Communicating across disciplines and cultures
A writing team drawn from several disciplines or cultures can communicate badly even when its science is sound, because each field and each culture works, speaks and reads behaviour in its own way. The writer stands between the members, so communicating well across those lines means reading the team's behaviour for the message it sends, knowing what colleagues in different regions value, gathering comments from authors whose cultural norms differ from the conventions of publication practice, deciding how much weight a colleague's culture deserves, adapting one's own style, writing the email and the request so that neither can be misread, and knowing what the functions around the writer need.
Why a mixed team miscommunicates
Innovative clinical research depends on multidisciplinary teams to envision, design and implement complex research protocols. But varied backgrounds and approaches can also cause culture clashes within a team when members from one field have trouble communicating with members from other fields. Such clashes can cause more than frustration: they can be a serious detriment to team function.
Group dynamics, the environment and members' perceived involvement in decision-making can influence a multidisciplinary team's communication and productivity. Themes bearing on it include how the group socialisation process affects new members, how members respond in a supportive environment as against a defensive one, and the strategies that overcome barriers to communication. Effective team communication enhances team functioning and can strengthen members' attachment and commitment to the team, as well as facilitate collaboration on research manuscripts. So it is important to identify the potential barriers to communication and team functioning and to develop strategies for overcoming them and for maximising the benefits of a multidisciplinary team.
Culture can be defined as the ideas, beliefs and customs shared and accepted by people in a society, be it a country, a region, a social class, a company or a school. Like an iceberg, a culture may show behaviours and practices above the surface, such as its arts, dress, cooking, music and literature, while many of its attitudes and beliefs, such as those about leadership, problem solving, superior and subordinate relationships and group decision making, may lie hidden underneath. Medical communicators often lead multicultural writing teams, and miscommunications or unexpected delays can occur when collaborators from different cultures have different perspectives, make different assumptions or employ different working styles. Being aware of cultural influences on collaborators' actions and business practices, and being able to adapt one's own work style appropriately, can therefore be invaluable for making a project team's interactions more successful. Opportunities for cultural misunderstanding abound, and so do the potential negative consequences: for building relationships and trust among collaborators, for reaching agreement on the content of documents or on issues such as authorship, and for managing project teams and timelines.
Cultural competence is an individual and organisational process that affects how people interact with those of different cultures and socioeconomic backgrounds, and it is particularly important on global teams with culturally and linguistically diverse members. Succeeding in the global market therefore requires an understanding of how different cultures think about and approach a specific business situation.
Cross-functional and cross-regional collaborations bring together diverse skills and perspectives across several fields of expertise. They foster innovation, enhance problem-solving and help groups work towards a common goal, leading to better outcomes and competitive advantage.
In the view of the writers and colleagues from other functions interviewed at one contract research organisation, successful collaboration requires supportive leadership, clear communication channels, shared goals and cultural sensitivity. Those interviewed emphasised that clear communication, setting clear expectations, addressing challenges proactively and making use of digital tools are all needed for successful cross-functional and cross-regional collaboration, and that understanding the perspectives and roles of others and practising active listening also matter in multidisciplinary and global teams. Challenges such as time zone differences and diverse work styles may arise, but writers who foster a collaborative environment and maintain cooperative relationships are better placed to succeed on projects that need global teamwork. Embracing cross-functional and cross-regional collaboration is a necessity for long-term success in medical writing.
The writer's place in the team
When it comes to writing and disseminating results, medical writers may find themselves in the middle of a team's cultural clashes, which makes the writing process all the more difficult. On a multicultural writing team the medical communicator plays many roles: as well as writing, managing timelines, resolving collaborators' questions, coordinating reviews, facilitating discussion among team members and anticipating roadblocks to deadlines.
Medical writers play a role in research and development by facilitating the communication of new ideas, and they can serve as an interface between scientists, physicians, regulatory representatives, businesses and others. Writers also have opportunities not only to communicate new ideas but to take part in other aspects of research and development. Potential scenarios in which a writer might play a role in communicating issues to team members include documenting missing information that was crucial to the accuracy of the data, with a response plan for the discrepancies for the project manager, and working with the principal investigator to develop protocol amendments after a serious adverse event that incorrect product calibration may have caused.
In one contract research organisation's medical writing services, document quality reviewers and document specialists collaborate primarily within the medical writing group, while medical writers act as the bridge between the writing unit and the other functional leads. Cross-functional collaboration with leads such as biostatisticians, medical monitors and project leaders is crucial for timely project delivery.
A principal writer in the United States collaborates internally with the other writers on her team and externally with clinical, safety, regulatory, clinical pharmacology and statistical leads; a pharmacovigilance writer in India with safety experts, regulatory specialists, scientists, project leaders, other writers and quality reviewers. For a quality reviewer the main contact on every check is the lead writer, coordination between reviewers is essential on a collaborative check, and depending on the check and its scope the reviewer sometimes needs to interact with drug safety physicians, medical monitors and biostatisticians. A document specialist team works with writers on formatting and on the internal and external links that make a document navigable, with clinical operations, data management, biostatistics, pharmacokinetics, regulatory affairs and safety on appendices, with project leads on timelines and tracking, and with study sponsors and regulators on formatting and submission requirements respectively.
Communication styles and the messages they send
Between the United States and Japan, two cultures often considered opposites, a behaviour typical of one culture's communication style is meant to convey one message but may send someone from the other culture an unintended one, and each such behaviour can be met on a medical writing team. The US styles are analytical, assertive, direct, informal and spontaneous: speaking specifically, asking why and requesting data, using the pronoun "I" and apologising rarely, getting straight to the point and maintaining strong eye contact, casual behaviour and first names, and brainstorming and saying whatever comes to mind. The intended messages include providing all the necessary information, wanting as much information as possible to make the best decision, being an individual and not appearing weak or a pushover, wanting to get as much accomplished as possible, showing confidence, being friendly, allowing everyone to contribute on the same level and wanting many good ideas to choose from. The unintended ones include treating others as children, not trusting others, being self-centred, arrogant or pushy, not allowing others to provide input, being disrespectful, not being thoughtful or reflective, and being impolite.
The Japanese styles are intuitive, harmonious, indirect, formal and disciplined: implying messages and using few words, conveying feelings, apologising apparently without reason, building consensus and rarely disagreeing, speaking first or interrupting, speaking ambiguously and making little eye contact, formal behaviour and doing things in set ways, and preparing thoroughly and paying attention to details. The intended messages include being willing to listen, not treating others as children, showing the importance of relationships, being polite, maintaining harmony, respect for people and traditions, and being reflective and thoughtful. The unintended ones include being unwilling to explain topics in detail, wasting time, an unclear opinion, showing weakness, causing problems by asking questions or disagreeing only at the end of a conversation, not providing the necessary details, being evasive, being shy or passive, being uptight, taking too long to make decisions or take action, and being unwilling to listen to others' opinions or ideas because one's mind is already made up.
Each example is set in a writing project. An American writer explains a detailed manuscript outline to the writing team, and the Japanese physician feels the content is obvious and does not need explaining to him in detail. An American physician asks to see the data before making a revision the Japanese writer suggested. An American writer asserts her opinion strongly to Japanese physicians at a protocol kickoff meeting. An American physician sends the Japanese writer a terse email about work issues only, which seems rude to the writer. An American writer calls a Japanese physician by his first name instead of his surname plus "-sensei", as Japanese custom has it. A group of Americans brainstorm ideas for new analyses at a planning meeting while the Japanese members wait quietly for them to finish. A Japanese physician relies on body language to express what he wants to say, and the American writer does not understand his true meaning. A Japanese writer sends an American physician an email with many greetings and terms of respect, which the physician thinks a waste of his time to read. A Japanese writer says "I'm sorry" when interrupting at a publication meeting, meaning "excuse me", and the American physician reads the apology as a sign of weakness. A Japanese writer makes little eye contact with an American physician, who feels the writer is shy and cannot capably lead the project. A Japanese writer at a pharmaceutical company wants to meet a Japanese thought leader face to face about manuscript comments, and the company physician believes the meeting would be inappropriate because the writer is lower in the hierarchy than the thought leader. And before a project kickoff meeting a Japanese physician prepares a list of the analyses he wants, rather than brainstorming ideas with the writing team at the meeting.
A writer can enhance cultural awareness, knowledge and skills by considering several factors. In cultures that put directness before diplomacy, the truth in any situation must be made clear; in business this may be regarded as rude in diplomatic cultures, where it may be rare to speak the truth directly if it could be perceived to affect others negatively. Some cultures speak in literal terms to avoid evasiveness or inefficiency, while others may use coded language to protect others' feelings, and each approach may present a challenge for the other in business interactions. Some cultures view it as a necessity to be reserved in business, and showing emotion may be interpreted as engagement or interest, which may lead to unintended outcomes. And in some cultures many people find it difficult to speak positively about themselves, preferring to understate their abilities. Germany, the Netherlands, Sweden, the United States and Australia are classed among direct and literal cultures, and Japan, China, India, Korea, the United Kingdom and Belgium among diplomatic and coded ones.
What colleagues value in different regions
Writers in different regions perceive different skills as important where they are based, and for a writer new to working with teams in a region, noting these may help build trust rapidly and start protocol development sooner. Different regions have additional cultural values that enrich the collaborative task of protocol development.
Asian cultures tend to value collectivism over individualism, self-control over emotional display, and respect based on status rather than achievement, and formality and professionalism are a basis on which trust develops. One speaker's short list of tips for surviving and thriving as a medical writer in the Asian market includes the following.
- Learn how to say hello in the local language.
- Use simple English phrases without jargon and slang.
- Use titles such as Professor when addressing an Asian colleague.
- Do not assume silence means agreement.
- Avoid pointing out mistakes in a public forum.
- Avoid language that might suggest fault or imply a lack of knowledge.
- Involve the relevant people in all discussions.
- Make an effort to reach consensus among the parties.
In Asia-Pacific, in the experience of a writer working with clients in Japan, mainland China, Hong Kong, Taiwan, Malaysia and Singapore, work ethic is highly valued and punctuality expected, so a writer does best to join a meeting a few minutes early to show punctuality and reliability, especially a first meeting with a sponsor such as a protocol kickoff. Greater flexibility is expected over completing the work in the given timeframe: when adapting global protocols into country-level ones, clients there more often than not expect extra hours to meet the deadline rather than an extended timeline. Clear verbal and nonverbal communication and cultural awareness are important with peers there. Not everyone has the same exposure to or fluency in English, and accommodating this through patience, repeating information to ensure correct understanding, and written follow-up can help ensure a productive working relationship.
In Europe's diverse and multicultural work environment, thinking ahead and understanding team members' needs, especially given their regional and cultural backgrounds, helps drive effective communication, and in any global team strong communication skills are particularly important to bridge cultural and language barriers. In one writer's experience there, adaptability is the most significant soft skill, because the diverse backgrounds in multicultural teams make it an asset for navigating uncertainties, overcoming setbacks and responding to evolving project requirements. Being open to new ideas, embracing change from unexpected requests to timeline changes, recognising cultural sensitivities and adjusting working styles to team members' needs all contribute to improved collaboration and engagement. A European client's team members may come from all over the world, a diversity that became more common over the 25 years to 2024 and at the same time less noticeable in how people communicate, collaborate and solve problems. Country- and client-related differences remain in how people work and interact internally and with a contract research organisation's writers, including whether they see them as an integral part of the team or more as contractors. Adapting to the team's expectations from the start of a protocol can be challenging, but it is required for the protocol to succeed.
In the experience of a writer authoring protocols for clients and teams in India, teamwork and adaptability are two key soft skills there. Protocol timelines there are generally short, to speed up the start of a trial. Development is often expected to start from available and sometimes incomplete sources, keeping placeholders for open items and adjusting the content as information or strategy changes. A writer's ability to collaborate with the team to obtain input and facilitate decision making that steers towards protocol timelines is important. Flexibility is perceived as positive within the team, and problem-solving helps a writer keep composure under pressure. For writers from other regions working with clients in India, cultural awareness is important, and summarising meeting decisions and action items in an email is advisable to avoid misunderstandings.
In the account of a South African writer, South Africa has a rich history of multiculturalism but faces challenges from the many cultures, languages and backgrounds of its citizens, and South Africans as a whole need to be highly adaptable and flexible. There is rarely an answer of just "no", but rather one of how to make do with what there is at the moment and then decide. Such traits can be particularly beneficial in almost any area of business, but especially when timelines shift. As an extension of living in a multicultural country, South Africans are mostly sympathetic in how they interact with other cultures.
With US clients, who are typically native speakers of English, cultural or practical misunderstandings are relatively uncommon, in the experience of a writer working with them. Most protocol communication is by email, and US clients prefer an informal, friendly tone, such as an email opening with "Hi" rather than an impersonal "Hello" or a very formal "Dear". In online meetings, chatting briefly about personal topics with early attendees or with the whole team shows interest in them and fosters a sense of togetherness. In meetings or email alike, it is important to pivot without too much delay to the outstanding issues that need their help. A willingness to go the extra mile to complete drafts on time, including time-consuming last-minute requests, is expected. But US clients recognise obligations outside work, so especially when unexpected and abstract issues arise close to a deadline, it is acceptable to tell them that more time may be needed to resolve them.
Gathering comments from authors in the Asia-Pacific region
Ethical publication practices apply universally, but differing cultural contexts can alter how the guidelines are interpreted and applied. In particular, collaborating with colleagues and authors in the Asia-Pacific region can sometimes be confusing and frustrating when the expectations of everyone involved in a medical writing project have to be aligned. Engaging with colleagues in other regions to develop flexible, culturally appropriate processes can help strengthen working relationships, expedite project completion and adhere to publication best practices.
Guidelines for ethical publication practice, and the industry standard operating procedures built on them, are often applied as though regional differences did not materially affect their application. Accordingly, many conventions for applying publication ethics and authorship in English-language medical publications were developed in predominantly English-speaking high-income countries. Under these conventions, every author is generally expected to share documents showing proposed changes and detailed comments openly with the authorship group and other stakeholders. Debate is expected and encouraged to improve the quality of the publication, and individuals' opinions are considered on an equal basis. Communication has traditionally been by formal written correspondence such as email, but real-time verbal discussion between authors by video call is now common.
Some of these practices can be inconsistent with cultural expectations and norms in the region. So there is a risk that important clinical insights from authors and other stakeholders may be missed if they are unable to articulate their ideas fully or feel hesitant to comment, especially speakers of English as a second language. Likewise, forms of communication prevalent in the region, such as verbal feedback given one-on-one in in-person meetings or feedback through messaging apps such as WeChat, may not strictly align with the standardised procedures for commenting and keeping formal records applied in Western countries.
Most discussions of medical publications are conducted exclusively in English, which makes complex ideas hard to communicate for those who do not speak English as a first language. There is also a growing expectation to engage in situations that can be challenging for non-native English speakers from the region, such as video conferences, in which it can be difficult to follow comments from numerous people who are often speaking quickly and with different accents.
East Asian cultures, such as those of Japan, China and Korea, tend to favour consensus-seeking and collectivism over individualism. So although interruptions can be routine and tolerated in video conferences, many participants from the region will default to agreeing with or approving statements from others, out of fear of embarrassing themselves or their colleagues and to avoid potential conflict. Likewise, people from some parts of the region can tend to be careful to defer to more senior colleagues, especially in public. Unwritten cultural protocols about marks of respect and polite interaction can also make it difficult for native English speakers to interpret comments and remarks correctly. For anyone not very familiar with a person's culture, this can be a source of substantial confusion and frustration. Addressing cultural differences with colleagues and authors in the region can be particularly challenging because many of these engagements are conducted virtually.
When engaging people in the region professionally, the following are recommended:
- Consult someone with substantial local knowledge before starting a project. People with regional expertise are generally eager to help their peers navigate cultural sensitivities and may help avoid pitfalls, and the mere act of seeking guidance in advance is likely to be widely appreciated.
- Allow extended review times and less formal methods of communication that the local team and authors are familiar and comfortable with, such as WeChat in China, where these may be necessary.
- Use the support of someone who can speak an author's native language or meet them in person, which can improve the volume and quality of comments.
- Engage one-on-one, in person or by email, so that individuals can speak freely without fear of disrespecting colleagues.
- In a group setting, individualise requests for feedback before they are communicated in a consolidated, anonymised form.
Considering cultural and communication differences is important when working with authors outside North America and Europe. Ensuring full access to the insights of authors who speak English as a second language, such as those from the Asia-Pacific region, can improve the quality of medical writing when approached in a culturally appropriate manner, ultimately benefiting patients.
A colleague's culture, the person and the team
Cultural awareness came first in one communicator's 2022 answer to what medical communicators of the future need, because in global companies a writer suddenly has to interact with someone in China or someone in Japan, there are cultural differences, and there are certain ways to behave to get done what needs to be done. The head of one global medical writing team found in 2024 that the biggest difference in how the writer is perceived probably lies between teams that have worked with medical writers before and teams that have not, and rests less on cultural differences than on experience of what a writer brings. Teams that have worked with writers before view them as an asset. Medical writing has evolved, and so has its perception, in a process that spans the globe independent of culture or location. In that team's experience, cultural differences and geographical locations influence teamwork and consistent quality only in a limited way, and in its head's view much more brings people together than differentiates them.
Although culture may appear to predominate in cross-cultural collaboration, collaborators are individuals within their own culture, and not all of them will fit its stereotypes; relationship building gives a communicator a better sense of the individuals they are working with. Writers should be cautious not to let knowledge of a person's origin trigger stereotypical biases and prejudice. Valuing each other's efforts and contributions helps team building: one writer who had worked in academic fields in India and the United States was pleasantly surprised, on starting as a medical writer in France, to be thanked for what she considered simply part of her job. In a team that crosses regions and functions, never assume: break away from group think, and stop and reflect on someone else's approach, motivation and probable next steps. By appreciating cultural differences and methodically minimising cultural misunderstandings, communicators can lead multicultural writing teams more effectively toward the ultimate goal, the disclosure of important scientific information to regulators, physicians or patients.
Adapting one's style and being understood
Medical communicators should continually hold themselves accountable and act professionally with collaborators, a behaviour all cultures value. An effort to respect and understand other cultures can help forge stronger, more trusting relationships and successful partnerships among cross-cultural team members, and stronger relationships can in turn make writing teams more cohesive and help members forgive the cultural faux pas that do occur.
Communicators should also change their own outlook on other cultures through reading, training or talking to trustworthy people from that culture, and then adapt their work styles, as far as possible, in ways that show respect for the other culture. One way is mirroring a colleague's communication behaviours, copying their gestures, body language, choice of words or writing style. An American communicator working with Japanese collaborators can continue to manage a project assertively but speak less directly and more formally than with American collaborators; a Japanese communicator working with American collaborators can continue to communicate formally while becoming more comfortable with speaking directly.
Communicators can promote clarity, understanding, trust and respect in written and spoken communication in a variety of ways, among them listening actively. Ensure conversations are not one-sided, avoid interrupting, and ask questions only after the speaker has finished. Speak slowly, pause frequently and keep sentences short, and avoid slang, idioms, acronyms and abbreviations; be mindful of language barriers and use clear, simple language so that everyone is on the same page. Do not rush to judge others' meanings or intentions, and check understanding after any meeting or team communication by asking collaborators to review and comment on the minutes. Ask as many follow-up questions as it takes to get clarity on instructions or information, an approach that prevents a lot of confusion during authoring, and clarify uncertainties up front.
In the view of the writers and functional leads interviewed at one contract research organisation, listening actively, clarifying uncertainties and learning from one another are of the utmost importance to managing a writing project successfully. Within the writing group, keep an open mind and learn from each other as much as possible, for a fresh perspective on writing and project-handling styles. To build learning across regions and functions, organise cross-functional training sessions or workshops and create a mentorship programme.
Emails and requests for input
Pertinent emails should be clear, concise and polite. Emails should be as short as possible and clearly point out the most important aspects without room for misinterpretation. A request should be acknowledged immediately, with a time for the full reply where one cannot be given at once; messages should be kept concise; points should be labelled or enumerated; and the main points and action steps should be summarised at the end.
Whatever a team member's role, transparent communication and addressing project risks up front are the keys to success. Know your remit, set clear expectations through transparent communication, anticipate risks and prepare mitigation plans, and identify and address potential challenges before they become significant issues. In one writer's view, setting clear expectations, monitoring and patience are key to a successful collaboration, and when input is needed from stakeholders, the background, the parameters on which feedback is wanted, the deadline and the format or collaborating platform need to be communicated clearly. Use the available digital collaboration tools to make working on a document together easier, and set up clear communication channels, such as Microsoft Teams, so that everyone is kept informed throughout. Across regions, respect time zone differences and set a reasonable timeline, and to speed things up, call a colleague directly instead of emailing.
What the functions around the writer ask for
Biostatisticians, medical monitors and project leaders generally cooperate with medical writers in developing or reviewing the study synopsis, the protocol, consent forms, the study report and other clinical and regulatory deliverables. A medical director in Czechia collaborates with writers most often on protocols, consent forms, reports, report addendums and development safety update reports; an associate director of project management in South Africa on master or global consent forms and on compiling report appendices at the end of a study; and a project leader in Hong Kong when a consent form needs drafting.
Project management and project leads advise engaging writers as soon as possible on project scope and expected timelines, giving them as much detail about the project and protocol as possible, and following up the writer's requests promptly or opening a direct line between the writer and other stakeholders to resolve complex questions about the protocol, the indication or the therapeutic area. A global head of neurology in Hungary wants writers to go through therapeutic-area training, and warns that email and tracked changes may not always resolve an outstanding issue, so it is important to stay flexible and have the option of online discussions outside regular team meetings. Therapeutic-area training is commonly conducted at contract research organisations for product- and client-specific projects. For the Czech medical director the project kickoff meeting is the most important point of cross-functional collaboration, where writers should clarify the purpose of the deliverable, such as the study drug, the phase and the population, and the expected timelines.
A biostatistics associate director in Germany warns that the pressure at the end of a study often leaves no room to adjust timelines without affecting final delivery, and that any neglected or uncommunicated detail comes back later with a much bigger overhead. So team members must stay in close touch, and efficient communication without gaps is paramount in cross-regional teams. The Czech medical director asks writers to make sure team members have the correct link to work on the latest draft and that comments clearly mark the text they refer to. Writers should also be mindful of time zones and cultural sensitivities in cross-regional collaboration.