Medical case reports in English and Vietnamese: A genre-based analysis

VIETNAM NATIONAL UNIVERSITY, HANOI UNIVERSITY OF LANGUAGES AND INTERNATIONAL STUDIES ***** NGUYEN THI TUYET MAI MEDICAL CASE REPORTS IN ENGLISH AND VIETNAMESE: A GENRE – BASED ANALYSI

VIETNAM NATIONAL UNIVERSITY, HANOI UNIVERSITY OF LANGUAGES AND INTERNATIONAL STUDIES

*****

NGUYEN THI TUYET MAI

MEDICAL CASE REPORTS IN ENGLISH AND VIETNAMESE:

A GENRE – BASED ANALYSIS (Các báo cáo trường hợp lâm sàng tiếng Anh và tiếng Việt:

Phân tích dựa vào thể loại)

A dissertation submitted in partial fulfilment of the requirements for the

degree of Doctor of Philosophy in Linguistics

HANOI – 2019

VIETNAM NATIONAL UNIVERSITY, HANOI UNIVERSITY OF LANGUAGES AND INTERNATIONAL STUDIES

*****

NGUYEN THI TUYET MAI

MEDICAL CASE REPORTS IN ENGLISH AND VIETNAMESE:

A GENRE – BASED ANALYSIS (Các báo cáo trường hợp lâm sàng tiếng Anh và tiếng Việt:

Phân tích dựa vào thể loại)

MAJOR: ENGLISH LINGUISTICS

CODE: 9220201.01

A dissertation submitted in partial fulfilment of the requirements for the

degree of Doctor of Philosophy in Linguistics

Supervisor: Assoc Prof Dr Le Hung Tien

DECLARATION

I certify my authority of the study project report submitted entitled:

MEDICAL CASE REPORTS IN ENGLISH AND VIETNAMESE:

A GENRE-BASED ANALYSIS

In fulfilment of the requirements for the degree of Doctor of Philosophy in

Linguistics at Vietnam National University, Hanoi

Except where the reference is indicated, no other person’s work has been used

without due acknowledgement in the text of the dissertation

Hanoi,2019 Signature

Nguyen Thi Tuyet Mai

ACKNOWLEDGEMENTS

Firstly, I would like to express my deep gratitude to my supervisor, Associate Professor Doctor Le Hung Tien, for his continuous constructive suggestions, guidance, help and encouragement over the last few years Thanks to his constant presence and aid, I can overcome many obstacles and hurdles along the stressful writing stages of this dissertation and find the motivation to keep moving

on my own work

Secondly, I would also like to thank Doctor Huynh Anh Tuan from VNU, Hanoi University of Languages and International Studies, Faculty of Post Graduate Studies and Doctor Pham Hien from Vietnam Institute of Lexicography and Encyclopaedia who contributed to this dissertation Their valuable and thought-provoking comments and feedback have helped me to enhance this work in its style and content

Thirdly, I would like to give many thanks to all the professors and teachers from the VNU, Hanoi University of Languages and International Studies whom I had during my coursework years for acting as members of the examination committee and for their constructive questions, suggestions and comments about this research

Next, I express my sincere and deepest gratitude to my friends and colleagues from Faculty of Foreign Languages, Vietnam Military Medical University who has patiently listened to all my problems and helped me at different stages of this research over the last few years Thank them for all the vivid discussions we have had

Most importantly, I would not have been able to complete this work without the support of my family; Many thanks to my parents, my mother-in-law, my sisters, my brothers and my lovely children who have always been there for me and supported me in all of my decisions I would like to thank them for their unconditional, unselfish love and support I also would like to give special thanks to

my big friend, my husband who even not knowing anything about this research, has motivated me endlessly

as a descriptive, qualitative, quantitative and comparative study The results obtained from the analysis of 80 MCRs in English and Vietnamese published within

2010 and 2015 lent weight to the following general conclusions: First, the genre of the MCRs was made up of twelve conventional moves with 22 steps Second, the Vietnamese MCRs were longer because of the amount of the information presented

in the reports Third, the typical phrases used in the Vietnamese MCRs were not as diversified as in the English MCRs due to a repetitive use of the same expressions

in the reports Finally, more reporting verbs were used in the English MCRs because the writers may lack judicious use of the RVs, efficiency in using the verbs,

or creativity of successful academic discourse The study acknowledged some limitations: First, the order of the moves was still neglected and second, it would be better if the thesis dealt with reporting verbs in some depth, taking into consideration the interpersonal function of language Despite these limitations, the study is hoped to provide some pedagogical implications for teaching ESP in Vietnamese settings to help students to be aware of the moves and steps when writing a MCR

TABLE OF CONTENTS

DECLARATION i

ACKNOWLEDGEMENTS ii

ABSTRACT iii

TABLE OF CONTENTS iv

ABBREVIATIONS vii

LIST OF TABLES viii

CHAPTER I: INTRODUCTION 1

1.1 Rationale for the study 1

1.2 Scope of the study 3

1.3 Aims and research questions 3

1.4 Research methods 4

1.5 Significance of the study 5

1.5.1 Theoretical significance 5

1.5.2 Practical significance 5

1.6 Structure of the thesis 5

CHAPTER II: LITERATURE REVIEW 7

2.1 APPROACHES TO GENRE ANALYSIS 7

2.1.1 The Systemic Functional Sydney School approach to genre analysis 8

2.1.2 North American New Rhetoric tradition approach to genre analysis 10

2.1.3 The ESP Approach to Genre analysis 12

2.1.4 Summary of the approaches to genre analysis 16

2.1.5 Distinction between genre analysis and register analysis 18

2.2 MEDICAL CASE REPORTS AS A GENRE 20

2.2.1 Definition of a medical case report 20

2.2.2 MCRs and other research methods in clinical settings 21

2.2.3 Limitations and merits of MCRs 22

2.2.4 Structure of a medical case report 25

2.3 PREVIOUS STUDIES OF MCRs 26

2.4 THEORETICAL FRAMEWORKS OF THE STUDY 29

2.4.1 Theoretical framework for move analysis 29

2.4.1.1 The notion of move analysis 29

2.4.1.2 Swale‟s move analysis 30

2.4.1.3 Major studies based on Swale‟s move analysis 33

2.4.1.4 The rationale for adapting Hyland (2000), Nwogu (1997) and M ndez-Cend n (2009) models of move analysis 41

2.4.2 Contrastive framework 42

2.5 CONCLUDING REMARKS 43

CHAPTER III: METHODOLOGY 45

3.1 THE DESCRIPTION OF THE DATA 45

3.1.1 The description of the chosen MCRs 45

3.1.2 The description of sources 46

3.1.3 Criteria for collecting the data 48

3.1.4 English and Vietnamese MCRs 49

3.1.5 Data entry 53

3.2 DATA ANALYTICAL TOOLS 56

3.3 DATA ANALYTICAL FRAMEWORK 57

3.3.1 The modified model of move analysis 58

3.3.2 The analysis procedures 60

3.4 CONCLUDING REMARKS 64

CHAPTER IV: DEPLOYMENT OF MOVES IN ENGLISH AND VIETNAMESE MCRs 65

4.1 DEPLOYMENT OF MOVES IN ENGLISH MCRs 65

4.1.1 Deployment of moves in English MCR abstracts 65

4.1.2 Deployment of moves in English MCR introductions 78

4.1.3 Deployment of moves in English MCR case presentations 84

4.1.4 Deployment of moves in English MCR Discussions 92

4.2 DEPLOYMENT OF THE MOVES IN VIETNAMESE MCRs 99

4.2.1 Deployment of the moves in Vietnamese MCR abstracts 99

4.2.2 Deployment of moves in Vietnamese MCR introductions 108

4.2.3 Deployment of moves in Vietnamese MCR case presentations 114

4.2.4 Deployment of moves in Vietnamese MCR Discussions 118

4.3 CONCLUDING REMARKS 123

CHAPTER V: SIMILARITIES AND DIFFERENCES BETWEEN MOVE DEPLOYMENT IN ENGLISH AND VIETNAMESE MCRs 126

5.1 COMPARISONS OF MOVE DEPLOYMENT BETWEEN ENGLISH AND VIETNAMESE MCRs 126

5.1.1 Comparisons of move deployment between English and Vietnamese MCR abstracts 126

5.1.2 Comparisons of move deployment between English and Vietnamese MCRs introductions 133

5.1.3 Comparisons of move deployment in English and Vietnamese MCR case presentations 137

5.1.4 Comparisons of move deployment in English and Vietnamese Discussions 142

5.1.5 Comparisons of move deployment in English and Vietnamese MCRs as a whole 147 5.2 SUMMARY 156

CHAPTER VI: CONCLUSIONS 158

6.1 SUMMARY OF THE FINDINGS 158

6.2 PEDAGOGICAL IMPLICATIONS 163

6.3 LIMITATIONS OF THE STUDY 164

6.4 SUGGESTIONS FOR FURTHER RESEARCH 164

THE AUTHOR’S PUBLICATION RELATED TO THE DISSERTATION 166 REFERENCES 167 APPENDICES I

ABBREVIATIONS

EAP: English for Academic Purposes

EMP: English for Medical Purposes

ESP: English for Specific Purposes

ICD: International Classification of Diseases

IMRD: Introduction – Methods – Results – Discussions M1: Move 1

MCR: Medical Case Report

MRA: Medical Research Article

RCT: Randomised Controlled Clinical Trials

RGS: Rhetoric Genre Studies

RV: Reporting verb

SFL: Systemic Functional Linguistics

VMMU: Vietnam Military Medical University

VNU: Vietnam National University

LIST OF TABLES

Table 1 Three approaches to genre analysis 16

Table 2 Ten common pitfalls of MCRs 22

Table 3 The individual sections and their contents of a medical case report 25

Table 4 The CARS Model 31

Table 5 The model of abstract move analysis by Hyland 36

Table 6 The model of move analysis of whole article by Nwogu 38

Table 7 The modified model of move analysis of case presentation section 40

Table 8 A Corpus of English MCRs 50

Table 9 The domestic journals rankedby the Council of Vietnamese Medical Professors 51

Table 10 A Corpus of Vietnamese MCRs 53

Table 11 Classification of the 11 disease groups with the codes based on ICD 10 54 Table 12 The modified model of move analysis of a MCR as a whole 60

Table 13 The data of the moves in English abstract section 66

Table 14 An example of English M1 abstract 69

Table 15 An example of English M3 abstract 71

Table 16 An example of English M4 abstract 72

Table 17 The use of RVs in English abstracts 75

Table 18 The data of the English introduction moves 78

Table 19 An example of English M6 introduction with two steps 79

Table 20 The use of RVs in English introductions 82

Table 21 Data of the English case presentation moves 84

Table 22 An example with two steps in M9 case presentation section 86

Table 23 The use of RVs in English Case presentation section 90

Table 24 Frequency of the occurrence of moves in English discussion section 93

Table 25 An example of M14 in English MCR discussion section 95

Table 26 The use of RVs in English discussion section 97

Table 27 The data of moves in Vietnamese MCR abstracts 100

Table 28 An example of Vietnamese M1 abstract (1) 102

Table 29 An example of Vietnamese M1 abstract (2) 102

Table 30 An example of Vietnamese M3 abstract (1) 103

Table 31 An example of Vietnamese M3 abstract (2) 103

Table 32 The use of RVs in Vietnamese abstracts 106

Table 33 The data of the Vietnamese introduction moves 109

Table 34 An example of Vietnamese M6 introduction with two steps 110

Table 35 An example of Vietnamese M7 introduction with two steps 110

Table 36 The use of RVs in Vietnamese introductions 112

Table 37 Data of the Vietnamese case presentation moves 114

Table 38 The use of RVs in Vietnamese case presentation section 117

Table 39 The data of the moves in Vietnamese discussion section 119

Table 40 The use of RVs in Vietnamese discussion section 122

Table 41 Frequency of the occurrence of the abstract moves 127

Table 42 The number of tokens, types and sentencesin English and Vietnamese MCR abstract moves 127

Table 43 The RV use in English and Vietnamese abstracts 131

Table 44 Frequency of the occurrence of moves in the introduction section 133

Table 45 The number of tokens and sentencesin English and Vietnamese MCR introduction moves 134

Table 46 The use of RVs in English and Vietnamese introduction section 136

Table 47 Move frequency in English and Vietnamese Case presentation section 138

Table 48 The number of tokens and sentencesin English and Vietnamese MCR case presentation moves 138

Table 49 The RV use in English and Vietnamese Case presentation section 141

Table 50 Move frequency in English and Vietnamese discussion section 143

Table 51 The number of tokens and sentencesin English and Vietnamese discussions 143

Table 52 The RV use in English and Vietnamese discussion section 145

Table 53 The RV use in English and Vietnamese MCRs 151

Table 54 A model of move analysis of a medical case report 162

LIST OF FIGURES AND CHARTS

Figure 1 Metafunctions in relation to register and genre 19 Figure 2 Categories of Reporting Verbs 62 Figure 3 An example of a longer concordance 64

Chart 1 The move frequency of occurrence in English and Vietnamese MCRs 147 Chart 2 Number of tokens in English and Vietnamese MCRs 148 Chart 3 Number of sentences in English and Vietnamese MCRs 149

CHAPTER I INTRODUCTION

1.1 Rationale for the study

Medical case reports (MCRs) serve as “primers” leading to discoveries of new

diseases or disease pathophysiology as well as development of new preventive and therapeutic measures According to Li et al (2013), MCRs are employed as a platform for the training of medical students and resident doctors in scientific writing and critical thinking MCRs are also an excellent means of describing important adverse drug effects and for postulating links between previously unrelated symptoms, signs and syndromes In addition, they can and should suggest new hypotheses and stimulate further studies However, compared to other research

in clinical settings such as overviews, randomised controlled clinical trials, cohort studies, case-control studies and cross-sectional surveys, MCRs have not received much consideration and are under-represented in genre studies since they are seldom definitive and can rarely prove causation

In Vietnam, the limited amount of research about MCRs has lead to a limited understanding in describing this structured writing and the understanding of scholars in the medical field trying to publish their research into international journals Almost all linguistic research concerning with the biomedical field has focused on finding the ways of translating medical terms from English to Vietnamese in order to standardize the system of Vietnamese medical terms and to propose concrete direction and solutions to designing a textbook for medical

students For example “Examining English medical terms and the way of

translating them into Vietnamese” by Minh (2005) and “English – Vietnamese methods of medical translation” by Huong (2008) In addition, there have been

some studies mapping and describing the generic characteristics of the biomedical

texts including “A study on the meaning and structure of a biology text: A System

Functional Grammar” by Mai (2008) and “Lexical and morphological characteristics of medico-pharmaceutical texts” by Hanh (2008)

In the world, in recent years, MCRs have been studied more extensively, such

as “Medical Case Reports and Scientific Thought-styles” by Taavitsainen (2011),

“Case Report writing in a Doctor of Physical Therapy Education Program: A Case Study Journal of Scholarship of Teaching and Learning” by Fillyaw (2011),

“Analysis of Published Medical Case Reports: Genre-Based Study” by Helán

(2012), etc.Each discipline has fore-grounded or back-grounded certain aspects of medical language due to different theoretical perspectives, different analytical methods, or different research emphases Nevertheless, so far, no reported research has been devoted to the contrastive analysis about the genre of MCRs in English and Vietnamese The issue thus has been an uncultivated land within Vietnamese applied linguistics

To fill the gap, the author of this paper, thus, desires to carry out a study titled

“Medical Case Reports in English and Vietnamese: a Genre-based Analysis” with

the emphasis on moves of the MCRs in both languages The important role of move analysis when analyzing a genre is emphasized by many linguists Bonyadi (2012), for example, agreed, “The central to the analysis of a certain genre is the identification of the moves in a text based on the conventions set by the discourse community” (p.7) Similarly, Biber et al., (2007) claim that move analysis is a subset of genre analysis that examines discourse by concentrating on its organization In their opinion, moves are considered as functional units in a text, together fulfilling the overall purpose of the genre and “moves of genre are considered as an inherent part of the genre” (p 32)

Hopefully, the thesis would help the novice researchers, who begin their study

as outsiders in the academic community “unfamiliar with the rules of the game” (Gosden, 1995) of academic research deal with serious problems when they attempt

to publish their research articles in international journals Firstly, they can understand how to conform to the overall organization as well as how to use certain expressions and vocabulary commonly employed in their respective discourse communities and academic disciplines Secondly, they can read and write a medical research article in general and a medical case report in particular in English with the

least challenges and they can handle academic writing tasks encountered in a higher education setting

1.2 Scope of the study

The moves are analyzed in terms of their frequency, length and steps while the lexical signals are analyzed regarding words/phrases and reporting verbs (Reporting verbs are known as one of the explicit ways for writers to establish the credibility of the reported claims and considered as one of the lexical devices that writers need for both expressing a stance and connecting or aligning themselves with the readers in scientific articles) In clinical settings, medical research papers are considered as persuasive texts by nature, and in reporting work by others, their authors need to show how their work is in agreement with a previous study or how

it is different, and must evaluate previous work accordingly, thereby presenting an evaluative stance The current research studies how the reporting verbs work in the moves and how a researcher can use the verbs in a specific context to show disagreement or agreement with the findings of others During the analysis, the taxonomy suggested by Hyland‟s (2002) including Research Acts Cognition Acts and Discourse Acts is referred

1.3 Aims and research questions

According to Swales (1990 & 2004), two levels of move analysis are the study

on moves and the lexical signals of the moves In the current study, Swale‟s theory (then developed by Hyland, 2002, Nwogu, 1997 and Mend z-Ced n, 2009) is used with the focus on move analysis to analyze the moves in English and Vietnamese MCRs with the following aims: (1) to explore how the moves and lexical signals of the moves work in English and Vietnamese MCRs and (2) to compare these moves

to establish the similarities and differences between English and Vietnamese MCRs

To reach the aims, the current study seeks the answers to the following research questions:

1 How do moves work in English and Vietnamese medical case reports?

1.1 What are the frequency and length of moves in English and Vietnamese medical case reports?

1.2 How do the steps of moves operate in English and Vietnamese medical case reports?

1.3 How do the lexical signals of moves operate in English and Vietnamese medical case reports?

2 What are the similarities and differences between English and Vietnamese medical case reports regarding the identified items?

The first research question identifies the moves in English and Vietnamese

MCRs regarding their length, frequency, steps based on the modified models adopted from Hyland (2000), Nwogu (1997) and M ndez-Cend n (2009) To

explore the lexical signals of moves, the typical words/phrases and RVs are picked

up and examined

The second research question attempts to find out the similarities and

differences between English and Vietnamese MCRs in terms of the identified items The comparison of the two sources of MCRs can provide with an understanding of how the English and Vietnamese researchers arrange moves in their writing

1.4 Research methods

The study is designed as a descriptive, qualitative, quantitative and comparative study that allows the researcher of the current study to analyze, describe and compare analyses the moves used in English and Vietnamese MCRs In particular, the analytical approach of comparative method is used to compare the shared and unshared identified items in English and Vietnamese MCRs The current study thus

is a Mixed Method Research Design According to Lazaraton (2005, p 219 cited in Angouri, 2010, p 32) combining approaches is not only feasible but also beneficial

in revealing different aspects of „reality‟ Angouri (2010 p 41) shared the same

idea when claiming that mixed method “can provide rich datasets and enhance our

understanding of complexities in most research areas in linguistics” In the current

study, the quantitative data reveal different frequencies of moves and lexical signals

used in MCRs At the same time, the closer qualitative analysis of discourse data shows how the moves and lexical signals are used by English and Vietnamese writers to achieve the goals

1.5 Significance of the study

1.5.1 Theoretical significance

The study provides an in-depth and detailed description of MCRs in English and Vietnamese not only of the surface linguistic features but also of the discourse conventions and underlying socio-cultural values In addition, it equips medical staffs with basic knowledge of English cultural background and understanding of the specific genre in both languages

1.5.2 Practical significance

The findings of the study help the lecturers develop pedagogical strategies and address problems in the context of a process-oriented writing course with the evidence of cross-linguistic influence and differences in discourse Moreover, they support students, doctors, researchers and medical staffs in studying, translating and writing MCRs in Vietnamese and English in social contexts relevant to their educational, social and cultural needs More importantly, the results make contribution to promoting and popularizing the medical achievements of training, scientific research and treatment of Vietnamese medicine in general and Vietnam Military Medical University where the author has been working as a teacher of English for over 20 years in particular

1.6 Structure of the thesis

This thesis includes six chapters After CHAPTER I - Introduction to the study

including the rationale to the study, aims and research questions, scope of the study, significance of the study, research methods, research data and structure of the thesis, the thesis is continued with the following chapters:

CHAPTER II – Literature Review – is concerned with presenting different

linguistic approaches of previous studies on the theme of genre analysis It is designed with the following main sections The first section deals with a critical review on different approaches of genre analysis in order to show the contributions

of the previous studies and to establish the gap that needs to be filled in the studied issues It also gives the reasons for the use of the appropriate approach in the current research The next section concentrates on the genre of MCRs and the last section focuses on the description of the move analysis as the theoretical framework for the current study

CHAPTER III - Methodology – provides a detailed research design, and

methodology for the current study in which the description of data set, the modified model, the analytical framework and the procedures of the moves analysis are given

CHAPTER IV – Deployment of moves in English and Vietnamese MCRs –

presents the main results of move analyses of English and Vietnamese MCRs regarding the move frequency, length, steps, typical phrases and reporting verbs The analyses are carried out section-by-section (Abstract, Introduction, Case

presentation and Discussion)

CHAPTER V – Similarities and differences between move deployment in English and Vietnamese MCRs – is provided with two purposes Firstly, it compares and

discusses the similarities and differences of the moves in terms of the identified items English and Vietnamese authors used in their papers During the analyses, the possible reasons for the similarities and differences in English and Vietnamese MCRs are discussed

CHAPTER VI – Conclusions is the final part of the study First, the prominent

findings of the study are summarized and it is followed by the pedagogical implications, contribution and limitations of the study It closes with some suggestions for further studies

CHAPTER II LITERATURE REVIEW

This chapter encompasses a literature review of the following issues First, three broad schools of genre analysis are reviewed in terms of their different conception and pedagogical approaches: Systemic Functional Linguistics (also known as the Sydney School), North American New Rhetoric studies, and English for Specific Purposes (ESP) tradition In addition, the distinction between genre analysis and register analysis is also discussed to draw a clear picture of why the ESP approach

to genre analysis should be used in the current study Second, the chapter concerns with the general understanding about the genre of medical case reports (MCRs) such as the definition, their benefits and limitations and the structure The genre is compared to other kinds of genre used in clinical settings The chapter then examines the previous research of the different sections of MCRs and discusses their limitations that the current study may do to fill the gaps Finally, it establishes the theoretical framework that guides the research

2.1 APPROACHES TO GENRE ANALYSIS

Henry and Roseberry (2001)stated that the general aim of genre analysis was to identify the moves and strategies of a genre, the allowable order of the moves, and the key linguistic features The next step was to explain why these features were chosen by expert users of the genre to achieve their communicative purpose The similar idea was also given by Quin (2000) who stated that the fundamental aim of

genre analysis was to “study the communicative purposes of a discourse and the

language use strategies” (p 42)

That is why genre analysis has been a useful method for the description of different text types According to the father of genre, Swales (1990), genre analysis was the study of how language was used within a particular setting Rhetorical styles and discourse types were the issues that genre analysis may focus on The

idea was also shared by Barron (2012) that this approach is “concerned with the

question as to how members of a specific community use language to get things

done” (p.7) He added that genre analysis was widely used and recognized

internationally by three schools, namely: (i) Australian genre-based educational linguistics (also referred to as the Sydney School) drawing on Systemic Functional Linguistics (SFL), (ii) Rhetorical Genre Studies (RGS, also known as North American Genre Theory) drawing on and contributing to New Rhetoric and (iii) English for Specific Purposes (ESP) – an umbrella term for areas of English study such as academic English, medical English, legal English or business English The following subsections discusses in details the three approaches

2.1.1 The Systemic Functional Sydney School approach to genre analysis

The Systemic Functional Sydney School approach to genre (known as Systemic-Functional Linguistics approach) was founded by a British-born scholar Halliday with the focus on the relationship between language and its functions in society The approach attempts to explicate why and how people in social contexts

used the language it thus “is more closely aligned with Sociology: it explores how

language is used in social contexts to achieve particular goals” rather than

concerning with “language as a mental process” (O‟Donnell 2012) It does not

study language for the sake of language alone but seeks to contribute to educational, economic and political processes It means that the approach understands the language as belonging to one of the semiotic systems constituting a culture Consequently, the language can be interpreted in the context of culture and the structure of language is inextricably linked to social function and context

Instead of viewing texts in relation to communities like Swales (1990, 2004), the SFL approach analyzes three meta-functions of meaning-making known as the ideational, interpersonal, and textual Ideational metafunction deals with how the language is used to represent our experiences of the physical, the psychological and the social world They can be realized through the „system of transitivity‟ with the focus on „a process‟ (realized by a verbal group) „the participants‟ involves (realized by nominal groups) and their „circumstances‟ (realized by adverbial groups) Interpersonal metafunction is realized by the „systems of mood‟ and

„modality‟ The former concentrates on the exchange of information and of goods

and services while the latter is used to show the relationship between the text‟s authors and their representations Textual metafunction expresses how the text is organized in relation to its context and its message through the „system of Theme/Rheme‟ Theme is related to the message‟s point of departure and Rheme‟ is concerned with its continuity in the clauses‟ syntactic organization

From a systemic point of view, the choice of the distinct metafunctions can create the context of a text and the register elements can activate different areas of semantics and grammar (Figueiredo, 2010) The register realizes genre by three

variables: field, tenor and mode Field is recognized in the culture, within which the

language is playing some part or the total event (Halliday & Hassan, 1985:45-46) It refers to what is happening, to the nature of the social action that is taking place

Tenor refers to who is taking part in the text and to the nature of the participants‟

status and roles, kinds of relationship obtained among the participants Mode refers

to what part of the language is playing (prototypically speech or writing) The register can be understood as the context that is constituted by texts Consequently,

register known as functional language variation, is a “contextual category

correlating groupings of linguistic features with recurrent situational features”

(Gregory & Carroll, 1978:4)

In “An Introduction of Functional Grammar” Halliday (1994) concluded that in any piece of discourse, there were always two possible levels of achievements to

aim at understanding and evaluating the text The former “enables one to show how,

and why, the text means what it does” It means that the linguistic analysis related

the text to general features of the language, especially grammar The later “enables

one to say why the text is, or is not, an effective text for its own purposes – in what respects it succeeds and in what respects it fails, or less successful”

Talking about this approach, Bawarshi and Reiff (2010) gave the summary of the theory by pointing out that according to this approach,

“… language is organized the way it is within a culture because such an organization serves a social purpose within that culture „Functional‟ thus refers to the work that language does within particular contexts „Systemic‟ refers to the structure or organization

of language so that it can be used to get things done within those contexts „Systemic‟ then

refers to the „systems of choices‟ available to language users for the realization of meaning” (original emphasis) (p 29-30)

By giving the explanation of the terms such as “Function” and Systemic” the summary makes the SFL theory clearer

The SFL theory of Halliday‟s work (2006) has attracted much attention from some researchers (Eggins, 2004), for example, provided an accessible first step into systemic for those who wish to equip themselves with the conceptual and practical tools to analyse and explain how people make meanings with each other in everyday contexts (Martin & Rose, 2008), on the other hand, introduced our general orientation to genre from the perspective of system and structure, and places

genre within our general model of language and social context In “The language of

schooling A functional linguistics perspective” Schleppegrell (2004) built on

current sociolinguistic and discourse-analytic studies of language in school She added a new framework of functional linguistic analysis focusing not only on the structure of words and sentences, but also on how particular grammatical choices created meanings in the different kinds of texts students were asked to read and write at school

In short, genre can be understood in simple and easy way from SFL approach

by the summary of Imtihani (2010) that the concept is used to “describe the impact

of the context of culture on language, by exploring the staged, step-by-step structure cultures institutionalize as ways of achieving goals” (p 92) The SFL genre analysis

concentrates not only on its situational contexts including field, mode and tenor, but also on its structure and the realizational patterns in the texts

From pedagogical perspective, Gebhard & Harman (2011) stated that “SFL

scholars have focused their research agendas on supporting the academic literacies

of non- dominant students in elementary and secondary schools” and that “teaching academic literacies involves apprenticing English language learners to using school-based genres and registers” (p.48-49)

2.1.2 North American New Rhetoric tradition approach to genre analysis

The principle for this approach is originated from the essay "Genre as Social

Action" by Mille & Miller (1994) who examines genre as typified social action, as

ways of acting based on recurrent social situations In other words, the discourse performs the rhetorical action as pragmatics, the genre thus must focus on the action not on the substance or the form of discourse it was used to accomplish The understanding of genre in her work in 1984 can be summarized as follows:

- a typified rhetorical response to (uptake of) a recurrent rhetorical situation

- pragmatic not formal or substantive; a “macro” speech act

- a significant social action, which created meaning

- a mediation between private intentions (purpose) and socially objectified needs (exigence)

Some further entailments of genre as social action include these considerations:

- Genres are categories, or types, of social action

- Typification is culturally dependent

- “De facto” genres are culturally important because they marked cultural categories; as such genres collectively help to “constitute” society in Giddens‟s sense (Giddens 1984)

- Genres are recognized by those who use them, as opposed to those who study them

- Rhetorical genres are an open, evolving class and as such, genres do not constitute a neat, mutually exclusive taxonomy (Miller, 2015)

According to Coe and Freedman (1998), the theory studied how particular discourses were socially motivated, generated, and constrained It thus put the

answer to the question “as what it means to say that an individual (or small group

of collaborating individuals) wrote a particular memo, article, or novel and what it means to say that we not only write but are written” (p 41) When comparing this

approach with other traditional theories they claimed while “traditional theories of

genre focused primarily on discursive form, the new theories explain the discursive structures of a genre functionally, as standard responses of a recurring type of rhetorical situation” (p 41)

The difference was also shown by Bawarishi & Reiff (2010) who said that instead of studying the context when analyzing the text, the North American New

Rhetoric Approach “viewed context as an ongoing, inter-subjective performance,

one that is mediated by genres and other culturally available tools”

Although this new approach to genre constitutes a particularly powerful and

promising approach to writing as social process and “provides a basis for

teaching/learning methods that could prepare students to handle the social

constraints they will face in practical writing tasks” (Coe & Freedman, 1998), some

linguists have been concerned about the pedagogical implications that this approach brought to education Bawarshi & Reif (ibid.), for example, wondered what the pedagogical quandary that this approach has faced To illustrate the idea they gave

an example situation where students would be asked to perceive a task as serving a certain function within an activity system In this case, they would likely select a mediational means (a genre or set of genres) that is appropriate to their understanding of the objective Subjectivity compatible with that understanding could be unavoidable because although some students may recognize the object/motives, they may not have accessed to the appropriate mediational means According to them, how we used the mediational means depended on how we understand the object and outcomes

Miller (2015) did a new research to revisit her work in 1984 and concluded that the genre in recent years has become much more complex It has been not only a

multidimensional social phenomenon but also a “structurational nexis between

action and structure, between agent and institution, between past and future”

Consequently “we can continue to learn from the diversity of recurrent categories

that structure our social worlds” (p 69)

2.1.3 The ESP Approach to Genre analysis

The ESP approach to genre subsumes areas of language study such as English for Academic Purposes (EAP), English for Business and Technology (EBT), English for Medical Purposes (EMP) and English for Professional Communication (EPC) In ESP genre analysis, the work of ESP researchers is based on the study of

the occurrence or absence of certain linguistic features such as hedges (Hyland, 2006), addresses features (Hyland, 2001a), imperatives (Swales & et.al., 1998), passive voice versus metonymy (Rundblad, 2007), self-mention Hyland (2001b), the expression of stance (Charles, 2003), collocational frameworks (Marco, 2000)

In the above work, formal and academic genres utilized by academic and professional discourse communities are the principal research objectives

From a pedagogic perspective, the description of ESP genre may be useful in instructing ESP learners In ESP, language analysis tasks help learners gain awareness of the communicative purposes and linguistic features of texts that they need to read and write in their disciplines and professions The analysis is believed

to help English as a Second/Foreign Language (ESL/EFL) learners deal with the nature of writing, understand and master the organizational and stylistic features of professional and academic genres

In ESP genre analysis “move” and “step” are the central recognition that have been given different meanings For example, Bhatia (1993:30) considered moves as

“discriminative elements of generic structure” Yang and Allison (2003) stated that

a move was a semantic unit of text achieving a unified purpose in ESP genre analysis Moves served the function and purpose of a segment of text at a more general level and step provided a more detailed rhetorical means of realizing the function of a move

The ESP approach is associated predominantly with the names of Swales

(1990) with three central terms: discourse community, genre and language learning

task

 Discourse community

According to Swales (1990), there were two different types of community:

speech and discourse The former “was seen as being composed of those who share

similar linguistic rules” (p 23) while the later was identified by six following

characteristics:

1 A discourse community has a broadly agreed set of common public goals

2 A discourse community has mechanisms of inter-communication among its members

3 A discourse community uses its participatory mechanisms primarily to provide information and feedback

4 A discourse community utilizes and hence possesses one or more genres in the communicative furtherance of its aims

5 A discourse community has acquired some specific lexis

6 A discourse community has a threshold level of members with a suitable degree of relevant content and discoursal expertise. (p 24 – 27)

When describing these characteristics, Swales noted several things Goals can

be published in documents or be implicit; high level or abstract Communication can be through text or confrontation Information exchange is relative to the common goals Discourse communities develop around the genres upon which it establishes itself Lexis is essentially a compilation of vocabulary, so each community has its own terminology specific to that group There should be a reasonable ratio between experts and newcomers

The term discourse here refers to language with a specific communicative purpose used in a given social context, and discourse community represents the

users of that particular discourse According to him, the experts in the discourse community are able to recognize the purposes of a genre As a rule, the people who have just been initiated into the discourse community are less capable of doing The main difference between discourse and speech communities is that discourse communities separate the existing people into groups whereas speech communities are looking to include outsiders In other words Swales‟ discourse community here is distinguished from speech community in sociolinguistics In sociolinguistics, the main objective of the community is in the socializing of its members whereas in Swales the main objective of the discourse community is in its members‟ sharing of the same interest either social or academic

 Genre

Swale‟s (1990) definition of genre attempts to capture how writers achieve their social purposes by using various structural forms, constructing different focuses and manipulating topics According to him, genre was determined by the actions they

help accomplish (communicative purpose) and the people interacting through them

(discourse community) as follows:

“a class of communicative events the members of which share some sets of communicative purposes These purposes are recognized by the expert members of the parent discourse community, and thereby constitute the rationale for the genre This rationale shapes the schematic structure of the discourse and influences and constrains choice of content and style Communicative purpose is both a privileged criterion and one that operates to keep the scope

of a genre as here conceived narrowly focused on comparable rhetorical action In addition to purpose, exemplars of a genre exhibit various patterns of similarity in terms of structure, style, content and intended audience If all high probability expectations are realized, the exemplar will be viewed as prototypical by the parent discourse community but typically need further validation.” (p 58)

In his definition of genre, the communicative event was a complex notion, comprising not only of the discourse itself but also of the role of the discourse and

the environment and culture surrounding it However „communicative purposes‟ were claimed for the challenges and difficulties As he put it: “… the fact that

purposes of some genres may be hard to get at is itself of considerable heuristic value Stressing the primacy of purpose may require the analyst to undertake a fair amount of independent and open-minded investigation, thus offering protection against a facile classification based on stylistic feature and inherited beliefs, such

as typifying research articles as simple reports of experiments” (p 46) However

there have been also some cases in which “identifying purposes may be relatively

easy” (p 46) Recipes and political speeches were obvious examples

In short, what adopted from his definition of genre are the use of language in a conventionalized setting and the structure The former reflects the communicative purpose and the latter is determined by smaller parts called "moves" by Swales (1990) Every move is characterized by its own specific purpose, which is reflected

in the subject matter For that reason, the generic structure is considered as one of the major representatives of the purpose of genre In other words, this approach to

genre analysis is characterized by identifying a set of „moves‟ and „steps‟,

embedded in a spoken or written discourse, which realizes the communicative purpose(s) of a member of a discourse community

 Language Learning Task

The third concept of Swales‟ (1990) genre analysis is language learning task

Swales defined the concept as “one of a set of differentiated, sequenceable

goal-directed activities drawing upon a range of cognitive and communicative procedures relatable to the acquisition of pre-genre and genre skills appropriate to

a foreseen or emerging sociorhetorical situation” (p 76)

Swales recommends performing a number of language-learning tasks to help students come closer to understanding the role of genre in their discourse communities For example, Swales provided three short request letters for papers

He designed critical thinking and reference questions to ask the students to perform

his requested tasks His conclusion is that “a genre-centred approach is likely to

focus student attention on rhetorical action and on the organizational and linguistic means of its accomplishment” (p 82)

2.1.4 Summary of the approaches to genre analysis

Table 1 summarizes the general features of the three approaches to genre analysis have been discussed above

ESP EAP, L2 tertiary

education

Structure move analysis

“A genre comprises a class of communicative events, the members of which share some set of communicative purposes.” (Swales, J., 1990)

SFL primary and secondary

education and adult migrant education

Analysis of linguistic features

“A genre is a staged, goal-oriented, purposeful activity in which speakers engage as members of our culture”

Table 1 Three approaches to genre analysis (adopted from Kobayashi, 2003, p 7)

As can be seen in Table 1, there are several ways in which these three genre approaches differed from one another The idea is shared in the work named Genre – An Introduction to History, Theory, Research, and Pedagogy by Bawarshi and

Reiff (2010) According to them, although SFL and ESP genre approaches both agree that linguistic features are connected to social context and function, they differ in their applied target audience, theory behind them and the methods of text analysis In the SFL approach, the definition of genre is based on Hallidayan theory

of systemic linguistics, the analysis is thus within the systemic functional approach The North American new rhetoric approach focuses on social purposes of genre (the study of genre involves an ethnographic study of the surrounding social context) In this approach, the analysts try to analyze a genre through the study of the society in which the genre is used Therefore, the method of analysis is more akin to that of ethnomethodology In the ESP approach, genre is defined as a class of communicative events The analysts look for textual patterns common in a genre by analyzing the moves The level of analysis is not only look at the level of text but also the lexico-grammatical level The analysts look at the use and the meaning of a particular word or phrase in a particular genre

In addition, Flowerdew (2013) found that the ESP approach was rather eclectic

in its approach, while the Sydney school worked with well-developed linguistic theory and descriptive model In addition, the ESP approach is easy to apply while the SFL school is more detailed and requires training in the theory and analysis On the other hand, RGS school does not have a model of language perse This research

is in support of this idea and choose the ESP approach to genre analysis, especially Swales‟ theory to apply to the current study It is relevant to the purposes of this study for the following reasons First, it gives priority to EAP, particularly to EMP (English for Medical Purposes) Second, it gives the application of discourse community through written communication (specialized texts known as MCRs) among healthcare professionals who use highly specialized terminology, specific abbreviations and acronyms that can be easily recognized by fellow community members Lastly, Swales‟ model not only focuses on rhetorical organization but also suggests the lexico-grammatical signals of each move and steps that are similar

to the purposes of the current study

2.1.5 Distinction between genre analysis and register analysis

The terms genre and register are the most confusing because they overlap to

some degree, they both apply to analyzing characteristics of varieties of texts and

“involve the adaptation of linguistic and discourse structures to a situation defined

by a complex of social, cultural, and communicative factors” (Ravid & Tolchinsky

2002, p 424) Consequently, they are often used interchangeably by the linguists such as Biber (1995), Guenthner and Knoblauch (1995)

However, it is worth noting that, despite the similarities between the two terms, there are considerable differences between them that should be emphasized Couture (1986), for example, offered an alternative explanation to avoid the

conflation of genre and register by claiming that registers are constrained at the linguistic levels of vocabulary and syntax, whereas genre operates at the level of discourse structure Further “Unlike register, genres can only be realized in

completed texts or texts that can be projected as complete, for genre does more than specify kinds of codes extant in a group of related texts; it specifies conditions for beginning, continuing, and ending a text” (p 82) In his opinion genres such as

research reports, business reports, and newspaper articles are compleTable structured texts, while register including language of scientific or newspaper reporting and bureaucratic language is more generalizable stylistic

Nunan (2008) also distinguished genre and register by saying that while genre related to the context of culture, register related to the context of situation Register analysis thus examined the relationship between a text and the situational context surrounding the creation of the text (p 58)

Similarly, Lee (2001) claimed one difference between the two terms was that

“genre tends to be associated more with the organisation of culture and social

purposes around language” and “is tied more closely to considerations of ideology and power, whereas register is associated with the organisation of situation or immediate context” (p 41-42)

Martin (2001) had a harmonious view by claiming that genre was realized

through registers and registers in turn “are realized through language” The

relationship between them can be illustrated in Figure 1 that illustrates how genre (context of culture) related to register (context of situation) as realized through the metafunctional diversity of language

Figure 1 Metafunctions in relation to register and genre

(Adopted from Martin, J R., 2001, p.52)

In short, register corresponds to the context of situation, and genre to the context of culture According to Swales (1990), the emphasis of genre studies falls into three following criteria:

- Genres as a types of goal-directed communicative events

- Genres as having schematic structures; and most strikingly

- Genres as disassociated from registers or styles (p.42)

Unsurprisingly register analysis thus “focuses mainly on the identification of

statistically significant lexico-grammatical features of linguistic variety” (Bhatia

1993, p.5) In other words, special importance to register analysis is the case of

“above-average incidence or even a lack of certain linguistic features, be they

lexical, grammatical or even discoursal / rhetorical, in the text under study” (p 17)

Although register analysis has common important aim with genre analysis - that it

to “characterize typical or conventional textual features of any genre-specific text”

(p 16), it possesses some limitations discovered by Bhatia (1993) First, the findings from register analysis do not provide adequate insights about the way information is structured in particular variety since it emphasizes on surface features Consequently, it is difficult to explain why a particular variety takes the

form that it does Second, the focus on surface-level description from the register

analysis fails to yield appropriate “insights into the rationale underlying selection

and distribution of surface linguistic features” (p 6)

In contrast, in his opinion, another aim of genre analysis is to “identify […]

form –function correlations” and to “explain such a characterization in the context

of the socio-cultural as well as the cognitive constraints operating in the relevant area of specialization, whether professional or academic” (p.16) In other words, it

attempts to go beyond “a surface level description to a more functional and

grounded description of language use” (p 5) taking into consideration “not only socio-cultural but psycholinguistic factors too” (p 39) Thick description taken

from genre analysis helps to clarify not only “the communicative goals of the

discourse community in question, but also the individual strategies employed by the members to achieve these goals” (p 39 - 40) According to him, “a genre is a recognizable communicative event characterized by a set of communicative purpose(s) identified and mutually understood by the members of the professional

or academic community in which it regularly occurs” (p.13) Thus, both authors

emphasize the communicative purposes of the text are the most important features related to genre, shapes the genre and gives it internal structure

Since genre analysis involves not only the analysis of lexico-grammatical features but also the analysis of text-patterning or textualization and structural interpretation of the text – genre, it becomes possible to justify the use of the term genre analysis for the analysis undertaken in this dissertation

In this study, the genre chosen to study is from the field of professional medical writing known as Medical Case Reports (MCRs) This genre is carried out as part of the everyday routine in hospitals and other health-care facilities and has received close attention The following sub-section gives more information about this kind of genre

2.2 MEDICAL CASE REPORTS AS A GENRE

2.2.1 Definition of a medical case report

MCRs play an important role in the decision-making process regarding the

steps in the management of pathological conditions They are “a time-honored,

important, integral, and accepted part of the medical literature” (Rison, 2013) A

Case report is a “report of a single case of a disease, usually with an unexpected

presentation, which typically describes the findings, clinical course, and prognosis

of the case, often accompanied by a review of other cases previously reported in the biomedical literature to put the reported case in context” (Segen's Medical

Dictionary, 2011) Similarly, (Kirthi, 2011) from Royal College of Physicians also

defined MCRs as “a means of communicating something new that has been learnt

from clinical practice It could be about an unusual or previously unknown condition, a rare presentation or complication of a known disease, or even a new approach to managing a common condition” In shorts the MCRs in this study can

be understood as a medical recount of a rare pathological condition in a single

patient

2.2.2 MCRs and other research methods in clinical settings

According to Greenhalgh (2001: 39 – 55), clinical decisions about interventions

in the treatment of patients made by medical professionals can be ranked from the most objective, statistically and reliable studies to the most subjective

1 Overviews: They are statistical syntheses of the results of several clinical trials addressing the same medical question The research tends to be more reliable, accurate conclusions, more generalizable findings and more consistent results because it can identify weak studies and limit bias

2 Randomised controlled clinical trials (RCTs): The participants are randomly selected and offer a medical standard intervention RCTs are the gold standard in medical research because their aims are to reduce bias when testing a new treatment and they allow rigorous evaluation of a single variable in a precisely defined patient group However, RCTs are claimed to be expensive and time consuming

3 Cohort studies: two (or more) groups of people are selected on the basis of differences in their exposure to a particular agent (such as a vaccine, a medicine) and follow up to see how many in each group develop a particular disease or other outcome Cohort studies may take years or even decades to measure

4 Case-control studies: Case-control studies are generally concerned with the aetiology of a disease (i.e what causes it), rather than its treatment The studies find out what might have caused a specific pathological condition in a group of patients The results of analysis of the patients‟ past medical records are then compared to a control group of patients

5 Cross-sectional surveys: In this type of research, the opinions, behaviour, habits, etc of a representative sample of randomly selected patients are collected by interviewing or using questionnaires

6 Case reports: “Case reports are often run together to form a case series, in

which the medical histories of more than one patient with a particular condition are described to illustrate an aspect of the condition, the treatment or, most commonly these days, adverse reaction to treatment” (p 53)

Among the research methods in clinical settings, MCRs are considered as relatively weak scientific evidence and (RCTs) are believed to be the most useful method for confirming a specific treatment option However, MCRs play an important role in recognizing adverse outcomes because every patient responds to a treatment in a different way In addition, as highlighted above, MCRs are the first indications of rare adverse reactions among the other methods in clinical settings (Greenhalgh, 2001) To understand the more about MCRs, the following sections focus on some key issues relating to this kind of genre

2.2.3 Limitations and merits of MCRs

Due to relatively weak scientific evidence and focusing mainly on the development of a pathological condition, its diagnosis and treatment in a single patient, MCRs have not been appreciated as highly as the genre of medical research articles that are predominantly based on randomized clinical trials Pierson, D J (2004) presented a Table involving 10 pitfalls of MCRs:

To overcome the problems, according to him, the researchers should be aware

of common mistakes in case report writing and take deliberate measures to avoid them In addition, they should focus on new syndromes, manifestations, associations, complications, or outcomes

Despite the limitations of MCRs, many researchers have acknowledged their merits Smith (2008) argued that every medical case containing a significant piece

of clinical information played an important role in teaching the medical professionals about something new or important The idea is presented clearly by him as follows:

“Health care is in some ways nothing more than an accumulation of case reports just as a population is a collection of people And just as every person is important and different so

is every case – even when „it‟s just another sore throat”

Similarly, Vandenbroucke (2001) highly evaluated the potential roles of case reports in clinical medicine According to him, MCRs recognized and described new diseases or rare manifestations of disease, detecting side effects of drugs, and medical education and audit In physical therapy, on the other hand, Fitzgerald (2007) claimed that they provided detailed descriptions of how therapists meet clinical, managerial, and educational challenges As Nissen and Wynn (2014) put it:

“the case report is the only one that presents day-to-day clinical practice,

clinicians‟ diagnostic reasoning, disease management, and follow-up” (p 3) and

“The major advantages of case reporting are the ability to make new observations,

generate hypotheses, accumulate scientific data about rare disorders, do in-depth narrative studies, and serve as a major educational tool” (p 6) From pedagogical

perspective, MCRs have been considered as ideal vehicles for teaching scientific writing (Neely, et al 2008) The idea was proved by Fillyaw (2011) who described the implementation of two courses that prepare physical therapy students to write and disseminate a patient/client-centered case report He concluded that by writing a case report, students were able to exemplify evidence-based practice

First they define their need for information about the patient/client‟s examination diagnosis, prognosis, or treatment into an answerable clinical question Second, they search the peer-reviewed medical literature for the best evidence to answer the clinical question

Third, they appraise the evidence for validity, impact, and applicability to their patient Fourth, they integrate the research evidence with their clinical expertise and experience along with the patient‟s circumstances and preferences to develop a patient/client care plan (p.148)

Consequently, the current research is in line with Greenhalgh (2001) who

voiced the support of the MCRs that “a vocal pressure group within the medical

profession calling for the reinstatement of the humble case report as a useful and valid contribution to medical science” (p.53)

Modern life has brought many benefits to human beings, it is, however responsible for life-threatening risks, especially diseases Many new medications have been launched into the general community every year However, the discovery

of their rare side effects or negative interactions between various medications taken together is revealed only when the study results of some MCRs came out Moore (2007) reported that thanks to MCRs, some specific drugs that caused rare side effects have been removed from the market such as the use of Zomax causing anaphylactic shock ultimately led to the withdrawal of the drug from the pharmaceutical industry

Concerning with the potential motives for publishing case reports in medical journals, Green and Johnson (2000) presented 16 reasons for submitting case reports for publication Helán (2013) then summarized this ideas and suggested

three main aims for publishing contemporary MCRs including “to advance the

knowledge about pathologies and their treatments (i.e., research aims), to demonstrate best practices helping physicians in their daily work (i.e., clinical aims) and to teach lessons through clinical successes and failures (i.e., educational aims).”

The current study thus is in support with the idea of Vandenbroucke (2001) who

states that a case report teaches us what is „un-known‟ or „un-recognized‟ either what medicine does not know yet („progress‟) or what individual doctors have not yet recognized („education‟) Usually there is „the element of surprise‟“ In other words “un-known” and “un-recognized” are two main features that MCRs brought

us The former refers to progress and the latter is concerned with education The

language of MCRs is thus concerned with lexis of description and explanation Although there have been clear limitations to the methodology of case studies in determination of treatment and establishment of new tests, the understanding of particularly rare diseases in terms of etiology, pathogenesis, natural history, and treatment could make contribution to the training of potential junior investigators

2.2.4 Structure of a medical case report

The layout (superstructure) of a medical case report may differ widely according to policies of Journals According to Rison (2013), individual sections of

an actual case report in a sequence that matches the requirements of the specific journals as in Table 3:

The Medical Case Report

Abstract “Background, an introduction about why this case is important and needs

Case

presentation

“A description of the patient‟s relevant demographic information, any relevant medical history of the patient; the patient's symptoms and signs; any tests that were carried out and a description of any treatment or intervention”

Discussion “An evaluation of the patient case for accuracy, validity and uniqueness;

comparison and contrast of the case report to the published literature”

Conclusion “Information on how it will significantly advance our knowledge of a

particular disease etiology or drug mechanism (if appropriate)”

Table 3 The individual sections and their contents of a medical case report

(adopted from Rison, 2013, p 4-5)

Rison concluded that the “Discussion” section might be optional for the above journals However, many researchers, such as Aitken and Marshall (2007), argued that the discussion section was the most important component for medical readers because they put the case into the right context with explanation of treatment decisions and giving an outline of the importance of the case and its future use in everyday medical practice Similarly, Cohen (2006) also agreed that among five

sections, the discussion section was the most important because it evaluated the patient case for accuracy, validity, and uniqueness

Some researchers, for example Nissen and Wynn (2014) stated that the general standard medical case report in the 20th century was towards neutralization of the authors and conventionalization of the textural structure that started with an introduction (usually without a heading) followed by the „case report‟ and the

„discussion‟ sections The conclusion section was considered as optional Helán (2012) because the discussion and conclusion sections were sometimes conflated into a single heading in articles (Adel & Moghadam, 2015) They also concluded that this standardization seemed to be an equivalent to the development of the IMRAD-norm for the quantitative research articles

The overall format of a medical case report in some ways thus resembles the research article However, some medical journals may have their own unique additional technical and orthographic requirements Therefore, the researchers need

to consider when writing medical research articles in general and medical case reports in particular

The MCRs chosen to study in this dissertation are based on general format of

MCRs suggested by Rison (2013) including Abstract, Introduction, Case

presentation and Discussion (More details can be seen in appendices 2.1 and 2.2)

Although conclusion section is seen in some MCRs, it is not put under investigation since they are considered as optional based on the view of Helán (2012) and Adel & Moghadam (2015)

2.3 PREVIOUS STUDIES OF MCRs

Recently, a number of studies have been done in the area of writing in academic and research settings for specific purposes MCRs, ones of the central mechanisms for the exchange of information, also received attention from international linguists Many researchers made an effort to report the discourse structure of MCRs from individual to complete sections

Having seen MCRs as the most narrative (i.e., the least argumentative) and the ones that presented the lowest level of scientific claim, Salager -Meyer (2001)

concluded that introduction academic conflict in MCRs “generally refer to a given

disorder that has never been reported in certain contexts or to the literature that so far has not provided enough information on a particular issue” In addition

academic conflict in the 'comment section was either quite direct and personal or

indirect

Since case presentation plays an important role in a MCR, it has attracted

much attention from linguists Hsuan Hung, et al (2012) identified the rhetorical

structure and linguistic features of case presentations to draw out the differences in

the linguistic features of case presentations between international and Taiwanese medical journals written in English Anspach (1989) examined a significant segment of medical social life: formal presentations of case histories by medical students, interns and residents The analysis focused on the four features: (i) the separation of biological processes from the person; (ii) omission of the agent; (iii) treating medical technology as the agent; and (iv) account markers such as “states”

“reports” and “denies” He concluded that “It is arena in which claims to

knowledge are made and epistemological assumptions are displayed, a linguistic ritual in which physicians learn and enact fundamental beliefs and values of the medical world” (p.1)

M ndez-Cend n (2009) focused on combinatorial patterns in case presentation

section of MCRs The linguistic features in her study were phraseological and

rhetorical structures Corpus-based approach was proposed to retrieve the phraseology specific to medical case reports Her model of move analysis of this section will be applied to the current study It thus will be presented and explained clearly in the chapter II: Theoretical framework

Murawska (2010) has analyzed a corpus of fifty-six medical case reports to reveal how particular linguistic choices (the grammatical, rhetorical, and lexical

configurations of texts) the authors made when writing about patient diagnosis and

treatment contributed to various spatial configurations in patient imaging Using

the figure/ground distinction or “segregation” and the metaphor of a container led him to the conclusion that what medicine focuses on was the patient as a case of a

given disease and not the whole person experiencing illness The results from figures and grounds convinced that the authors seemed to have chosen the patient‟s perspective for the description of the situation because of the fact that the patients were referred to as whole persons and they could be treated as the grounds as well

While “patients as containers” showed that the readers‟ paid attention to the

diseases examined and the treatment performed rather than to the patients themselves In other words, although the patients were textually presented, they did not hold sententially prominent positions

Being interested in the whole section of MCRs in “Hedges and Textual

Communicative Function in Medical English Written Discourse”, Salager-Meyer

(1994) stated from the study of hedges used in both medical research papers (RP) and case reports (CR) that:

“The Discussion (RP) /Comment (CR) sections are the most heavily hedged sections, whereas the Methods (RP) and the Case Report sections (CR) are the least-hedged rhetorical divisions (p=.001 and 071 respectively) The Introduction section of both RP and CR favors shields (mainly epistemic verbs) as a hedging convention followed by approximators (negative or quasi negative expressions in RP Introductions, and adaptors of frequency in CR Introductions) In the Introduction hedges allow researchers to establish

an "early niche" for their research” (p 149)

According to him, to evaluate, interpret and comment on the findings of the research being reported researchers used shields (mostly modal verbs) in result section of RP However, in the Discussion/Comments sections of both RP and CR, the researchers tended to use compound-hedges devices

Helán (2012) used structural move analysis method of English for Specific Purposes (ESP) genre research to examine medical case reports published in on-line medical journals and present-day medical case reports Specific textual aspects deemed important for the investigation have been selected such as biomedical rhetorical features and conventionalized lexis characteristic of this written medical discourse After attempting to explain the key differences between the three established genre research traditions, she used the ESP approach to genre analysis to explain the specific conventions of the medical discourse community, the SFL