Medical English and its vocabulary
Medical English is a specialist language with a research literature of its own, on its written and its spoken discourse and on its vocabulary. Its vocabulary comes in degrees of technicality that differ in how far they are worth teaching, and knowing a word takes more than knowing its meaning. A competent writer is still caught by it: by spellings, by the publishing senses of familiar words, and by opposites that do not exist. Some medical words appeal to a writer for their sound alone.
Research on written medical discourse
English for Medical Purposes is a branch of applied linguistics. Its research on English-medium written medical discourse runs from early register analysis in the mid-1980s, which aimed to teach non-Anglophone medical students and health professionals to read English-language medical discourse, to more sophisticated genre and rhetorical studies later on.
The field's first journal grew out of a 1983 English for Specific Purposes conference for the Arab world. A subgroup there discovered by chance a shared involvement in English for the health sciences, and two British linguists then working at the University of Kuwait, Nigel Bruce and Liz Nakhoul, volunteered to start an information network that became the EMP Newsletter. Applied linguists and English language practitioners in the field welcomed it. It was published twice a year and distributed free to about 450 subscribers across 60 countries until Operation Desert Storm in 1990 ended their work in the region and the journal with it, so researchers had to find other outlets.
The research of the early 1980s, in the Newsletter and elsewhere, was mainly pedagogical, because the need for assessment was fundamental to curriculum design. It was descriptive and statistical, working on rather small corpora to analyse the grammar, sentence patterns and lexis of medical discourse, an approach called register analysis. Françoise Salager-Meyer, for example, analysed a 100,000-word corpus drawn from twelve medical specialties and determined from it the core lexis of medical articles written in English: the lexical items distributed homogeneously across the medical spectrum irrespective of specialty. Course-design studies then became very popular, with short or intensive courses and tailor-made in-house textbooks appearing around the world, especially in the Middle East and Latin America. But course-design papers based on the early register studies became scarcer, and the research became more empirical.
Later research turned to word lists and to genres. Chung and Nation found that technical and specialised words, narrow in range of occurrence and unknown in general use, accounted for as much as 37.6% of all word types in an anatomy text against 16.3% in an applied linguistics article. Ferguson argues that specialised vocabulary is better learnt while studying medicine, and that the difficulty of understanding it depends to a great extent on the learner's mother tongue and level of medical knowledge. By contrast, there is a general consensus that the semi-technical vocabulary is the greatest obstacle for intermediate non-native students, so reading courses should emphasise that part of the medical English lexis. That is why Chen and Ge and Wang and colleagues turned to it to create an academic medical word list. Wang and colleagues analysed over a million running words from research articles across a wide range of specialties and drew a list of 623 word families accounting for 12.24% of the tokens in their corpus. As of 2014, the latest known lexicographic study of medical discourse was Mungra and Canziani's academic word list for clinical case histories.
The most frequently analysed genres are research article abstracts, case reports, and research articles themselves, studied both diachronically and structurally. Book reviews, editorials, letters to the editor, narrative and systematic review articles, and the acknowledgement paratext have also received attention from applied linguists, but not to the same extent as the research article and the case report. Most of these genre studies combine the investigation of a genre's communicative function with the study of certain lexico-grammatical features, while some focus exclusively on one feature, such as hedges, conditionals across medical genres, or the expression of criticism examined from a cross-linguistic, cross-generic and diachronic perspective. Over the thirty years to 2014, research on written medical discourse moved from quantitative analyses of syntax and lexis to more socially oriented studies.
Research on spoken medical discourse
Research on spoken medical discourse divides into three partially overlapping categories: one with a pedagogical goal, focused on improving the English language skills of non-Anglophone medical students and health professionals so that they can participate in their academic cultures; one consisting of linguistic analysis of medical conference presentations; and one sociolinguistic, dealing with healthcare communication and in particular with how doctors and patients, and their families, interact in consultations.
Quite a few research-based courses in the pedagogical category teach doctor-patient communication skills. In Cuba, for example, the Ministry of Public Health rather than the Ministry of Education takes full responsibility for all medical education, including the English language training of undergraduates and postgraduates, and a major step in developing the teaching of English for Medical Purposes there was the 1989 link with the Institute for Applied Language Studies at the University of Edinburgh, with a similar project running in 2014 with the University of Westminster. Shi and colleagues video- and audio-taped ward teaching sessions to identify the communicative skills Hong Kong medical students needed as future hospital doctors, including using appropriate everyday and technical terms to translate information from doctor-patient discourse in Cantonese into doctor-doctor discourse in English. The course developed from it used the video sequences with teaching tasks, and the study illustrates how authentic data can be exploited to construct a tightly focused curriculum. Basturkmen describes a course for overseas-trained doctors seeking work in New Zealand, built from prior observations of medical consultations and their typical sequence and language, with role-play or simulation exercises used throughout.
Developing oral skills is also very important for medical professionals from developing countries who often seek to migrate to, or practise in, Anglophone countries. Other researchers have turned to more occluded genres such as nursing care plans: Hussin analysed the linguistic needs of immigrant nurses in training in English-dominant settings facing a shortage of domestic healthcare workers, such as Thailand, where there is an urgent need to train clinic and hospital staff to interact with English-speaking patients. Tokyo Medical University's English for Medical Purposes site offers an interactive course covering 18 modules of clinical therapeutics.
Medical conference presentations have drawn less research. Betty Lou Dubois is the most frequently cited researcher on them: her interest in the juxtaposition of the visual with the verbal led her to examine the use of slides in biomedical speeches, and she later studied the design and presentation of posters at biomedical meetings and the use of imprecise numerical expressions in biomedical slide talks. Webber examined the question-and-answer phase following medical presentations and analysed the interactive features of conference monologues, such as the use of personal pronouns, specific discourse markers and imprecise quantifiers. Carter-Thomas and Rowley-Jolivet analysed if-conditionals as a multifunctional resource in such presentations.
The sociolinguistic literature covers healthcare communication, especially between doctor and patient and, to a lesser extent, between doctor, nurse and patient, and the great majority of it points to the conflictive nature of these encounters. So the role, form and frequency of questions have been its most frequently analysed features, and the findings confirm the asymmetrical power relations of the consultation. West found that almost 90% of questions were asked by doctors; Ainsworth-Vaughn reported a lower figure of 62% and observed that question frequency seems to depend on the patient's gender, culture and ailment and on whether the consultation is a first or a follow-up. A description of consultations conducted in English between doctors and patients of various nationalities in hospitals in Abu Dhabi found a doctor-centred consultation style in which doctors tended to ask closed questions, seldom enquired about patients' social or psychological history, and seldom checked their patients' understanding. Patients want to express the subjective experience of their illness and how it affects their daily lives, while doctors work to direct the interview towards a diagnosis, which Mishler calls the struggle between the voice of the life world and the voice of medicine.
Patients' narratives have attracted considerable interest as a constitutive element of medical discourse and as a source of information for clinical problem solving. Berkenkotter's book is, as far as one reviewer of the field knows, the first and only one focused exclusively on psychiatric interviews; it examines the evolving role of case-history narratives in the growth of psychiatry as a medical profession and shows how discursive changes in the genre mirror evolving assumptions among those who cared for the mentally ill. Euphemism and metaphor in doctor-patient communication, especially around distressing and taboo subjects such as death and dying, have also been studied: Allan and Burridge analysed the motivation of euphemisms in medicine, and Tsai made a cross-cultural analysis of birth and death metaphors. Specialised journals such as Communication and Medicine and books carry this literature, and discourse-analysis research has examined doctor-patient end-of-life discussions and post-traumatic stress disorder, gender-relevant differences in the description of chest pain, doctor-patient communication in multilingual settings, and psychiatric interviews.
By 2014, over more than thirty years, the field had accumulated a significant body of knowledge on the linguistic, sociolinguistic and rhetorical features of both written and oral English-medium medical discourse.
Research on healthcare vocabulary
As of 2014, very little was known about the nature of healthcare vocabulary, although healthcare communication had become an increasingly important field of study. Medical schools once failed to take communication seriously, let alone include it in the curriculum, but associations, organisations, journals and specialist books on it now proliferate, universities frequently have departments dedicated to it, and in 2010 more than 50 graduate schools in the United States alone offered a postgraduate degree in it. A likely explanation for the gap is disciplinary: most of the academic interest came from sociolinguistics, anthropology and related fields, much of it concerned with cross-cultural and intercultural communicative competence, and vocabulary seems to be of little interest in most of those studies. Information written for patients is receiving long overdue attention from the regulatory authorities and the pharmaceutical industry, and that attention has produced a plethora of research articles on communication strategies in healthcare, yet very little is known about the influence of vocabulary there either.
Studies suggest that nurses and doctors use different communication styles and tend to use different proportions of vocabulary type. Nurses, often described as communication brokers, are able to switch between more technical vocabulary and the general vocabulary of their patients, while doctors seem to switch less successfully and are less aware of their communicative limitations; put another way, doctors can hold a distorted view of their own communication skills. Vocabulary is consistently cited as the primary barrier to successful communication for non-native-speaking healthcare professionals, an ever-growing number, and many of them struggle both to have enough of it and to know what to use and when. What they lack is frequently the vocabulary needed to interact socially, and not necessarily the technical vocabulary of the job. Nor are vocabulary problems confined to non-native speakers: studies on both sides of the Atlantic have shown that native-speaking patients often fail to fully understand common terms, unbeknown to the professionals treating them, with fracture and break, sprain and sprained, and tendon and ligament among the words that frequently cause problems. The problems were magnified in patients who had English as a second or other language, but it cannot be assumed that native speakers fully understand the gravity of their medical condition, even when apparently simple terms are used.
Little is known about the communication styles or vocabulary of healthcare professionals other than doctors and nurses, and for many years even nurses failed to feature, almost certainly a reflection of the traditional hierarchy in medicine. The vast majority of studies of medical and healthcare vocabulary have used research articles and academic and medical coursebooks as their source data; spoken data, it seems reasonable to assume, might reveal a different lexical picture, though the information from those studies is still highly useful.
Over thirty years before 2014, the applied linguist Paul Meara called vocabulary a neglected aspect of second-language acquisition research, and one writer on healthcare vocabulary holds that it had by then taken on a new role as the neglected aspect of healthcare communication studies. The dearth of research into the vocabulary of English for Specific Purposes and the paucity of specialist healthcare English teaching material seem all the more surprising given what is known about the effect of poor vocabulary on healthcare communication, its role in acquiring a second language, and how difficult vocabulary is for a student to learn. For course writers, course developers and teachers in healthcare language education, the lack of knowledge is compounded by, and results in, a lack of teaching materials. The teacher of English for Specific Purposes is very often required to write a course from scratch or adapt an existing one, and the vocabulary content of that course is vitally important. The commercial materials that exist are generally aimed at medicine or nursing, pre- or post-training, often show a disparate range of approaches and methodology, and none seems focused on English as a lingua franca, which seems a curious omission given how many non-native professionals use English to communicate with other non-native speakers. A Filipino nurse in a British hospital, a Swiss nurse using English with a Turkish patient in Geneva and an Austrian doctor speaking to a Japanese tourist do not always have the same vocabulary needs.
Degrees of technicality
Medical and healthcare vocabulary, like many other kinds of technical English, seems to come in different degrees of technical, and it is becoming increasingly apparent that two or even three categories of technical exist, which has significant implications for materials writers, teachers and students. The few studies that exist agree on the categories. General and non-subject-specific vocabulary is likely to come from the first 2,000 words of English. Lay or semi-technical vocabulary is related to the field of medicine and likely to be known by a non-professional, as with influenza, fracture, period and migraine, though the non-professional may not always fully understand the word. Fully technical vocabulary contains the items that would be impenetrable to a non-professional, and is what is usually meant by the phrase medical English. Some researchers add a fourth category: hidden technical items, which students initially believe they know, while the item in fact carries more than one technical meaning. Protocol, for example, means one thing in information technology, another in pharmacology and another in business English.
Simon Fraser's work suggests that the proportions of these categories are not consistent across disciplines and that pharmacology is particularly rich in hidden technical words. He found that anatomy textbooks had a greater proportion of fully technical words than pharmacology textbooks, which in turn had more lay technical and more hidden technical items.
Just because a word exists does not mean it must be taught. A healthcare professional whose mother tongue is a Romance language is already very familiar with a sizeable number of the fully technical terms they will meet in an English course, so time seems far better spent on the hidden technical and the semi- or lay technical terms, because these are the ones their patients are more likely to understand.
How many words a reader needs
Studies have consistently shown that vocabulary is the strongest predictor of success for language students. The more words a student knows, the easier it becomes to acquire more, particularly through reading, and the opposite is also true. Coverage, the percentage of words a student needs to know in order to read a text comfortably, is estimated at between 95% and 98%. In a 1,000-word text, that means knowing between 950 and 980 of the words in order to understand it without hours in a dictionary and to stand any chance of guessing new meanings from context, and too many unknown words can mean little or nothing is understood.
The first 2,000 words of English should provide more than 85% coverage of most texts, medical and other specialist texts included, so a student needs those 2,000 before tackling the more complex technical and semi-technical items. Specialist English was once assumed to be studied at tertiary level by students who already had a reasonable level of the language, but students can now begin it at secondary level with little more than basic competency, for reasons that include the growth of medical tourism and the influence of English on education systems. Where a student lacks that core vocabulary, it is essential that the teacher tackle the deficit immediately, before the technical vocabulary is introduced.
What knowing a word involves
Knowing a word goes beyond mapping form to meaning, which is just the tip of the iceberg, though all too many teachers and students forget this. It includes the word's multiple meanings, its collocations, its connotation, its morphology, its appearance in formulaic language and idiom, restrictions on its use of register, appropriacy and culture, and its pronunciation. Polysemy is a source of great difficulty for the language student, and similar-sounding and similar-looking words are not always equivalent in meaning or in connotation across languages. Compassionate, for example, does not carry a positive connotation for an Italian medical professional, for whom it suggests an inability to keep one's emotions in check, and the same is quite probably true in other Romance languages.
Corpus linguistics has made it increasingly easy to analyse vast amounts of text, websites included, at the click of a mouse. A keyword analysis, comparing the vocabulary of one text type against that of a different genre, can be of great help to teaching and materials development. Investigating word behaviour such as collocation and categorising words by their degree of technicality is the kind of applied linguistics research that helps in understanding the nature of specialist language.
Commonly misspelled medical words
Professional writers still need to check spelling, and the writer who never has to go to a dictionary is probably in trouble. Some writers double the m of hemorrhage and many drop its second h; some write quadriceps with an a in the middle, because pronunciation often deceives; inoculate takes only one n but is often given a second because it starts like innocent and innovate; and diphtheria frequently loses its first h because many people say it that way. Barbiturate, with its second r, is misspelled by many people, doctors and nurses included; ophthalmology takes an h after the p; and people at times forget the first s of abscess. Tendonitis is acceptable alongside the more widely accepted tendinitis.
Publishing senses of medical words
Those in the medical field who write or publish work in three vocabularies. The first, at least in the United States, is English. The second is medical terminology, a separate language to be conquered, as anyone who struggled with proximal, distal, retroperitoneal and rhabdomyosarcoma will concede. The third, where writing and editing training did not precede the medical training, is the vocabulary of publishing and communications, in which a bone is a flat piece of bone for folding paper, a bite is a publication's acceptance of a publicist's offering or a major quotation or excerpt from an interview, and a bromide is a trite remark. The three vocabularies sometimes get mixed up in the mind. In a crossword, the clue dope suggests a narcotic to the medical vocabulary and information or a substance added to printing ink to the publishing one; kill is murder to a medical-legal vocabulary and eliminate or cancel to a journalistic one.
Some words appear both in medicine and in communications jargon. An angle of vision is the angle from which an audience views a film or television screen; a backbone is the spine of a book, while a spine is the backbone of a hardcover book or, in typography, the main arcs of the letter S; a bleed is printed text that overruns the usual dimensions of a page; a cell is a small sample used in marketing research or a single image in a film; cold describes a presentation with little or no introduction or preparation, or a colour lacking warmth; a face is the appearance or general look of a publication or the surface of a piece of type; a Foley is not the catheter, invented by Frederic Foley, but a sound-effects term named after Jack Foley of Universal Studios, meaning to add or replace a sound; a head is the top of a page, a headline, or the beginning of anything printed; a lip is an edge or margin in printing; toenails are printer's slang for parentheses; and a treatment is the tone of an article or advertisement, a story outline, or the method by which a book is turned into a script. Cut, brace, ear and doctor also carry both senses.
Word pairs that are not opposites
English, medical English included, has a number of word pairs that define opposites or appear to. Many pairs are real: high and low pitch, high and low pressure, high and low frequency, overweight and underweight, large and small intestine, greater and lesser omentum. A number are not: there are no low jinks, no low schools, no low commands, no low priests, and noon can only be high. In medical vocabulary, preeclampsia, presystolic and precordium have no post- counterparts at all. Some look like pairs but are so different that the meaning of one cannot be worked out from the other: a highlight is a lighter spot or something significant while a lowlight is an unpleasant event; the high life is an existence on the expansive and expensive side while a lowlife is a person of ill repute; a highball is a cocktail and a lowball a deceptively low price; knuckling down is working hard and knuckling under is giving in, knuckle having two different origins in the two terms; shutting up is ceasing to write or talk and shutting down is closing an enterprise completely. Some pairs that look as if they should not exist do: there is a low five, a clapping of hands in a low position, and a lowboy to go with the highboy. So a writer should always be careful and make no assumptions about opposites.
Some opposites in English are not opposites: rain drops but snow falls, a boxing ring is square, quicksand works slowly, and sweetmeats are candies while sweetbreads are not sweet and are meat. Some opposites mean the same thing: a house burns down as it burns up, a form is filled in by filling it out, an alarm goes on by going off, slowing down is slowing up, and a slim chance and a fat chance are the same chance. Some words have opposite uses: people recite at a play but play at a recital, noses run and feet smell, people drive on parkways and park on driveways, and the stands at athletic events are made for sitting. Some words have no opposite at all: filthy lucre with no clean lucre, high jinks with no low jinks, short shrift with no long shrift, out of whack with nothing in whack, pre-cut with no post-cut. And some morphological questions have no answer: if the plural of tooth is teeth, why not beeth for booth; if teachers taught, why did preachers not praught.
English also has paradoxes: the man trusted to invest money is called a broker, and the slowest traffic time is called the rush hour. Some other languages have puns, but perhaps not the variety of confusion English has, and that may be why English is so difficult to learn as a second language.
The sound of a word
A medical word can appeal to a writer for its sound rather than for any clinical or intrinsic meaning: the sound that strikes the ear, the nuance of tone in pronunciation, the beauty of the sound, and sometimes the alliteration or the onomatopoeia.
To those who recognise it, borborygmus is one of the most onomatopoeic words in health jargon. Its roots are very similar in Middle English, Latin, French and Greek, and its meaning is universal: in Greek and French it simply means to rumble. A modern dictionary would probably define it as intestinal rumbling caused by moving gas, and once that meaning is known, the sound suggests it. To lay people it sounds like an impressive scientific word, and used with them it has value and impact, impressive to say the least for a little intestinal gas.
Flatus is defined variously as gas in the stomach or intestine or as gas emitted from the intestinal tract through the rectum, and its meaning today is mostly limited to the second. It is neither onomatopoeic nor beautiful-sounding, yet to one writer's ear something about it still attracts, even though it is not a commonly used word.
Singultus is a fancy term for hiccups. Hiccup and hiccough are exact synonyms that can always be used interchangeably, and they are so widely used that singultus is rarely used, usually only for ostentation and obfuscation and for spelling bees. It is supposed to be onomatopoeic, but to one writer's ears it does not sound like hiccups, though he still likes its sound.
The only anatomical connection of cockles is the single phrase about warming the cockles of the heart, which denotes a sensation of immense pleasure or affection. Many dictionaries do not list the word, those that do offer varying interpretations, and none suggests any other definition or place for it; there seems to be no indication of a single cockle. A word with no exact definition and one known use that is nonetheless universally recognised and understood occupies an unusual role in linguistics. Its widespread use in that one idiom is, in one writer's view, what explains its universal recognition and acceptance.