Abstract
Although various studies in genres of writing have not been considering Medical Case Reports, as a genre, there are emerging evidences that more and more healthcare organizations are adopting them as their preferred medical texts. Their abilities to present unique and rare conditions that concern an individual patient, in his/ her context, but at low costs, have seen them being considered as the most scientific texts of studies. Therefore, this study has carried out oral interviews to medical students and medical professionals, and analyzed various written medical case reports from two medical journals to reveal their features as a genre in writing. It had been hoped that upon its completion it would be utmost useful to medical students and professionals who are supposed to contextualize their services within a particular community. The study found that unlike conventional medical research articles, they are in narrative forms and employ short lengths and local words, with some unique moves and structural features. These features enable them to provide rare and authentic medical situations that lead to fresh researches, innovations and discoveries. Although the study is limited with interviewing few people in one organization and selecting few articles from few journal articles, it contributes to the current medical literature by emphasizing on the community contextualization of medical situations by medical professionals in healthcare.
Introduction
Medical Case Reports (MCRs) are medical recounts that medical professionals and medical students take regarding pathological conditions of a single patient (Helan, 2012). Authors of medical case reports, who are physicians, medical students and other medical professionals, encounter very strange cases, which may be at most time, newest cases of patient pathology in diagnosis, treatment and adverse reaction. Therefore, the reports are purported to present unique or rear conditions that influence researchers to begin new studies. In this way, they enrich the medical bank knowledge. Medical journals have reported that medical case reports, as a genre, have been in use since 19century (Helan, 2012). Despite their long period of usage, medical professionals have regarded them as inferior to the more conventional academic research articles (Mendez-Cendon, 2009). However, by the fact that they represent more and accurate information regarding individual patient’s conditions as compared to randomized research articles, they possess just equal importance. Some organizations report that for those novices in medical fields who do not have strong financial backings, medical case reports will go well with low-cost budgets compared to costly and time-consuming research papers. Currently, the policy of evidence-based medicine is becoming accepted in every health organization. Evidently, MCRs are gaining increasing acceptability on this ground, as many medical authorities are taking them as the most scientific when it comes to rational decision making in particular hospital environments. Despite the role, the MCRs play in the medical field, very few researches had been done on their functional features that make them become classified as a distinct genre (Kunt-Akbas, 2013). This research will seek to interview students and professionals in the medical field, and analyze various written medical case reports revealing their features as a genre in writing.
Whom Does This Study Address
This study, upon completion, it will be utmost useful to medical students and professionals who are supposed to contextualize their services within a particular community. Unlike academic research papers, MCRs as a genre is less known to students studying English as a foreign language or those who study Medicine and other health sciences in English as a foreign language. Therefore it should be expected that such students and professionals will exploit the findings of this study to develop their rhetoric technique in medical case reports. Nonetheless, findings of this study will enable various stakeholders like researchers to generate hypothesis, hospitals to enhance peer reviews for quality healthcare and educational institutions to support case-based learning.
Literature Review
Origin of MCRs as a Genre
Historically the genre dates back in ancient Egypt where physicians wrote individual patients' medical accounts on papyrus papers (Kunt-Akbas, 2013). In 5th century BC, Hippocrates also wrote medical case reports about diseases that were not well known at that time like melanoma (Helan, 2012; Hung, Chen, & Tsai, 2014). In 19 century, elements of case reporting can be attributed to Sigmund Freud, Fredrick Treves, Paul Broca, Joseph Jules Dejerine, and William MacIntyre among others (Helan, 2012; Hung, Chen, & Tsai, 2014; Kunt-Akbas, 2013). According to the analyses in the British Medical Journal, twelve case reports obtained revealed that the genre became prevalent as early as in the second half of the 19th century (Berkenkotter, 2009; Helan, 2012). For instance, well-known MCRs include those of Hodgkin’s lymphoma written first by Thomas Hodgkin to the Medical-Chirurgical Society of London in 1832. In the 20th-century doctors and medical students have written many MCRs that have featured mostly, diseases and conditions that concern AIDS, SARS and malignant hyperthermia. Therefore, it seems that this genre had occupied a dominant position in healthcare literature throughout history even before research articles begun gaining prominence at the beginning of 20th century (Helan, 2012).
Context of the Medical Case Reports and the Purpose
The writing of medical reports happens in the community and will, therefore, be contextualized according to the kind of medical professionals and the people in it (Mendez-Cendon, 2009).Thus, the reports published will be based on the diseases and other medical conditions found in that community, and in some cases, borrowing the language terms of the local community (Helan, 2012; Hung, Chen, & Tsai, 2014; Kunt-Akbas, 2013). Not surprising, some of the diseases and conditions are rare and mainstream academic journal articles could not have published them (Kunt-Akbas, 2013).Many authors have noted that the purpose of Medical Case Reports should be making original contributions to medical knowledge, by presenting phenomena that are completely rear (Hung, Chen, & Tsai, 2014; Kunt-Akbas, 2013). In this regard, they will present important scientific observations that current clinical trials do not normally detect, which will influence various researches to expand the community's medical knowledge (Kunt-Akbas, 2013). The rare medical cases may include rare complication, rare condition, rare treatment, rare diagnosis, rare patient outcome, rare first case and rare side effect.
Features of the Medical Case Reports
The general feature of the Medical Case Report is that medical writers divide it into introduction, case report, discussion, summary points or comments and references (Kunt-Akbas, 2013). Introduction part has the writers mentioning how rare the medical case may be and why he considers the case to be important about the patient’s conditions (Yanoff, 2014). Case report stage will involve one narrating the patient’s case in a general approach. In this stage, the medical writers should be narrating about the history, finding, investigations and treatment of such condition (Yanoff, 2014).The discussion point should briefly sum up the introduction, before venturing into the literature review (Kunt-Akbas, 2013).Using their formulated hypotheses, they should critically use relevant theories in explaining that the case is rear. The next part will be a message to explain what a writer has learnt and how it could affect the whole medical profession (Gardner, 2012). Summary points that include a brief conclusion should succinctly summarize key themes in the discussion. The abstract part will summarize the presentation of the case and key messages of the report. References would have to be few, like 10 of them (Gardner, 2012; Melles, 2004).
The textual structures of the medical case reports are normally examined according to their text length and macro-structures (Hung, Chen, & Tsai, 2014; Kunt-Akbas, 2013). For textual macrostructure, it has to be in four main parts: abstract, introduction, description of patient, discussion and conclusion report (Kunt-Akbas, 2013). However, for Green and Johnson model, it should be in five parts: abstract, introduction, case report, discussion and conclusion (Mendez-Cendon, 2009). Further, some studies have indicated that the formal structure of the Medical Case Reports should be the schema of TAIMRad (Title, Abstract, Introduction, Method, Results and Discussion), followed by legal subsections such as competing interest, consent and references (Helan, 2012; Kunt-Akbas, 2013; Mendez-Cendon, 2009). Apparently, the medical case report presentation seems to be majorly composed of five major parts: abstract, introduction, report of the case, discussion, recommendation and conclusion (Hung, Chen, & Tsai, 2014; Kunt-Akbas, 2013). The other structural feature of the medical case report is its brevity in length compared to a journal article. Most of them range between 1000 and 2500 words in length (Helan, 2012). On lexico-grammatical features, the medical profession has developed with its language (Hung, Chen, & Tsai, 2014; Kunt-Akbas, 2013). Although English remains its lingua- Franca in academic and professional usage, there are also emerging slang languages (Tseng, 2011). In moving the structure of the text, studies have found out that normatively, physicians introduce the case, describe the diagnosis, explain treatment, indicate patient outcome and comment on the case, in that order (Hung, Chen, & Tsai, 2014; Kunt-Akbas, 2013; Mendez-Cendon, 2009; Yanoff, 2014).
Research questions
- How has the genre been evolving from the 19th century?
- What are the contexts (kind of professionals and the community) of the medical case reports as a genre?
- What are the purposes of the communications that define medical case reports as a genre?
- What are the textual-structural properties of the standard medical case reports?
- What are lexico-grammatical features (vocabularies and grammar) that characterize the
text to meet its communicative purposes?
- How do medical writers move the structure of the text in order to attain the best presentation of their MCR reports?
Objectives of the Study
Methodology
Primary Research
Primary research involved interviewing medical professionals and medical students that involved in drafting medical case reports at Mayo Clinic. I interviewed them mostly on the context, structure, purpose before embarking on textual features such as structures and lengths and periodic evolution in the genre. In the help of other two other researchers, we transcribed medical students and medical professionals’ views. Using NVivo and manual data coding, we managed to carry out word count, tense analysis, structural and textual analysis, contextual analysis and other themes (Schryer et al., 2014).
Oral Interview Results (Smith, T. et al., personal communication, November 20, 2014) - see appendix 1
Concerning when doctors and other medical professionals think the genre can be traced, the first doctor reported that by 19th-century MCRs were already in use; people like Christiaan Barnard wrote a case report for the first heart transplant. The second doctor noted that the first context of the MCR is the oral context; this will influence the language that may be used to describe diseases, social issues among others. The doctor-patient communication will mostly be influenced by this context. The third doctor added that in the oral domain too, there is an emerging slang among professional doctors. Further, two medical students said that medical students use this slang language majorly in pejorative or derogatory way. However, in academic research article, formal research English language is employed.
The first student perceived that these reports are necessary when a patient undergoes distress conditions like respiration distress, so that one can discuss with colleagues to get the best way to go. The first doctor added that just as research article papers, they are gaining importance in the medical field. They are more evidence-based compared to academic papers and therefore can easily stimulate research to enhance new knowledge. Since they are locally-based, they are more preferred by various health authorities to help in bringing solutions to patients. On structural features, the second doctor generalized that they have to have the title, then abstract, keywords, introduction, presentation of concerns, clinical findings, timeline, diagnostic focus and assessment, therapeutic focus and assessment, follow-up and outcomes, discussion, patient perspective and recommendation or comments and conclusion. The third doctor saw it necessary that one obtain the patient’s commission before publishing it. Necessary, too, is that any information that can reveal the identity of the patient must be de-identified and if there are any potential competing interests, physicians should disclose them. The second medical student supposed that MCRs should be narratives, with some sort of slang and local vocabularies. However, the second doctor clarified that when writing the medical cases, it is a norm that the agent is omitted to emphasize that the text is scientific and objective, but not stereotypical. This will lead the drafters to write the text at a large extent in passive voice. The third doctor illustrated the verbs used are factive to refer to scientific claims and knowledge; for instance, “noted”, “revealed”, “confirmed” and so forth. Factive verbs are verbs that presuppose factual truths of their objects. For instance in this case, “The Hispanic woman revealed that she was sick”. In factual sense it can just be written as, “The Hispanic woman was sick”, and therefore “revealed” is just a factive/ presupposing verb to show that she was sick.
Concerning the general move to create a rhetoric, the first medical student said physicians introduce the case, describe the diagnosis, explain treatment, indicate patient outcome and comment on the case, in that order. The first doctor elaborated that , it is more comprehensive if they have the title, then abstract, keywords, introduction, presentation of concerns, clinical findings, timeline, diagnostic focus and assessment, therapeutic focus and assessment, follow-up and outcomes, discussion, patient perspective and recommendation or comments and conclusion. The second and the third doctor noted that the most telling difference between MCRs written in the 19c and those written presently is that the former were in pure English, without most slang that can be seen today, and they were temporal and interdisciplinary as well.
Secondary Research
I contacted the university librarian to gain access to medical case reports from two medical journals; Journal of Medical Case Reports (JMCR) and Gülhane Medical Journal (GMJ). I picked three articles from each journal for analyses. In the analyses, the study analyzed the texts according to their purposes, contexts, textual features such as structures and lengths and periodic evolution in the genre. To examine quantitatively linguistic features such as tenses, noun phrases and pronouns of the text, I employed Lexico-grammatical techniques. I used the MS Word program to note the ratio of passive to active tenses, whilst the GATE software counted noun phrases. However, I examined the structures of the MCR texts according to the Swales (1990) suggested lines (Goodier, 2008; Kunt-Akbas, 2013).
Results
Communicative Purpose
In all of the articles analyzed, the most salient purpose of the text is to surprise the audience. Most authors had compelling and unexpected case concerning diagnostic experiences that they wanted to put across. In this way, they were making original contribution to the medical knowledge, by bringing into light phenomena that were most surprising or typically new. Therefore, the study sought to examine, how the medical cases communicated rare cases that included rare complication, rare condition, rare treatment, rare diagnosis, rare patient outcome, rare first case and rare side effect.
Communicative Purposes of Case Report
Apparently the purposes of the medical cases were to report rare complications, rare conditions, rare treatments, rare diagnoses, rare patient outcomes, rare first cases and rare side effects.
Textual Features
The study sought to analyze if the text features mentioned in the various MCR literatures, as discussed earlier were prevalent in the candidate medical articles being analyzed: introduction, case report, discussion, summary points or comments and references.
Text Length Averages
The text length analysis sought to compare average lengths between MCRs and conventional academic research articles. It should be noted that most academic research articles have an average lengths ranging from 8,000-10,000 words, excluding notes and references (Oxford Journals, 2014).
Lexicographical Features
Lexicographical analysis sought to investigate how linguistic features such as personal pronouns, tenses and noun phrases make them different from other genres like academic papers. It had been noted that since medical case reports are scientific papers, third personal pronouns, “He”, “She” and “They” are used to render their objectivity. However, to render their narrative formats, they were presumed to make a great use of past tenses and noun phrases.
Tenses
The writers generally used past tense to explain their cases. For instance, “She retained respiratory and autonomic functions.” (See appendix 2: JMCR 1);
“A 52-year-old man who had previously documented CAD was referred to our department with a typical chest pain. He was a heavy smoker with hypercholes-terolemia. He had a history of percutaneous coronary intervention (PCI) to the right coronary artery at another medical center 7 years ago. Physical examination was normal” (see appendix 2: GMJ 2).
Personal Pronouns
In the two journals, first personal pronouns had been avoided. However, third personal pronouns as “He’ “She” and “They” were prevalent (see appendix 2: JMCR 1 and JMCR 2).
Nouns Phrases, averages
As indicated above, case studies have a lot of noun phrases due to nominalization in its sentences to fit specific situations that they discuss:- “A 52-year-old man who had previously documented CAD was referred to our department with a typical chest pain”. Much use of noun phrases to specify particular people in their situations indicates that MCRs are written in narrative form. This distinguishes them from academic papers which are more specific on their ideas than on people.
Move Structure
In move analysis, the study sought to confirm if the medical case reports employed the general formats explained in various literatures to be distinct from conventional academic papers: case study description, case history, condition, tests, diagnosis, treatment, further tests, complications, further tests, referrals, adjustment, outcome, follow-up and comment. This would determine the most appropriate move steps that medical writers should consider to create an optimal rhetoric in their writing.
Discussion
The study has few limitations that can be instrumental for next researchers. It has selected few journals, all written in English language. Moreover, it has only consulted five individuals from the same health care organization. All these factors may hinder its generalizability. However, it contributes to the current medical literature by emphasizing on the community contextualization of medical situations by medical professionals in healthcare. Further, it should be expected that medical students and medical professionals studying English as a foreign language will exploit the findings of this study to develop their rhetoric technique in medical case reports. Nonetheless, findings of this study will enable various stakeholders such as researchers to generate hypothesis, hospitals and clients to enhance peer reviews for quality healthcare and educational institutions to enrich their case-based learning.
Conclusion
The study tells that MCRs present unique and rare conditions that concern an individual patient in his/ her context. Unlike conventional medical research articles, they are in narrative forms and employ short lengths and local words, with some unique moves and structural features. Despite the genre having gained importance even before the coming of medical academic papers, it has provided rare and authentic medical situations that have led to researches, innovations and discoveries. Apparently, professionals and medical students should consider their usage with equal importance as they do with conventional research articles.
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Appendix
Appendix 1
Oral Interview Results (Smith, T. et al., personal communication, November 20, 2014)
Appendix 2
JMCR 1
Tan, L.B.K., Jimmy B.Y. So & Asim S. (2012). Connection tubing causing small bowel
obstruction and colonic erosion as a rare complication after laparoscopic gastric banding: a case report. Journal of Medical Case Reports, 6(9).
JMCR 2
Fellerhoff, B., Barbara L. & Rudolf W. (2012). Responsiveness of a patient in a persistent
vegetative state after a coma to weekly injections of autologous activated immune cells: a case report. Journal of Medical Case Reports, 6(6).
JMCR 3
Groth, K.A., Jens K. & Bo L. (2012).Cardiacarrest due to lymphocytic colitis: a case report.
Gülhane Medical Journal
GMJ 1
Taşkesen, M., Nurettin O., Murak S. M. & Ali T. (2010).An unusual diagnosis in a child
presenting with hypercalciemia:acute lymphoblastic leukemia. Gülhane Medical Journal, 52, pp.47-48.
GMJ 2
Bozkurt, A., Rabia E.A., Yüksel G. (2009). Apicalhypertrophic cardiomyopathy coexsisting
with coronary arterydisease: a case report. Gülhane Medical Journal, 52, pp. 55-57.
GMJ 3
Baysan, O., Uğur B., Serdar F., Mehmet Y., Barış B., Celal G. (2010). An ascending aort
dissectiondetected in transthoracic echocardiography as a posteriorly locatedmass. Gülhane Medical Journal, 52, pp. 219-221.
