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 ANALYSIS Cá

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

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

Firstly, I would like to express my deep gratitude to my supervisor, AssociateProfessor Doctor Le Hung Tien, for his continuous constructive suggestions,guidance, help and encouragement over the last few years Thanks to his constantpresence and aid, I can overcome many obstacles and hurdles along the stressfulwriting stages of this dissertation and find the motivation to keep moving on myown work

Secondly, I would also like to thank Doctor Huynh Anh Tuan from VNU, HanoiUniversity of Languages and International Studies, Faculty of Post Graduate Studiesand Doctor Pham Hien from Vietnam Institute of Lexicography and Encyclopaediawho contributed to this dissertation Their valuable and thought-provoking commentsand 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 teachersfrom the VNU, Hanoi University of Languages and International Studies whom Ihad during my coursework years for acting as members of the examinationcommittee and for their constructive questions, suggestions and comments aboutthis research

Next, I express my sincere and deepest gratitude to my friends andcolleagues from Faculty of Foreign Languages, Vietnam Military MedicalUniversity who has patiently listened to all my problems and helped me at differentstages of this research over the last few years Thank them for all the vividdiscussions we have had

Most importantly, I would not have been able to complete this work withoutthe 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 andsupported me in all of my decisions I would like to thank them for theirunconditional, 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, hasmotivated me endlessly

as a descriptive, qualitative, quantitative and comparative study The resultsobtained 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 ofthe MCRs was made up of twelve conventional moves with 22 steps Second, theVietnamese 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 asdiversified 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 becausethe writers may lack judicious use of the RVs, efficiency in using the verbs, orcreativity of successful academic discourse The study acknowledged somelimitations: First, the order of the moves was still neglected and second, it would bebetter if the thesis dealt with reporting verbs in some depth, taking intoconsideration the interpersonal function of language Despite these limitations, thestudy is hoped to provide some pedagogical implications for teaching ESP inVietnamese settings to help students to be aware of the moves and steps whenwriting 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

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

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 andtherapeutic measures According to Li et al (2013), MCRs are employed as aplatform for the training of medical students and resident doctors in scientificwriting and critical thinking MCRs are also an excellent means of describingimportant adverse drug effects and for postulating links between previouslyunrelated symptoms, signs and syndromes In addition, they can and should suggestnew hypotheses and stimulate further studies However, compared to other research

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

In Vietnam, the limited amount of research about MCRs has lead to a limitedunderstanding in describing this structured writing and the understanding ofscholars in the medical field trying to publish their research into internationaljournals Almost all linguistic research concerning with the biomedical field hasfocused on finding the ways of translating medical terms from English toVietnamese in order to standardize the system of Vietnamese medical terms and topropose 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 ofmedical language due to different theoretical perspectives, different analyticalmethods, or different research emphases Nevertheless, so far, no reported researchhas been devoted to the contrastive analysis about the genre of MCRs in Englishand Vietnamese The issue thus has been an uncultivated land within Vietnameseapplied 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 moveanalysis when analyzing a genre is emphasized by many linguists Bonyadi (2012),for example, agreed, “The central to the analysis of a certain genre is theidentification of the moves in a text based on the conventions set by the discoursecommunity” (p.7) Similarly, Biber et al., (2007) claim that move analysis is asubset of genre analysis that examines discourse by concentrating on itsorganization In their opinion, moves are considered as functional units in a text,together fulfilling the overall purpose of the genre and “moves of genre areconsidered 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 canunderstand how to conform to the overall organization as well as how to use certainexpressions and vocabulary commonly employed in their respective discoursecommunities and academic disciplines Secondly, they can read and write a medicalresearch 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 highereducation setting.

1.2 Scope of the study

The moves are analyzed in terms of their frequency, length and steps while thelexical signals are analyzed regarding words/phrases and reporting verbs.(Reporting verbs are known as one of the explicit ways for writers to establish thecredibility of the reported claims and considered as one of the lexical devices thatwriters need for both expressing a stance and connecting or aligning themselveswith the readers in scientific articles) In clinical settings, medical research papersare considered as persuasive texts by nature, and in reporting work by others, theirauthors 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 anevaluative stance The current research studies how the reporting verbs work in themoves and how a researcher can use the verbs in a specific context to showdisagreement or agreement with the findings of others During the analysis, thetaxonomy suggested by Hyland‟s (2002) including Research Acts Cognition Actsand 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 usedwith the focus on move analysis to analyze the moves in English and VietnameseMCRs with the following aims: (1) to explore how the moves and lexical signals ofthe 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 researchquestions:

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 modelsadopted 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 ofhow the English and Vietnamese researchers arrange moves in their writing

1.4 Research methods

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

is a Mixed Method Research Design According to Lazaraton (2005, p 219 cited inAngouri, 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 datashows how the moves and lexical signals are used by English and Vietnamesewriters 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 andVietnamese not only of the surface linguistic features but also of the discourseconventions and underlying socio-cultural values In addition, it equips medicalstaffs with basic knowledge of English cultural background and understanding ofthe specific genre in both languages

1.5.2 Practical significance

The findings of the study help the lecturers develop pedagogical strategies andaddress problems in the context of a process-oriented writing course with theevidence of cross-linguistic influence and differences in discourse Moreover, theysupport students, doctors, researchers and medical staffs in studying, translating andwriting MCRs in Vietnamese and English in social contexts relevant to theireducational, social and cultural needs More importantly, the results makecontribution to promoting and popularizing the medical achievements of training,scientific research and treatment of Vietnamese medicine in general and VietnamMilitary Medical University where the author has been working as a teacher ofEnglish 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 isdesigned with the following main sections The first section deals with a criticalreview 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 studiedissues It also gives the reasons for the use of the appropriate approach in the currentresearch The next section concentrates on the genre of MCRs and the last sectionfocuses on the description of the move analysis as the theoretical framework for thecurrent study.

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

methodology for the current study in which the description of data set, the modifiedmodel, the analytical framework and the procedures of the moves analysis aregiven

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

presents the main results of move analyses of English and Vietnamese MCRsregarding the move frequency, length, steps, typical phrases and reporting verbs.The analyses are carried out section-by-section (Abstract, Introduction, Casepresentation 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 identifieditems English and Vietnamese authors used in their papers During the analyses, thepossible reasons for the similarities and differences in English and VietnameseMCRs 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 pedagogicalimplications, contribution and limitations of the study It closes with somesuggestions for further studies

CHAPTER II LITERATURE REVIEW

This chapter encompasses a literature review of the following issues First, threebroad schools of genre analysis are reviewed in terms of their different conceptionand pedagogical approaches: Systemic Functional Linguistics (also known as theSydney School), North American New Rhetoric studies, and English for SpecificPurposes (ESP) tradition In addition, the distinction between genre analysis andregister 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 concernswith the general understanding about the genre of medical case reports (MCRs)such as the definition, their benefits and limitations and the structure The genre iscompared to other kinds of genre used in clinical settings The chapter thenexamines the previous research of the different sections of MCRs and discussestheir limitations that the current study may do to fill the gaps Finally, it establishesthe 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 toidentify the moves and strategies of a genre, the allowable order of the moves, andthe key linguistic features The next step was to explain why these features werechosen by expert users of the genre to achieve their communicative purpose Thesimilar 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 ofdifferent text types According to the father of genre, Swales (1990), genre analysiswas the study of how language was used within a particular setting Rhetoricalstyles 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 educationallinguistics (also referred to as the Sydney School) drawing on Systemic FunctionalLinguistics (SFL), (ii) Rhetorical Genre Studies (RGS, also known as NorthAmerican Genre Theory) drawing on and contributing to New Rhetoric and (iii)English for Specific Purposes (ESP) – an umbrella term for areas of English studysuch as academic English, medical English, legal English or business English Thefollowing 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 asSystemic-Functional Linguistics approach) was founded by a British-born scholarHalliday with the focus on the relationship between language and its functions insociety 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 thelanguage as belonging to one of the semiotic systems constituting a culture.Consequently, the language can be interpreted in the context of culture and thestructure 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 theideational, interpersonal, and textual Ideational metafunction deals with how thelanguage is used to represent our experiences of the physical, the psychological andthe social world They can be realized through the „system of transitivity‟ with thefocus on „a process‟ (realized by a verbal group) „the participants‟ involves(realized by nominal groups) and their „circumstances‟ (realized by adverbialgroups) 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‟sauthors and their representations Textual metafunction expresses how the text isorganized in relation to its context and its message through the „system ofTheme/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 cancreate the context of a text and the register elements can activate different areas ofsemantics 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) Itrefers 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) Theregister 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 inany 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 ofthe 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” thesummary makes the SFL theory clearer

The SFL theory of Halliday‟s work (2006) has attracted much attention fromsome researchers (Eggins, 2004), for example, provided an accessible first step intosystemic for those who wish to equip themselves with the conceptual and practicaltools to analyse and explain how people make meanings with each other ineveryday contexts (Martin & Rose, 2008), on the other hand, introduced ourgeneral 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 Sheadded a new framework of functional linguistic analysis focusing not only on thestructure of words and sentences, but also on how particular grammatical choicescreated meanings in the different kinds of texts students were asked to read andwrite 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, butalso 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 discourseperforms the rhetorical action as pragmatics, the genre thus must focus on the actionnot on the substance or the form of discourse it was used to accomplish Theunderstanding of genre in her work in 1984 can be summarized as follows:

needs (exigence)

Some further entailments of genre as social action include these

considerations:

categories; as such genres collectively help to “constitute” society inGiddens‟s sense (Giddens 1984)

study them

constitute a neat, mutually exclusive taxonomy (Miller, 2015)

According to Coe and Freedman (1998), the theory studied how particulardiscourses 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 thatinstead 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 approachbrought to education Bawarshi & Reif (ibid.), for example, wondered what thepedagogical 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 acertain function within an activity system In this case, they would likely select amediational means (a genre or set of genres) that is appropriate to theirunderstanding of the objective Subjectivity compatible with that understandingcould be unavoidable because although some students may recognize theobject/motives, they may not have accessed to the appropriate mediational means.According to them, how we used the mediational means depended on how weunderstand the object and outcomes

Miller (2015) did a new research to revisit her work in 1984 and concluded thatthe 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 Englishfor 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 andprofessional discourse communities are the principal research objectives

From a pedagogic perspective, the description of ESP genre may be useful ininstructing ESP learners In ESP, language analysis tasks help learners gainawareness of the communicative purposes and linguistic features of texts that theyneed 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 thenature of writing, understand and master the organizational and stylistic features ofprofessional and academic genres

In ESP genre analysis “move” and “step” are the central recognition that havebeen 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 leveland step provided a more detailed rhetorical means of realizing the function of amove

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 Communicationcan be through text or confrontation Information exchange is relative to thecommon goals Discourse communities develop around the genres upon which itestablishes itself Lexis is essentially a compilation of vocabulary, so eachcommunity has its own terminology specific to that group There should be areasonable 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 discoursecommunity are able to recognize the purposes of a genre As a rule, the people whohave just been initiated into the discourse community are less capable of doing.The main difference between discourse and speech communities is thatdiscourse communities separate the existing people into groups whereas speechcommunities are looking to include outsiders In other words Swales‟ discoursecommunity here is distinguished from speech community in sociolinguistics Insociolinguistics, the main objective of the community is in the socializing of itsmembers whereas in Swales the main objective of the discourse community is in itsmembers‟ sharing of the same interest either social or academic

Swale‟s (1990) definition of genre attempts to capture how writers achieve theirsocial purposes by using various structural forms, constructing different focuses andmanipulating 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 aconventionalized setting and the structure The former reflects the communicativepurpose 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 ofthe 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 communicativepurpose(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

EAP: English for Academic Purposes; L1/L2: first/second language

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

16

Reiff (2010) According to them, although SFL and ESP genre approaches bothagree that linguistic features are connected to social context and function, they differ

in their applied target audience, theory behind them and the methods of textanalysis 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 (thestudy of genre involves an ethnographic study of the surrounding social context) Inthis approach, the analysts try to analyze a genre through the study of the society inwhich the genre is used Therefore, the method of analysis is more akin to that ofethnomethodology In the ESP approach, genre is defined as a class ofcommunicative events The analysts look for textual patterns common in a genre byanalyzing the moves The level of analysis is not only look at the level of text butalso the lexico-grammatical level The analysts look at the use and the meaning of aparticular word or phrase in a particular genre

in its approach, while the Sydney school worked with well-developed linguistictheory and descriptive model In addition, the ESP approach is easy to apply whilethe SFL school is more detailed and requires training in the theory and analysis Onthe 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, especiallySwales‟ theory to apply to the current study It is relevant to the purposes of thisstudy for the following reasons First, it gives priority to EAP, particularly to EMP(English for Medical Purposes) Second, it gives the application of discoursecommunity through written communication (specialized texts known as MCRs)among healthcare professionals who use highly specialized terminology, specificabbreviations and acronyms that can be easily recognized by fellow communitymembers Lastly, Swales‟ model not only focuses on rhetorical organization butalso 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 linguistssuch 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 registerincluding language of scientific or newspaper reporting and bureaucratic language ismore generalizable stylistic

Nunan (2008) also distinguished genre and register by saying that while genrerelated to the context of culture, register related to the context of situation Registeranalysis thus examined the relationship between a text and the situational contextsurrounding 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 themetafunctional 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 thecontext of culture According to Swales (1990), the emphasis of genre studies fallsinto 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, thefindings from register analysis do not provide adequate insights about the wayinformation is structured in particular variety since it emphasizes on surfacefeatures 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 featuresrelated to genre, shapes the genre and gives it internal structure

Since genre analysis involves not only the analysis of lexico-grammaticalfeatures but also the analysis of text-patterning or textualization and structuralinterpretation of the text – genre, it becomes possible to justify the use of the termgenre analysis for the analysis undertaken in this dissertation

In this study, the genre chosen to study is from the field of professional medicalwriting known as Medical Case Reports (MCRs) This genre is carried out as part ofthe everyday routine in hospitals and other health-care facilities and has received closeattention 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 singlepatient

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 themost objective, statistically and reliable studies to the most subjective

trials addressing the same medical question The research tends to be morereliable, accurate conclusions, more generalizable findings and more consistentresults because it can identify weak studies and limit bias

randomly selected and offer a medical standard intervention RCTs are the goldstandard in medical research because their aims are to reduce bias when testing anew treatment and they allow rigorous evaluation of a single variable in aprecisely defined patient group However, RCTs are claimed to be expensive andtime consuming

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 orother outcome Cohort studies may take years or even decades to measure

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

habits, etc of a representative sample of randomly selected patients are collected

by interviewing or using questionnaires

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 asrelatively weak scientific evidence and (RCTs) are believed to be the most usefulmethod for confirming a specific treatment option However, MCRs play animportant role in recognizing adverse outcomes because every patient responds to atreatment in a different way In addition, as highlighted above, MCRs are the firstindications of rare adverse reactions among the other methods in clinical settings.(Greenhalgh, 2001) To understand the more about MCRs, the following sectionsfocus 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 thedevelopment of a pathological condition, its diagnosis and treatment in a singlepatient, MCRs have not been appreciated as highly as the genre of medical researcharticles 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 avoidthem In addition, they should focus on new syndromes, manifestations,associations, complications, or outcomes

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

of clinical information played an important role in teaching the medicalprofessionals about something new or important The idea is presented clearly byhim 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 casereports in clinical medicine According to him, MCRs recognized and describednew diseases or rare manifestations of disease, detecting side effects of drugs, andmedical education and audit In physical therapy, on the other hand, Fitzgerald(2007) claimed that they provided detailed descriptions of how therapists meetclinical, 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 scientificwriting (Neely, et al 2008) The idea was proved by Fillyaw (2011) who describedthe implementation of two courses that prepare physical therapy students to writeand disseminate a patient/client-centered case report He concluded that by writing acase 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, howeverresponsible for life-threatening risks, especially diseases Many new medicationshave been launched into the general community every year However, the discovery

of their rare side effects or negative interactions between various medications takentogether 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 sideeffects have been removed from the market such as the use of Zomax causinganaphylactic shock ultimately led to the withdrawal of the drug from thepharmaceutical industry

Concerning with the potential motives for publishing case reports in medicaljournals, Green and Johnson (2000) presented 16 reasons for submitting case reportsfor 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 indetermination of treatment and establishment of new tests, the understanding ofparticularly rare diseases in terms of etiology, pathogenesis, natural history, andtreatment 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 widelyaccording to policies of Journals According to Rison (2013), individual sections of

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

The Medical Case Report

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

intervention”

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

Discussion

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

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

Conclusion

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 abovejournals However, many researchers, such as Aitken and Marshall (2007), arguedthat the discussion section was the most important component for medical readersbecause they put the case into the right context with explanation of treatmentdecisions and giving an outline of the importance of the case and its future use ineveryday medical practice Similarly, Cohen (2006) also agreed that among five

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

Some researchers, for example Nissen and Wynn (2014) stated that the generalstandard medical case report in the 20th century was towards neutralization of theauthors and conventionalization of the textural structure that started with anintroduction (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 conflatedinto a single heading in articles (Adel & Moghadam, 2015) They also concludedthat this standardization seemed to be an equivalent to the development of theIMRAD-norm for the quantitative research articles

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

to consider when writing medical research articles in general and medical casereports 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 investigationsince 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 academicand research settings for specific purposes MCRs, ones of the central mechanismsfor the exchange of information, also received attention from international linguists.Many researchers made an effort to report the discourse structure of MCRs fromindividual to complete sections

Having seen MCRs as the most narrative (i.e., the least argumentative) and theones 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 Taiwanesemedical 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 ofbiological processes from the person; (ii) omission of the agent; (iii) treatingmedical 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)

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

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

Murawska (2010) has analyzed a corpus of fifty-six medical case reports toreveal 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 ledhim to the conclusion that what medicine focuses on was the patient as a case of a