blurry and that one has to distinguish between medical writers who are also in the medical profession and those who are not. The roles and relationships within and among these three groups as well as economics have much to do with shaping the discourse of medical writing--and with what seem to me to be unavoidable clashes in medical communication style and goals.

In this country several factors influence the medical writing of medical professionals, professionals in a field that prides itself on combining art with science. The fairly exclusive culture of the medical professional, the power and highly competitive nature of publishing within that discourse community, and the need for accurate, reliable information for immediate use in solving problems, and a strong inclination to put medical "facts" first and communication of those facts second create interesting dynamics and rhetorical complexities in medical writing. For over a century the quality of medical writing has been a great concern to both medical professionals and lay readers. According to Dr. Lester King, physician and retired, long-time editor of the Journal of the American Medical Association (JAMA) "more than a century ago critics deplored the repulsive quality of medical prose" to such an extent that the AMA set up committees to evaluate the problem of medical literature as early as 1851 (King 1978, 6).

Physicians themselves recognize that the communication problem exists, positing several reasons for it, most of which they see as inevitable and unchangeable. Stressing that medical writing in journals with medical professionals as the primary audience is intended to impart quick and accurate information, they are inclined to be somewhat defensive. In A Physician's Guide to Medical Writing, for example, John Dirckx, M.D. explains that medical writing is not meant to entertain, it is not especially lucrative, and it contains such a strong intellectual appeal that readers will remain interested despite the convoluted and pompous quality of the writing (153). Among journalists in the field of medical editing, the name Franz Ingelfinger is practically legendary; he was the editor for the prestigious New England Journal of Medicine . He, too, sees a clash between the medical professionals need for reliable information that can be used for immediate problem solving and a more thorough, deeper understanding of the medical issue at hand. He claims that general medical journals should educate and foster understanding "like universities, not like information booths" (King 10).

It seems that to physicians medical writing "properly includes technical exposition on any subject related to medical science, such as biochemistry, pharmacologic studies, sanitation, and psychoanalysis" (Dirckx 40) As a physician-medical writer, Dirckx draws a very clear line between the kind of writing that is legitimate medical writing (what Ingelfinger would see as "information booth" writing in journals read only by physicians/nurses) and "popularized treatments of medical topics addressed to a lay audience, advertising copy, or articles written in 'throwaway' magazine style" (40). The latter, of course, is the kind of writing that professionals in the field of medical communication produce, the kind of writing that is necessitated by the unintelligibility to much physician-originated medical writing, inaccessible to lay readers or even to allied medical health professionals.

From surveying medical writing books aimed at the medical professional audience, it is clear that some of the concerns are political within the medical community. Academics need to remember that those medical writers who are physicians tend to be researchers and academics as well, facing the some of the same kinds of publishing and grant writing pressures as other academics in the university. In the medical world, publishing is extraordinarily competitive, with 50 to 90% of articles and research papers submitted to journals being rejected (Huth 161), the readers of professional medical writing books want to know what goes in to editors' decision making before they decide which journal to send their manuscript to. I thought it was fascinating, for example, that in listing three steps to following before doing a first draft--in order of importance--Huth lists deciding on authorship as Step 1. An elaborate discussion of legitimate and illegitimate claims to authorship follows, and he even includes a comprehensive chart to demonstrate the difference between the two. (See Table 1.) He cautions readers about the dangers of having one's paper reviewed by professional rivals, explaining that "you can properly ask the editor not to use as reviewers the persons you specify" (Huth 157), reminding them also that an extremely long list of undesirable reviewers adds little to credibility or apparent self-confidence in their research findings. The second and third steps in preparing the write a draft include knowing required manuscript format and having all the evidence at hand, including permissions for any paper, illustration, statistics, or personal communications with other physicians that went into one's article. In this highly competitive world, it is not enough to simply cite previously published papers (copyrighted by the publisher); one is expected to ask for permission from the original writer/researcher "as a reasonable courtesy (Huth 45). To an academic, who clearly has publish-or-perish pressures to deal with, this kind of protection of one's work reflects a ratcheting up of the intensity of professional competition to yet an even higher level.

In the handbooks I examined, all three authors saw the need to consider medical writing as a type of critical argument, an argument in which the most important instrument for persuading readers--other medical professionals--was the validity and reliability of evidence presented in great detail. The readers most often are looking in these journals to find ways of solving current problems with treating patients; they are problem-solvers first and generally curious seekers of information (for future use) second. Personally, I have seen just how urgently medical professionals need to access information to use, not necessarily to study. When I worked in a hospital library for a brief time, I was surprised at how often physician would come in to read up on something in the morning that would help him or her deal with a patient's problems that same evening or during the following day. Medical writing handbooks reflect this awareness by reminding physicians about their readers, stressing the importance of the "sequence" or practical and expected organization of information in the articles, the accuracy of findings, and critically sifted through evidence to insure reliability and relevance.

Finally, physician-medical writers stress problems caused by word choice, style, sentence-level issues in medical writing. One writer felt that because physicians lead such a busy life, they rarely read nonmedical literature and therefore write in a very nonliterate style; he recommended reading the classics and seemed particular fond of Moby Dick (Dirckx 47). Again tied to the culture and lifestyle of the physician, efficient and well-focused use of time is often cited as an issue. This concern (an understandable obsession, all things considered) with time came up in Charles Roland's Good Scientific Writing when he tested the readability and conciseness of several paragraphs by time how long they took to read--down to the seconds. He then compared how long it took to read well-edited versions of the same paragraph, saving the busy reader as much as 14 seconds in some cases!

In the how-to articles I read as well as in the handbooks, I found the writing and thinking were clearly separate processes. There is a long of sorts of sophisticated and clear prose that is held simultaneously with a strong suspicion that good writing is trying to cover up flawed thinking and can lead readers down the path to unreliable, unscientifically valid conclusions. One must always struggle, the reader is told "against the temptation to cover his lack of information with a rhetorical snow job, to palm off muddy thinking under a veneer of smooth writing" (Dirckx 99). Nonetheless, a great stress on the use of metaphor to link the known with the unknown, to present a visual image of an abstract concept is often recommended. Frequently these discussions on the use of metaphor are included in discussions of clarity and jargon. Medical editors (usually physicians themselves) tell their medical professional readers to look for the most accurate word choice, to avoid Latinate words if at all possible, and to use metaphors. The number of writers who focus on the use of metaphor is tremendous. Similar to advice about using abbreviations in most technical documentation, the writing "procedure" seems to be using a technical term along with a metaphor early in a text and then depend on the metaphor alone for the rest of the article. On the other hand, Dirckx's handbook reminds physicians that American medical research is likely to be read around the world and should therefore stress the "literal," rather than "figurative" use of language--to make it easier for non-native speakers to understand the meaning. Unfortunately, he makes these claims without backing them up with any sort of linguistic of communication theory .

At first, as both an aspiring academic interested in medical communication and an ex- medical writer/editor for popular audiences, I was struck by the way that this particular discourse community was so concerned with intra-community power issues and rhetorical dynamics and with language choices at the word and sentence level, but showed little concern with how communication issues between themselves and "outsiders" to the community--those seeking medical knowledge for personal health reasons or simply out of intellectual curiosity. The larger political issues seem to fall to the medical editors in their relationship to the physicians and to the non-physician medical writers whose audience includes a lay readership.

The attitude of several physicians toward the field of medical journalism or medication communications in general is often quite strong--and quite negative. They are seen as writers who present watered-down versions of the "facts," who sensationalize findings with premature reporting, and whose appeal to lay readers is mere pandering. They are criticized as having "the undisciplined fireworks fo the popular novelist...part of the blame lies with the public, whose insatiable but uncritical demand for reading matter annually calls forth millions of tons of facile, sleazy claptrap" (Dirckx 47).

Medical writers function somewhat like foreign who are sent off to a strange place where they really don't know much, if anything at all, about the language and culture of the world they've landed in. The readers of medical writing, perhaps unlike many of the readers of other types of technical communication, are intensely and personally interested in what the writers discover and report on, yet they too often know nothing of the language and culture of the medical world. It is then the job, I believe, of the medical writer to translate information to the public and to do more than that--to look ahead at implications of the research they are translating for readers and their families. Like environmental health writing for the public, medical writing issues are personal and political because they do involve the community outside a purely medical professional one. No technology, it could be argued, is more applicable to humankind than that of health and medicine. For many idealistic medical writers and editors, it is this kind of sense of human urgency and importance that can mitigate the tainted, for lack of a better word, real-world, nonacademic, mercenary nature of technical writing for money.

The relationship between the medical professional (who is not also a medical writer) and the writer is complicated. First of all the medical writers who are not medical professionals must depend on what has been written already by those physicians, nurses, researchers, etc. who themselves have published their own medical writing. They are reporters, so to speak, of published materials rather than events to be investigated firsthand. Clashes between potentially "good copy" and bad medicine (premature reporting of conclusions from clinical trials, for example) occur when the two discourse communities or cultures (medical and medical communicator). Doctors rarely ask, "Who will profit by this research?"; reporters and other medical writers often do. Conflicts between those who believe that the popular medical writers created an AIDS hysteria and those who believe that writers reflected the seriousness that already existed again bounce back and forth between these two discourse communities.

At medical and scientific conferences over the past several years, reporters' booths are often set up so that the professional medical communicators will be able to gather the information, interview researchers, and translate findings for the public. It seems that within the professional medical community, there maybe a slowly growing recognition of the need for medical communicators to bridge the gap between discourse communities. One of the groups that is highly regarded and invited right along with newspapers from around the country is the American Medical Writers' Association (AMWA).

Just like the STC functions as a professional organization for technical communicators in general, AMWA, was organized to bring medical professionals together. Recognizing the need for a great deal of education in this foreign culture of the medical world, medical communicators join medical professionals as well as academic technical writing professionals interested in studying medical communication and teaching future medical communicators in this organization. By looking at the publications of this organization and perhaps more importantly by looking at the kinds of workshops and courses offered by AMWA, did find what sorts of issues they found essential in medical communication.

A CORE CURRICULUM as well as an ADVANCED CURRICULUM (always printed in all caps for some strange reason) are offered, course-by-course over the years, at the annual and regional conferences. Once one has completed a certain number of the courses (usually 8-hour workshops), one can earn a certificate. Here the need for legitimization is seen as these medical communicators p work on establishing themselves as professionals in their own right. In addition to the kinds of writing issues one might expect (sentence patterns, punctuation, visuals, etc), the course offerings that I found outlined in the 1997 AMWA conference handout included the following: statistics for medical writers and editors; bibliographic resources for medical communicators on-line; author-editor relationships, writing the nonfiction book proposal, writing abstracts, writing patient education handouts, investigational new drug applications, nature and significance of three phases of clinical trials reports, medical scriptwriting, medical terminology, basics of biotechnology, regulatory aspects of drug development, authorship ethics--a clash of cultures; writing package inserts; writing patient education materials for children, project management, public relations, and legal responsibility of medical editors. This sampling of workshops, many of which are taught by physicians and some of which are taught by academics, illustrates the kinds of things a medical communicator is interested in learning about.

Another place one can find reflections of issues for medical writers is in the call for papers for last AMWA conference. Among requests for presentations were several aspects of technology and medical information gathering--how such services affect medical communication, how the public deals with this kind of electronic information and what can be done about the safety factors, how informed consent is actually functioning as both a written and verbal communication, how doctors can develop more effective communication strategies with patients, what curricula have been developed for medical writing classes and the current status of medical writing at universities in this country and abroad, how complex issues of biotechnology are being conveyed to the public, and strategies for testing patient education materials.

Unfortunately, when I searched for copies of the AMWA Journal to look at articles firsthand, I found that the distribution of the journal was pretty limited to those who were members of AMWA; no library in Michigan carried it and no local hospital libraries carried it. By phoning the AMWA headquarters, I was able to get copies of several of the tables of contents for the last couple of years' issues. The articles were a mix of professional association news, writing advice, and practical business advice. They concerned software for medical research, writing lessons, starting up freelance businesses, author-editor relationships, and a considerable number of articles focused on persuading the public concerning a medical issue. The latter included one article on motivating blood marrow donors and another on recruiting subjects for a study on depression. Persuasion here was aimed at the patients, not the physicians.

Perhaps indicative of the "mixed bag" that membership in AMWA represents (medical professionals, academics in both medical and communication fields, and medical communicators who may or may not also be medical professionals) was the inclusion of an article of interest to academics, one that uses discourse analysis--"For Caring Out Loud: A Classical Rhetorician's Updated Guide to Physician-Patient Conversation" by Mary Knatterud.

Finally, turning to journals recommended for technical communication--some more workplace oriented and some more academic, I found few and scattered articles on medical communication from 1990 until the present. In Technical Communication Quarter ly and in Technical Communication I found no articles on medical issues. This seems to indicate that the field is somewhat new to technical communication. In both Journal of Business and Technical Communication and Journal of Technical Writing and Communication, however, I found a few very interesting articles.

Other than those written by Jennifer Connor, most of the articles were not concerned with historical aspects of medical writing. I found that the article we read for class--Connor's criticism of those who write about medical writing without a strong grounding in the history and sociology of the historical times--was one in a series of back-and-forth debates with Jo Allen, the writer she was criticizing. In another article (Connor 1994) she traces the historical development of "plain language" in 19th-century Canadian self-help medical books; again, the emphasis is historical but this time it was linked to the continual concern about the inaccessibility of medical language.

Although the other articles I read from the two technical communication journals were all concerned with medicine, they were too few for me to be able to discern--or construct--a clear pattern of issues. One stylistic feature that was glaringly obvious was the writers' use of medical metaphors to discuss everything from editing as surgery to the dissection of a medical communicator's career--medical metaphor overkill at work! Three of the articles were "how-to" essays--Pakes, Spears, and Koski--in which readers learned more about using research tools, particularly electronic tools. One article concerned writing pharmaceutical brochures for clinical investigators and the need to produce writing that was clear and "pleasant" (Pakes ). And strategies for writing to an audience of lay people who get medical information from the WEB were discussed by Koski (use "concrete" language as opposed to "abstract" language), for example.

Other issues concerned the differences between medical textbooks written for trauma nurses and those written for trauma physicians where style was a reflection of role. Here the social aspect of the communication situation was touched on. In effect the writer showed that since the doctor is more focused on the injury and the nurse is more holistically focused on the patient, the doctor's sentences and paragraphs were shorter and far less background and system-like connections were made in the physicians' textbook than in the nurses' textbook.

Issues of responsibility came up in several places where the readers were reminded of consequences of unclear writing. Apparently, more and more lawsuits are focusing on the work of technical writers and there is an "increasing willingness of courts to carefully analyze and perhaps second guess the writer's phraseology" (Caher 10). The example used in this article about technical writers in general was that of a medical writer responsible for writing package inserts for prescriptions in accordance with FDA regulations. Again it was the sequence of the information, the accuracy, and the clarity that were under question. If more than one interpretation of the information could be arrived at due to the order in which warnings were presented, the medical writer would have been found liable for problems that a patient had in taking the medication. t

I think that the most clearcut conclusion that I can come to from surveying articles, handbooks, and AMWA materials is that there is no doubt that medical communications is a very young field. It seems to me that of the materials I examined, the clearest picture of the issues, problems, and needs of a discourse community with as complex a membership as that of medical communicators comes from the AMWA materials. Drawing boundaries between academic vs. medical professional vs. medical communicator seems pointless because of the nature of the medical communication. It also seems to be an area ripe for study by those interested in power issues in rhetoric and certainly in research in communication systems. Medical communication really is both the most and least specialized area of technical communication.

Allen, Jo. Commentary: A Response to JTH Connor and Jennifer Connor's Analysis, Technical Writing and Communication ,Vol 22, Number 2, 1992, 203-210.

Caher, John. Technical Documentation and Legal Liability, Journal of Technical Writing & Communication Vol 25, Number 4, 1995, 5-10. JTH Connor and Jennifer J Connor. Commentary on Rhetorical Analysis of Willian Harvey's De Motu Cordis (1628) Technical Writing and Communication Volune 22 Number 2, 1992, 195-202.

Connor, Jennifer. Medical Test and Historical Context: Research Issues and Methods in History and Technical CommunicationTechnical Writing and Communication , Vol 23, Number 3, 1993, 211-232.

Connor, Jennifer Self-Help Medical Literature in 19th-Century Canada and the Rhetorical Convention of Plain Language. Technical Writing and Communication, Vol 24, Number 3, 1994, 265-284.

Dircksx, John, Dx+Rx: A Physician's Guide to Medical Writing. Boston: G.K. Hall & Co., 1977.

Huth, Edward J. How to Write and Publish Papers in the Medical Sciences . Philadelphia: ISI Press, 1982.

Karanikas, Marianthe. Describint Acupuncture: A New Challenge for Technical Communicators. Journal of Technical Writing & Communication Vol 27, Number 1, 1997, 69-86.

Kesselring, Linda. Putting Trauma Care in Writing: Parallels Between Doctors' and Nurses' Responsibilities and Textbook Number 2, 1993, 129-136.

Koski, Cheryl. Down the Rabbit-Hole: Exploring Health Messages on the World Wide WEB Journal of Technical Writing & Communication Vol 27, Number 1, 1997, 49-56.

Lester King, Why Not Say It Clearly: A Guide to Scientific Writing. Boston: Little and Brown, 1978.

Pakes, Gary. Writing Clinical Investigator's Brochures on Drus for a Pharmaceutical Company. Technical Writing and Communication , Vol 23, number 2, 1993,

Robinson, Alice and Lucille Notter, Clinical Writing for Health Professionals London: Prentice-Hall, 1982.

Roland, Charles. Good Scientific Writing, Chicago: AMA, 1971.

Spears, Lee. Nurses as Technical Writers: What They Need to Know. Journal of Technical Writing & Communication Vol 25, Number 4, 1995, 401- 414.