A Functional Grammar Approach
to a Text Comparison of Taiwanese EMP
Students and International EMP Experts
for an Understanding of the EMP Writing Gap
Wenli Tsou
Hue-lin Hung
National Cheng Kung University National Cheng Kung University
wtsou@mail.ncku.edu.tw huilin57@yahoo.com.tw
Abstract
This study is part of a medical education reform project conducted in a university hospital in southern Taiwan. To fulfill the goal of advancing medical students’ English communicative abilities, interdisciplinary collaboration between the language department and the medical college was launched, beginning with a writing workshop in 2009. Insights drawn from the workshop shed light on the students’ needs with regard to learning the micro-level lexical-grammatical resources of Medical English. The current study was undertaken using a Functional Grammar approach to comparisons of word choices and grammatical usages in two sets of medical texts, one written by NNS learners and the other by published authors. The discrepancies of particular word frequencies between learners and experts highlighted the problematical conception of language utility in terms of the EMP writing gap. Thus, the improper language contexts of student texts were examined in detail and interpreted by using the three perspectives of semantics, grammatical pattern, and cultural assumptions. Importantly, the results reveal the inevitable language gap derived from the learners’ lack of awareness of native cultural assumptions in line with word choice and grammatical structure, which might lead the NNS medical descriptions to be more subjective, personal, and less professional.
Key Words: text comparisons, diagnostic description, functional grammar, English for medical purposes (EMP)
INTRODUCTION
As the world has become even more globally interconnected and interdependent, NNS medical students must acquire English language skills along with other fundamental courses of medicine to overcome traditional perceptions and keep up-to-date on innovative and effective techniques. Consequently, when entering the fifth-year of their clinical training, Taiwanese medical students start learning to convey patient-interview conversations in diagnostic texts in English. A thorough diagnostic document in terms of the patient’s History of Present Illness (HPI) or History Taking systemically and chronologically summarizes the course of symptom development, results of previous tests, treatments, physical examinations, and relevant patient background. This cognitively and linguistically demanding process requires these EFL (English as Foreign Language) medical students to recall, analyze, synthesize, interpret, summarize, and translate the information into a comprehensible English diagnostic text.
Legally, the medical information provides evidence to protect the interests of patients, hospitals, and practitioners. Clinically, the diagnostic summary serves as a crucial source of scientific knowledge during the diagnostic process for healthcare professionals, as they seek to formulate the natural course of the condition and treatment. In recent years, the critical role of medical documents has gone beyond their legal and clinical positions as the question of making medical records public is now an ongoing debate in Taiwan. The readability and quality of English medical texts written by medical practitioners is thus under increasing scrutiny. Accordingly, the medical college at
National Cheng Kung University has realized the urgency of advancing the English communicative competence of medical students, and thus proposed incorporating a medical writing project into the school’s Medical Curriculum Reform Plan. To put the proposal into practice, a pilot writing workshop1
Twelve medical students participated in the nine-hour writing course and were involved in the genre-based learning research. The pilot study aimed to investigate whether inducing the staged, process-based, and explicit move structure as the textual organizers would facilitate the EFL students’ cognition when composing the medical text of an HPI. Surveys, pre-tests, post-tests, class observations, and interviews were conducted regarding the teaching of the sequential steps in History Taking. Although the numerical data failed to show significant differences between the pre- and post-tests, the participants’ annotations contributed to the interpretation of the reasons for insignificant move structure learning outcomes: 1) a lack of consent among the responsible authorities (i.e., the faculty members in the medical department) on the move structure
first took place in the summer of 2009.
2
1 In fact, what motivated us to initiate the pilot workshop was the fact that medical students need to see how the specialized English literacy of a diagnostic document (History of Present Illness) is different from basic skills of the English composition they had learned in general English classes.
, and 2) a miscalculation of student needs in regards to the macro-level of text-organization over the micro-level of text-linguistics. Briefly, the doctor-in-training participants explained that the move structure taught in the workshop was different from the HPI format that they
2 After the workshop investigation we came to realize that there is no general agreement on HPI organization or style, not to mention the micro-level of register.
had previously learned from other faculty members. As well, questions regarding appropriate verb choices (e.g., the patient was
sent to vs. was referred to), collocation, and grammar usages were
frequently raised by the participants during the workshop sessions, highlighting the need for improved learning at the micro-level of the lexical-grammar constituents. Therefore, instead of focusing on the teaching of a genre-based move structure, it was surmised that exploring the functions of a grammatical and semantic lexis for conveying the diagnostic meaning was highly valued. In other words, this study focused on the contextualized language of the register variables featured in different social-cultural conventions.
Building on the previous workshop study insights, this project involved a medical discourse analysis of two sets of HPI contents: one collected from an international medical journal and the other from the fifth year medical students’ assignments. The purpose of the discourse comparative scheme was to reveal the prominent differences between the two groups of texts at the micro-level of lexical-grammar constituents. This would hopefully lead to the discovery of language gaps for use as topics of reflection in the corresponding writing course. Ultimately, the researchers aim to call the attention of the EFL medical students to the relationship of text in context by (a) the demonstration of English grammar as a systemic and functional resource for the maintenance of medical communication for different readers, and (b) consciousness-raising on the relevance of word choice and lexical-grammar constituents to the implicit social-cultural meaning.
LITERATURE REVIEW
The literature review illustrates the conceptual framework for this study centered on medical discourse comparisons.
Review of Genre-Based Medical Research
Although the genre-based approach has aroused considerable controversy regarding its theoretical basis (Belcher, 2004; Freedman, 1993, 1994; Hyland, 2002; Pennycook, 1997), very few studies, if any, have produced convincing evidence against the explicit teaching of language patterns in conveying regularly occurring social purposes and activities (Henry & Roseberry, 1998; Hyon, 2001; Swales, 1990). In general, the genre analysis process works to differentiate the rhetorical units or move structure of a text type by identifying language strategies of the lexical choices made to achieve the intended linguistic purposes (Henry & Roseberry, 2001). Given that genre is a staged, structured, and purposeful activity, the genre-based pedagogy is convenient for the instructor to guide his/her students step by step in learning how the parts of language contribute to the whole and how the whole is made up of the parts.
Since the mid-1980s, genre approaches to research and pedagogy in the second language classroom have been widely utilized, with increasing sophistication in both theoretical perspective and application (Freedman, 1993; Hasan, 1995; Hyon, 1996; Johns, 2002; Martin, 2002). According to Hyon (1996), overall genre scholarship can be located in the three schools of ESP, Australian systemic functional linguistics (SFL), and North American New Rhetoric
studies (NR). Among the three genre traditions, Flowerdew (2002) synthesized the fundamental difference lies in their pedagogic agenda of either focusing more on learning the linguistic features, as in ESP and SFL classrooms, or setting the priority on learners’ acquaintance with the context expectations, as in NR.
The approach to genre influenced by Michael Halliday’s Systemic Functional Linguistics emphasizes “the relationship between language and its function in social settings” (Hyon, 1996, p. 696) as Christie (1999) noted that a “text is known only because of the context that gives it life” (p. 760). In application, the text is activated through the micro-level of register—the field (subject matter or social activity), tenor (relationship of the participants), and mode (the channel of language interaction), in line with the macro-level of genre to fulfill the social purpose. Therefore, as Eggins (1994) indicated, the register vitally shapes the forms of language and thus the linguistic consequences. Hence, the micro-level register variables explain why we use different words for conversation or composition to communicate with different people (children or professors) on different topics (fishing or air pollution) to achieve different discourse purposes (to explain or to argue).
Along this line, genre-based and register-based studies on medical discourse, investigating the linguistic features and rhetorical functions have been conducted to make EMP courses more useful to NNS students (Busch-Lauer, 1995; Marco, 2000; Nwogu, 1997; Wang, Liang, & Ge, 2008; Wood & Head, 2004). For instance, Nwogu (1997) divided the medical research articles into three moves (introduction, methods and results), and also illustrated the sub-structures and linguistic features of each move. Hoekje’s (2007) study
focused on EFL medical graduates in U.S. hospitals during and after their residency training. The author discovered that language and cultural problems are very common among NNS doctors, and thus argued in favor of a more EMP-oriented curriculum design and research agenda for EFL doctors and medical students. Marco’s research (2000) incorporated the genre and register concepts that provided a practical application for the teaching of EMP at both the micro- and macro-level. By asserting that “medical research papers have a specific phraseology” (p. 76), Marco gave an insight into the collocational framework of phraseology. She demonstrated that the common pre-patterned frameworks (e.g., the … of) when used in association with lexical items (e.g., determine the number of) will constitute particular moves (e.g., occupying the niche) in a medical research paper. Wang, Liang, and Ge (2008) conducted a register-based study to examine the high frequency of specialist vocabulary in medical texts. The authors highlighted the importance of preparing a medical word list for EFL students in order to increase their lexical knowledge, as well as to aid EFL instructors when designing curricula. As Busch-Lauer (1995) pointed out, the intention of an ESP study is to “economize specialist communication” (p. 769). Although the various genre-based studies above have pursued a number of different agendas and research questions, all of them have analyzed the language patterns chosen to organize and specify a designated type of socio-rhetorical activity in medical field. Significantly, Swales (1990) claimed that genre pertains to “the enlightened and enlightening concept that language is ultimately a matter of choice” (p. 33). Together, Christie (1999) theorized genre as a systemic
functional language, “when people use language, then, they
simultaneously (a) make choices within the various linguistic systems and (b) represent ideational, interpersonal, and textual meanings” (p. 760). Thus the goal of the present study was to make NNS aware of the relationship between language choice and the aforementioned semantic features in context through the functional grammar (FG) approach.
The FG Conception of the Genre Approach to Medical Discourse Analysis
Rooted in sociology, functional linguistics asserts that language and context are interrelated. This is to say that when we use language, the text we construct simultaneously reflects our point of view, attitude, and role we conceive toward the particular social situation and the audience we are communicating with. The linguistic descriptions convey three coexisting meta-meanings of human life. They are: (a) experiential meaning dealing with how language is used to interpret our worldview, (b) interpersonal meaning showing our perceived attitude and role embedded in our experiential-based communication, and (c) the textual meaning concerning the word choices and grammatical structure to make the experiential description coherent and cohesive (Richards, 1996). Functional linguistics has thus made an invaluable contribution to our understanding of language as a semantic system through its constitution of lexical-grammatical resources (Halliday, 1994). Hence, FG is considered a useful concept as it integrates grammar, meaning, and context in a way that enables the language instructor to present the material with explicit and systematic explanations in the same
way that writing works to communicate with purposes (Eggins, 1994; Lock, 1996; Martin, 2002; Thompson, 1996).
Drawing on the FG perspective, an important grammatical concept is the transitivity system, which in clauses consists of the three fundamental elements of participant, process, and circumstance. Normally, the participant element found in medical texts is construed by nouns (e.g., the patient, name of symptom, treatment, or examination) as semantic characters that signify who or what is involved in a symptom or treatments. The process element is realized by a verbal group, the expansion of a main verb to indicate how a symptom is evolving, physical examinations proceeding, and/or the treatments involved. The circumstantial element is realized through a prepositional phrase or circumstantial adjuncts (e.g., before admission, on examination) to pinpoint the co-occurring or co-existing conditions related to the diagnosis of when—the chronological relevance (e.g., seven months before admission), how—the symptoms with their qualitative and/or quantitative characteristics (e.g., by eating, talking, or touching his mustache), and where—the position or location (e.g., around the left kidney). Table 1 gives an example of how the three transitivity elements are put together to complete the experiential observation of a physician.
Tab le 1
Examples of the Three Transitivity Elements within Clauses The patient had been well until seven months before admission, when numbness developed in his left arm … Atenolol and nortriptyline were prescribed, and three and a half weeks before admission, he was referred to the surgical clinic of this hospital.
Experiential meaning
Participant Process Circumstance
The patient had been well until seven months before admission, when
numbness developed in his left arm, Atenolol &
nortriptyline
were prescribed and three and a half weeks before admission,
he was referred to the surgical clinic of this hospital.
Likewise, the experiential meaning is understood because the functional and semantic constituents of participant, process, and
circumstance together bring life to the lexical and grammatical
resources (nouns, verbs, and prepositions). In addition, the three elements lead to breaking down the clauses into meaningful chunks which assists EFL medical students in making a connection between the grammatical resources and the intended diagnostic meaning of the HPI.
For the purposes of this study, the analysis of the participant element (noun groups) was excluded for two reasons. First, naming or explaining the medical terminology of symptoms, treatments, and examinations was beyond the ESP scholarship of the researchers. Second, the remaining of the participant elements (disease, patient,
or locations were considered less complicated for the advanced EFL medical students. Instead, the comparative procedure focused on the two grammatical constituents of finite verbal groups—particularly the finite element plus event (was suspected) and the finite fused with the event (suffered), as well as prepositional phrases. According to Halliday and Matthiessen (2004), “it [finite] brings the preposition down to earth … It relates the preposition to its context in the speech event” (p. 115). Thompson (1996) added “the basic function of the finite is to orient the listener towards the kind of validity being claimed for the preposition, by relating it either to the here-and-now reality of the speech event or to the speaker’s attitude” (p. 45).
In addition, Halliday and Matthiessen (2004) explained “The experiential structure of the finite verbal group is Finite (standing for Finite operator) plus Event, with optional elements Auxiliary (one or more) and Polarity” (p. 335). Two examples are presented:
1) … the patient could be roused with mild stimulation 2) Mr. Chou has been diagnosed with gastric cancer
Both finite verbal groups above consist of a finite (could, has), auxiliary verb (be, been), and the lexical verb (roused, diagnosed) together activating the event in context. The finite verbal groups thus function as the core for (a) exchanging the interpersonal meaning about the degree of certainty in diagnostic judgment, (b) conveying the experiential meaning in representing the logical-semantic relationship within the diagnostic context, and (c) simultaneously circumscribing the textual meaning. Hence, the analysis of finite verbal groups is considered crucial for the understanding of diagnostic meaning and explicit for the pedagogic demonstration.
First of all, a particular research effort had to be made for access to the appropriate HPI material. Due to the strict laws meant to protect the confidentiality of patients’ files, access to authentic HPI content documented within the confidential medical record was not readily available. As a result, the open access Journal of Medical
Case Reports was adopted to demonstrate how experienced
physicians who are also published authors record the Patient History. According to Swartz (2006), the history of present illness (HPI) refers to “the recent changes in health that led the patient to seek medical attention at this time” (p. 18). In addition, Orient (2005) summarized that “the composed HPI is a reflection of the implicit logic in the differential diagnosis” (p. 85). Overall, Macken-Horarik (2002) suggested two descriptive stages, the general statement and the
implication sequence to organize the HPI text. The general statement
summarizes the information about the chief concern of a patient to be explained throughout the implication sequence. As Macken-Horarik said, it “sets out steps in a process or the factors influencing a phenomenon in a logical sequence” (p. 21).
Similar to the HPI descriptions written by the medical students, the Medical Case Report account starts with a personal identification and fulfills the rhetorical function of introducing the symptoms and duration of the patient complaint ahead of a more detailed description (see Appendix A as a case report example and Appendix B as a student HPI text). Certainly, it is recognized that the international journal published authors are more confident than the EFL medical students in the management of a clausal system to represent the staged information in a manner that is logical, accurate, and chronological.
Based on the above theoretical consideration in line with the FG scheme, two research questions were proposed to better understand the related EFL language needs, and which might lead to some pedagogical insights.
1. How do the lexical-grammar constituents, in terms of the finite verbal groups and prepositional phrases, vary in learners’ and medical writing experts’ medical descriptions? 2. What are the pedagogical implications of the different lexical,
grammatical, and semantic choices made by the EFL learners and the medical writing experts?
Our rationale in addressing the above research questions is to help the EFL medical students comprehend that grammar has a function for making the textual meaning relevant to the context. As a result, the students will be able to anticipate the readers’ expectations before they write.
METHODOLOGY
For the micro-level lexical-grammatical comparisons, the texts collected consisted of 20 EFL medical students’ HPIs (35,722 words) and 20 open access Journal of Medical Case Report3
3Since there are strict rules to protect the confidentiality of medical records, the efforts to collect authentic documents recorded by doctors, either Taiwanese or native speakers, were not successful. As a result, we turned to the Journal of Medical Case Reports recommended by one of the medical faculty members.
(122,584 words). Both the student samples and the medical case reports had the same rhetorical purpose and staged information for the micro-level of
lexical-grammar comparisons. The two sets of 40 collected texts were selected by the instructor of the EMP writing courses, a faculty member in the medical college at National Cheng Kung University. The twenty EFL texts were composed by the medical students in their fifth year of specialized training for a clinical clerkship4
The research scheme aimed to raise the EFL students’ language awareness via examination of different lexical and grammatical choices made for the same discourse purpose of diagnostic description. Ultimately it was hoped that the students would be able to recognize the language functions necessary to represent the appropriate rhetorical purposes for the diagnostic content. A procedure for text comparisons was developed: 1) a study of the finite verbal group in the medical process to uncover the linguistic and conceptual gaps in EFL students’ diagnostic descriptions, and 2) an analysis of the appropriate use of prepositional phrases for
circumstantial descriptions.
. During the clinical training stage, the students were required to compose the HPI of assigned patients and submit it to clinicians for correction. As a matter of fact, right before they moved on to this training stage, one session of formal instruction on the principles of medical writing was provided. Other than that particular medical writing session, the students were compelled to develop medical composition skills on their own.
4Medical students in Taiwan enter a college of medicine after completion of their secondary education, and then study medicine for seven years. The senior clerkship that Taiwanese medical students participate in when they are in their sixth year of training would be equivalent to the fourth year of clinical training in a medical school in the United States.
Finding the Language Gaps
The next two subsections describe the analytical procedures for finding the differences between the NNS students and medical writing experts with regard to the lexico-grammatical structure of finite verbal groups and prepositional phrases.
Exploring the finite verbal group. First, the researchers reviewed all the collected texts in order to distinguish among the three experiential elements of participants (recognized mostly through the nominal groups), processes (recognized through the finite verbal group), and circumstances (recognized through the prepositional phrases) in the clauses. Second, the researchers pulled out the finite verbal groups and particularly looked into the finite operator along with a lexical verb (did not have) or without (was), as well as the
finite fused onto a lexical verb (suffered). Next, the researchers
manually counted the number of times a particular finite verbal group was used by the experts and learners for language comparisons in the clause. The density estimation of the examined finite verbal groups was processed and is presented in the Tables 2 and 3. Finally, the language context within a clause along with the finite constituents were categorized and highlighted to identify language gaps among the EFL medical students.
The frequency of a particular finite, either comes with a lexical verb (her headache was increasing) or fuses with a lexical verb (e.g., she felt dull headache) to depict the medical event, indicated how often it was used or recognized by the experts and learners. Accordingly, the researchers were able to notice the difference in usage toward the same finite element. For example, the finite present
tense of “has” was encountered frequently (both the observed numbers and density) in the students’ texts to indicate the possessive
relational process in a medical event, but was not found in the
experts’ clausal system. This indicated possibly problematic usages in the learners’ texts, which thus deserve greater attention in order to further understand such apparent language gaps. Likewise, the researchers started the micro-level analyses to differentiate the language context in terms of the semantic lexical choices and grammatical structures used by the experts and learners. Utilizing a comparison protocol, two categories were first recognized and considered useful for the discovery of NNS medical students’ language gaps: 1) finite verbal groups frequently chosen by learners but rarely or never by experts, and 2) finite verbal groups frequently chosen by experts.
Analyzing the prepositional phrases for the circumstantial descriptions. The prepositional phrases served to represent a particular circumstance (e.g., two days before admission) as necessary information to complete the experiential meaning of a medical observation. Similar to the verbal group analysis process, the researchers singled out the circumstantial resources of prepositional phrases to compare their differences in usage for the purpose of making the clauses informative and relevant. The prepositional phrases were constructed with a preposition (e.g., in, on, under) followed by a prepositional object (e.g., the bed) to properly describe a related circumstantial intent (e.g., in the bed, on the bed, or under
the bed). The textual comparisons contributed to the understanding of
accommodate the grammatical resources of the prepositional phrase in extending the medical information.
RESULTS AND DISCUSSION
Utilizing the collected expert texts as a writing model, a significant difference was discovered relating to the grammatical function of finite verbal groups and prepositional phrases. Importantly, it was discovered that appropriate constituents in finite verbal groups contributed to making the diagnostic meaning more professional and objective (e.g., CT scanning of the abdomen was performed vs. abdominal CT was done). As well it was realized that the prepositional phrases not only serve as a circumstantial element in a transitivity clause to fulfill the medical description, but also a circumstantial adjunct between clauses to create text cohesion.
The following subsections give the analytical interpretation regarding the conceptual and linguistic gaps of the EFL medical students based on the two grammatical resources of finite verbal groups and prepositional phrases. The first two subsections examine the EFL language difficulties using two categories: (a) finite verbal groups frequently chose by learners but rarely or never by experts, and (b) finite verbal groups frequently chosen by experts. In addition, the language context along with the circumstantial description of prepositional phrases between the two sets of expert- and learner-texts was also examined.
Comparative Protocol to the Understanding of EFL Language Gaps in Verbal Groups
If a verbal group includes a finite, the finite will be the first constituent of the group and marked for tense and number agreement. Hence, Thompson (1996) claimed that “finiteness is a property of the group rather than just of the verb (p. 15).” The grammatical functions of the finite verbal group (e.g., Blood was drawn for laboratory
testing.) semantically depict the proposition of medical events along
with the temporal movement. Thus, EFL writers might need to have a better understanding of English grammar in order to implement the choice of an appropriate verb and matched tense structure. To investigate the language gaps in the lexical-grammatical constituent, the researchers intensively looked into the language context surrounding a targeted verb. The micro-level investigation thus contributed to the identification of the conceptual and linguistic gaps of EFL medical students while constructing their intended international and experiential meaning into diagnostic texts. Tables 2 and 3 provide samples of the problematic verbs with their related frequencies.
Tab le 2
Finite Verbal Groups Frequently Chosen by Learners but Rarely by Experts
Verbs Learner Frequency Expert Frequency
denied 4.7 per 10,000 words 0.08 per 10,000 words
(was)suspected 4.7 per 10,000 words 0.16315 per 10,000 words
has 3.6 per 10,000 words 0
suffered 2.23 per 10,000 words 0
Note. The verbs being compared are the finite plus the event (was suspected) or fused into the event (denied, has, suffered). The verb density is calculated to compare the particular finite (plus or fused with a lexical verb) occurrence in terms of the usage of times per 10,000. For example, the frequency of denied is 4.7 per 10,000 words (0.00047 × 10,000).
Tab le 3
Finite Verbal Groups Frequently Chosen by Experts
Verbs Expert Frequency Learner Frequency
developed 1.5 per 10,000 0.8 per 10,000
did 1.38 per 10,000 0.8 per 10,000
administered 0.99 per 10,000 words 1.1 per 10,000
To make the above numerical reference more explicit and meaningful, a descriptive interpretation of the linguistic gap was needed. The interpretation of language gaps was framed around the three inferences of semantics, grammatical pattern, and cultural perspective, which overall would address the insights derived from sociolinguistics (Lantolf, 1994, 2000). The semantic inference drew
its definition from the dictionary. The grammatical patterns refer to the underlying rules, particularly syntax, morphology, and sentence structure, that need to be followed for textual meaning to be appropriately made. The gap interpretation drawn from the cultural perspective was considered limited as the interpreters in this study (NNS researchers) may not fully comprehend the cultural assumptions of the experts (the international published authors). However, the researchers recognized that the cultural aspect needs to be highlighted, as a lack of cultural awareness might cause linguistic and cognitive confusion for EFL learners in choosing appropriate words, and thus lead to the occurrence of language gaps.
Finite verbal groups frequently chosen by learners but rarely or never by experts. In total, eleven finite verbal groups were discovered in the first problematic group (denied, suspected, has,
suffered, was done, sent, complained, is, may, got, and will). For the
scope of this paper, only four items were used in the discussion due to their significant pedagogical implications related to EFL language gaps, as enlightened by the three inferences of meaning, grammatical structure, and cultural aspect. The presentation and interpretation of the language gaps are elaborated for the first problematic finite verbal group in sequence (denied, was suspected, has, suffered) along using the following layout: (a) the descriptions of staged information (the course of symptom development, the medical examination, and patient background); (b) excerpts to compare the language contexts surrounding a targeted verb, and (c) the interpretation inferred from the dictionary, grammar, and/or cultural perspective.
Verb 1 – Denied (used17 times by the learners while only once by the experts)
1) To describe the course of symptom development 2) Excerpts for language context comparisons:
Expert excerpt
• A 19-year-old man was
admitted to this hospital because of acute abdominal pain …. Weight gain had ceased after the age of 11 years …. On a 5000-calorie diet he gained 2.6 kg. The patient and his family expressed concern that the amount of food prescribed was excessive, and they appeared not to understand the severity of his illness …. Psychiatric evaluations documented that the patient had poor insight into the severity of his medical condition. He continued to limit his caloric intake and was observed performing sit-ups in bed but denied that he was exercising …
Learner excerpts
• This 32 years female was quite
well before. She felt general malaise and lower back soreness yesterday. … She
denied she has any illness
before yesterday …
• The patient denied dyspnea,
vomiting, diarrhea, constipation, hematuria, or any discomfort during urination …
• He had bilateral flank pain. He
had burning sensation when voiding and hematuria was also noted. He denied decrease urine output, urgency, urinary frequency, and dysuria …
3) Interpretation
According to the dictionary, denied means to say something is not true. Therefore, it seems to be legitimate for the EFL medical students to use the word to describe the patients’ rejection of specific conditions or information. However, from a cultural perspective, colloquially deny could also signify a doubtful reaction of the listener(s) toward the speaker, which might not be clear from the dictionary. The hidden meaning embedded in a particular word is beyond the understanding of EFL students who come from a cultural background other than an English-speaking one. With such a realization, the international writers show a more cautious attitude when referring to the patient’s behavior of denial. Given that, the expert language context lays out the psychological issue as the justification for the false acknowledgement by the patient. In comparison, none of the student texts provide a context for the rationale of the denial behavior, but simply use the verb to state a denial related to specific symptoms.
Verb 2 – Suspected (used 17 times by the learners and only 2 times by the experts)
1) To describe the course and results of examination and treatment 2) Excerpts for language context comparisons:
Expert excerpts
• Treatment with antibiotics was
given on several occasions and with famciclovir on one occasion for suspected
bacterial or viral infections....
Learner excerpts
• He went to local clinic for help,
myofacial pain was suspected, so that he received 2 muscle injections on buttock and one iv injection in the subsequent 3 days.
• Antipsychotic medications,
including haloperidol …, were
administered, without improvement. Fever
developed … she was transferred to another hospital because of suspected
neuroleptic malignant syndrome.
• She was sent to our ED and
decreased BP (97/55) was noted. Vasovagal reflex was
suspected. Holter monitor and
cardiac echo revealed no specific findings.
3) Interpretation
Semantically, suspect is used to say that something is probably true. From the FG perspective, the mental process of suspected can be used to show the sensor’s attitude of modality, in terms of the degree of possibility the sensor holds. In comparison, the experts constructed the grammatical pattern of the nominal group “suspected + noun” to avoid presenting one’s modal attitude. The medical students chose the finite element was plus the lexical verb suspected to suggest the physician’s attitude toward the likelihood of diagnostic propositions. Specifically, the grammatical patterns of “was/were + suspected” might inevitably bring out the “suspect-or” of a medical physician. Therefore, it is considered that the experts conveyed their diagnostic perceptions in the manner of an objective perception while a more subjective manner of description was chosen by the NNS authors.
Verb 3 – Has (used 13 times by the learners while never used by the experts)
1) To describe the aspects of the symptom development, examination procedure, and the patient’s background
2) Learner excerpts
• The 27-year-old female has a history of systemic lupus
erythematosus. She was diagnosed to have SLE in 2001/1. She then had regular OPD followed up in our hospital …
:
• The patient had intermittent headache for a long time, and it
would subside spontaneously. She is doing well with ADLs, but she has mild dyspnea while walking for a long time or climbing up stairs. This time she had severe headache …
3) Interpretation
The fused form of finite element and lexical verb had was equally chosen by both EFL students and experts to describe the past possessive relations (with the patient as the possessor/carrier of the
possessed/carried symptom/illness), while the present possessive
process has was found only in the students’ possessive clauses. First, it is apparent that the NNS students found the propositions (here- and -now reality, there- and -then occurrence of the description) ambiguous, and thus tense errors occurred unavoidably. Second, it is worth noting that all the diagnostic descriptions constructed by the case report writers used the past tense, as the diagnosis had already been completed. Therefore, it is crucial that EFL students be aware of this HPI (History of Present Illness) writing convention, which is a logical review system utilizing the past tense agreement—“It is legitimate to refer to available portions of the old … previous accounts of what was then the present illness but is now past history” (Orient, 2005, p. 80).
Verb 4 – Suffered (used 8 times used by the learners while never used by the experts)
1) To describe the course of symptom development 2) Learner excerpts
• This 15 years old male was a case of juvenile dermatomyositis
and generalized calcinosis …. He suffered from tarry stool for one week and fever with chills for three days.
:
• He denied dizziness or vertigo at that time, and he denied any
neurologic signs.
• But his family claims that he suffered from easily fall asleep
and lower limb weakness since 10/26.
• In this morning, he suffered from general soreness and found
fever during waking up. And there was no chillness, malaise, sweating, or headache.
3) Interpretation
The verb suffer is defined in the dictionary as follows: to be badly affected by a disease, pain, sadness, a lack of something; to experience something unpleasant, such as injury, defeat or loss. It thus seems to be semantically sound for the EFL students to illustrate how the patient’s physical uneasiness affected his/her mind to choose the term suffered, although the mental process did not appear in the expert texts.
From a cultural perspective, Hofstede (1986) asserted that Westerners value individualism (featuring objective and impersonal attitudes), while East Asians appreciate the collectivism of maintaining close relationships and reducing human distance. Different from the collectivist EFL students, the diagnostic writing
convention adopted by the international journal writers modeled different verbs to avoid projecting a psychological state that might be personal into their assumptions. Hence, verb alternatives chosen by the experts with a similar language context to suffered were identified in their texts, with examples as follows:
• He had been well until approximately 4 weeks before
admission, when he began to have decreased energy and a change in mood. He told his family that he felt as if he was “living in a fog.”
• The patient felt increasingly unwell, with malaise, nausea,
anorexia, and increased abdominal pain.
• One week later, at a follow-up visit with her psychiatrist, the
patient was alert and appropriate, and her mood appeared to be normal.
Accordingly, it was found that the experts predominantly used the behavior process of appeared in describing the observed patient behavior physically, and projected the emotional condition with additional information. Again, the experts thus demonstrated a more objective and impersonal manner when describing their observations of the patients’ attitudes and emotional states.
Finite verbal groups frequently chosen by experts. Eight finite verbal groups (developed, did, administered, performed, had
been, was shown, reported, appeared) were found to fit in the second
category, with details given below in relation to the three most prominent finite elements (developed, did, administered).
Verb 1 – Developed (used 19 times by the experts and 3 times by the learners)
1) To describe the course of symptom development 2) Excerpts for language context comparisons:
Expert excerpts
• Over the course of the next 4
days, a nonproductive cough, shortness of breath with exertion, orthopnea, and swelling and tenderness of the right breast developed.
Learner excerpts
• During the 3 years before this
evaluation, he gained 13.6 kg in weight, and stretch marks
developed on his abdomen. • On endocrinologic evaluation,
the patient reported that pubic hair, adult body odor, and acne had developed at the age of 13 years.
• About 2 months ago, bilateral
lower legs swelling developed. There was no skin wound. Pain and tenderness occurred about 1 month ago.
• He developed chills and spiking
fever since 97/10/15, turbid urine and hematuria was noticed …
• Headache developed at the
same time.
Due to progressed lower legs pain and swelling, she visited …
3) Interpretation
First, all the expert clauses were constructed with the grammatical pattern of “symptoms + developed,” instead of “patient + developed + symptom,” as in the students’ texts. Second, the students might not be aware of the well recognized utility of the material verb, develop, in describing the transitivity of an occurring and ongoing disease or illness. Instead, verbs like complained,
suffered, and suspected were chosen by the EFL students for the same
language function of introducing the illness and complications.
Verb 2 – Did (used 17 times by the experts and 3 times by the learners)
1) To describe all the medical aspects: the course of symptom development, the examination and treatment procedure, and the patient’s background.
2) Excerpts for language context comparisons: Expert excerpts
• In the early hours of the
morning of admission, the patient’s mother noted that the patient was awake and using a nebulizer, as she did frequently.
Learner excerpts
• The patient did not have
rashes, fevers, myalgias, numbness, weakness.
• He did not smoke, drank a
moderate amount of alcohol, and did not have occupational exposure to chemicals.
• He did farm work and fishing
barefoot. He had left foot swelling, heat, and pain for two days.
• She denied any trauma of
chest or abdomen recently. She did not have heart surgery or heart attack before. She had cough with whitish sputum, but she did not have fever. She
3) Interpretation
It is worthy of note that there were three different applications in form and semantic functions found along with the “did” clauses. First, the finite verbal group “did + not + have” was frequently structured by the experts to indicate the negative (the finite past did
not) possession (the relational process have) to rule out non-existing
complications. Second, there was one occasion when an expert applied “did” as a cohesive device (the patient was awake and using a
nebulizer, as she did frequently). Third, the finite “did” fused with the
material process was constructed by one medical student (He did farm
work and fishing barefoot …). This language gap deserves attention as
such a clause might be more appropriate in conversation rather than in professional writing.
Grammatically, the basic function of the finite is to orient the readers toward the intended message in a context (both temporal and conceptual situation). The finite verb did indicates that the not have is valid for the past. However, for the same descriptive purpose, the EFL students tended to choose denied, and relatively few used the same grammatical patterns as the experts did for the same semantic purpose. In this regard, the experienced clinical lecturer Orient’s (2005) advice might be useful to the Taiwanese medical students, “Of course the term denial also implies that the doctor knows what is true and what is not …. The implication is that the patient was lying (p. 79).”
Verb 3 – Administered (used 12 times by the experts and 4 times by the learners)
1) To describe the course of symptom development and the examination and treatment procedure.
2) Excerpts for language context comparisons: Expert excerpts
• Fluids and Fluids and
antibiotics were administered intravenously, and the creatinine level decreased to 1.9 mg per deciliter (168.0 £gmol per liter).
Learner excerpts
• Two liters of normal saline
were administered in the emergency room, and the patient was admitted to the pediatric intensive care unit.
• Hydrocortisone was administered for persistent
hypotension, and Levophed was tapered gradually due to more stable BP.
• Due to obvious dyspnea on
exertion and … we administered inhaled and oral
bronchodilator combined with short-term steroid to get quick symptom relief.
3) Interpretation
First, the grammatical pattern of “medication/treatment + were/was administered” was found in expert texts, and most of the students followed the same pattern. The only problematic clause “we + administered” was shown in one learner text. Notably, none of the experts used the first-person “we” in their medical descriptions, while “we” occurred eight times in EFL student texts. Second, the dictionary explains that if a doctor or a nurse administers a drug, they give it to a patient, and here it is noted that the material process of
given was used 12 times within a similar language context in the
Aggressive IVF supplement was given due to hypovolemic shock.
Although given was adopted by the experts as well, they referred to the previously administered treatment or medication from other physicians or medical facilities.
… acetaminophen (1000 mg) was given through the rectum. After the seizure, the patient became increasingly somnolent and did not respond to painful stimuli. The trachea was intubated for airway protection. Approximately 5 hours after arrival, she was transferred by ambulance to this hospital.
Comparisons of the Language Contexts Made for the Circumstantial Descriptions
It was found that the EFL medical students had less difficulty in constructing prepositional phrases in a clause to draw out the related diagnostic circumstances, as the example below demonstrates:
• He was discharged on the
eighth day
Expert prepositional phrases
• … in the right upper quadrant
• She was discharged on
2005/01/31
Learner prepositional phrases
• … in the right upper lobe Importantly, the prepositional phrase that functions as a textual linker within the clauses was found to be frequently utilized among the experts, while its use was less apparent among the students.
The propositional phrases constructed by the EFL medical students mostly served to provide additional information, as seen in the circumstance element in the transitivity clause above, such as the date (on 96-8-9) and setting (on EKG monitor, on chest CT). However,
it was noticed that very few EFL students adopted the language strategy of utilizing the propositional phrases as textual linkers to connect with the previous clause, as the experts did (e.g., On the third
hospital day, On the day of the scheduled bronchoscope, In the following month). Instead, the medical students tended to use
conjunctions for the grammatical descriptions of cause and effect (because, thus, so, therefore), concession (although, nevertheless,
however), and time sequence (then, accordingly), and to signal
transitions and show the relations among the clauses. Examples of these various usages are found below.
The 52-year-old male with history of …. He went to local clinic for help … myofacial pain was suspected, so that he received 2 muscle injections on buttock …. However, the pain progressed on 10/15 night, he received another injection at that night but the pain did not improve. Therefore he visited our ER for help.
In contrast, it was found that the experts rarely used the conjunctions as grammatical descriptions to signify the semantic relations, and were less concerned with the transitional effect among the clauses. Rather, the majority of experts constructed their prepositional phrases as circumstantial adjuncts to make their diagnostic texts cohesive by means of the layout of chronological information, as shown in the next example.
Six months before the current evaluation, he began to have
abdominal discomfort after eating …. Four months before the
months before the current evaluation, the patient saw his
primary care physician for routine follow-up …. Five days later, upper gastrointestinal endoscopy was performed …
This chronological system adopted by the case report writers is recommended by Orient (2005), because such a system allows for the readers to consistently relate events in the course of the complication to the time of admission. By means of utilizing the prepositional phrases as circumstantial adjuncts, the experts chronologically and systematically described the symptom occurrence and medication procedure. It would seem that the NNS medical students were less acquainted with the language strategy of utilizing the circumstantial elements as adjuncts to make a connection between diagnostic clauses. Instead, the transitional devices (however, so, therefore, but,
accordingly) were often found in the medical students’ experiential
descriptions to indicate how the clauses related to each other and how the transitional process evolved in a text.
It is believed that the Asian inductive thinking process of explaining before making an assertion and the Chinese writing convention of emphasizing the text structure of qi-cheng-zhuan-he,5
5Qi stands for the introduction and provides relevant information as a background for the later disclosure of the main idea. Cheng and zhuan refer to the supporting explanation and reasoning evidence together, leading to the turning point of he for the assertion of a conclusion.
(Chien, 2007; Zhu, 1997) might have reinforced the NNS students’ EMP tendency to choose the familiar conjunctive adjuncts and conjunctions they had learned in English classes during their secondary school education. Swartz (2006) noted that “Chronology is
the most practical framework for organizing the history … to comprehend the sequential development of the underlying pathologic process” (p. 18). Thus the chronological system implemented by international medical writers should be demonstrated to NNS medical students.
Indeed, the research scheme of the FG analytical approach applied to the text comparison for this writing project is used to support Taiwanese medical students’ grammatical awareness in a more functional and economized manner. Based on the two research questions, the observation drawn from the lexical and grammatical comparative outcome is summarized below.
First, the lexical-grammar constituents of final verbal groups and prepositional phrases vary in the learners’ and experts’ medical descriptions. It is noticeable that the experts’ diagnostic descriptions were more versatile, professional, and cohesive, which is understandable since they have more capacity in the language context of the applied medical English. Second, the discovery of different finite verb choices and less frequent acquaintance with the cohesive devices of prepositional phrases observed in the students’ texts reveals the inadequate support they had received in the teaching and practice of medical writing. It was noted that while the finite elements the EFL medical students structured are semantically correct in the local context, they might be confusing for a reading audience from a different medical community such as an international publication of case reports. This highlights the fact that with the very limited opportunity of exposure to such register in a medical English literacy context, the students can only refer to a dictionary for verb definitions or seek out advice from other NNS medical students. The restriction
leads to a pedagogic concern of whether we are preparing our medical students to present themselves professionally as equal partners or authors in an international setting.
CONCLUSIONS
This research was initiated to understand NNS writing problems with the ultimate goal of improving the related corresponding writing pedagogy and design of ESP material. Although this paper is within the context of medical English, the analytical scheme of text comparison could be adopted to most settings of English language teaching if a genuine EFL writing curriculum is desired. Significantly, the interpretations demonstrate the critical role of contextual awareness in facilitating EFL professional writing.
The analytical design was structured to compare the two sets of experts’ and learners’ texts of diagnostic descriptions. Drawing on systemic functional grammar, the transitivity system that conveys the experiential meaning of the diagnostic description was adopted. With the three transitivity elements (participants, process, and
circumstance) in mind, the researchers examined and compared every
single clause in the two sets of collected texts, one circulated in an international journal and the other in a Taiwanese medical context. As a result, two groups of problematic verbal groups were found for the researchers to interpret the language needs of EFL medical students. These included finite verbal groups frequently chosen by learners but
rarely or never by experts, and finite verbal groups frequently chosen by experts. The two verbal categories were helpful for conducting micro-level investigation in order to (a) uncover differences in the lexical and grammatical usage between the learners and experts, (b) contribute to the understanding of NNS language needs, and (c) provide insights for medical English writing pedagogy.
Truthfully, it is not the intention of the researchers in this discourse analysis to differentiate good or bad writers by investigating their distinctive lexical and grammatical constituents. Instead, the researchers aim to raise awareness about the relationship of text in context by demonstrating different language choices made by international writers. As a result, the NNS medical students will be able to accommodate the expectations of readers in varying cultural contexts. Thompson’s (1996) reflection is well suited to the current researchers’ FG attempt for this study:
the functional aim of a functional approach to language analysis, is that we can in principle use even individual lexico-grammatical choices in context to understand something of the way in which language, and thus language users, construe the world—that we can see the world in a linguistic grain of sand (p. 160).
LIMITATIONS AND RECOMMENDATIONS
Two research limitations are related to the text collection and language gap interpretation applied in this work. The first limitation is
based on the simple fact that the two sets of expert- and learner-texts are inconsistent, as their sizes vary greatly in the amount of words utilized for the comparison (122,584 in the expert texts vs. 35,722 in the learner texts). This discrepancy makes perfect sense, as the NNS EFL students naturally have a more limited English vocabulary than the NS experts. Moreover, the shorter HPIs the doctor-in-training participants produced might be the result of less medical expertise. However, the two sets of writings must still be compared to demonstrate the experts’ chronologic system and language choices. This provides our students with a model and helps them to economize their text in a way that is content concise and meaning coherent.
To compensate for the quantitative discrepancy, the researchers concentrated on qualitative investigation, intensively examining the clausal systems to provide insight for the different language decisions made by the experts and learners. Second, ideally, it was the intention of the researchers to present the interpretation of the linguistic gap from three perspectives, based on semantics, grammar, and cultural assumptions. Unfortunately, with unavoidable restrictions on resource information, such as the lack of authentic medical records, and the NNS position of the EFL researchers, cultural references and analytical assumptions drawn from the English-speaking texts were considered insufficient.
It is strongly recommended that the integration of a functional grammar approach to genre-based corpora comparisons has potential for future researchers and ESP educators seeking to examine the linguistic features of registers and genres (Conrad, 1999, 2000; Flowerdew, 1998, 2003; Lee & Swales, 2006). This integrated
approach will lend itself toward the goal of making the related teaching material authentic and context specific. Such a micro-level of text-linguistic awareness will orient the EFL medical students toward becoming independent language analyzers which will be necessary in their future careers in the medical profession.
ACKNOWLEDGEMENTS
This work was supported by grants from the National Science Council and National Cheng Kung University in Taiwan. We would like to thank the anonymous reviewers for their incisive comments and Professor Jing-Jane Tsai and Ms. Hsuan Hung who made it possible for us to conduct this study.
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ABOUT THE AUTHORS
Professor Wenli Tsou is currently leading an ESP team at National Cheng Kung University in Taiwan. The goal of this team is to transform EGP courses (English for general purposes) to ESP-oriented courses (English for specific purposes). Her intention is to incorporate the most recent developments in language learning into the reform of English education at the tertiary level. Her recent research focuses include the following areas: ESP, English as Lingua Franca and academic learning.
Hue-lin Hung, a post doctoral researcher, has also worked with the ESP team at National Cheng Kung University. Her research interests are the micro and macro structures used in academic writing.
APPENDIX A
An Example of an HPI Extracted
from the Journal of Medical Case Reports
A 45-year-old man was transferred on an emergency basis to this hospital from a community health center because of abdominal pain and hypotension. On the day of admission, while lifting an air conditioner, he suddenly experienced severe abdominal pain, along with weakness and diaphoresis. He went to a community health center, arriving approximately 20 minutes later. He rated the pain as 10 on a scale of 0 to 10 (with 10 representing the most severe pain). He had not vomited. On examination, he was pale, profusely diaphoretic, and in extreme discomfort. His blood pressure was 84/49 mm Hg, and his pulse 100 beats per minute; respirations were 20 breaths per minute and shallow; oxygen saturation was 98% while he was breathing ambient air. His neck was supple, and his chest clear. His abdomen was rigid and diffusely tender, with guarding in all quadrants; the point of greatest tenderness was in the periumbilical area. Blood was drawn for laboratory testing, and a peripheral 20-gauge intravenous line was placed. Crystalloid intravenous solution was infused rapidly, and oxygen was administered at a rate of 2 liters per minute by nasal cannula. Emergency medical services were called to transport the patient to this hospital 15 minutes after his arrival at the health center.
