Medical narratives in empirical frameworks.

Abstract

This paper examines the use of narrative in medical and scientific research writing by analyzing the research report and the grant proposal, genres familiar to many health care educators and practitioners. It is our intention to outline a pedagogical paradigm based in rhetoric and composition theory which we feel teaches both healthcare professionals and medical researchers to write within (and for) particular workplace environments which seek to provide patient and public health information to a variety of audiences. Narrative has a place in the pedagogy of technical communication for both groups. For technical writers who present complex research and medical information to wider audiences, an understanding of narrative elements present in research writing provides a way to read and interpret, as well as write. Our focus here is on medical researchers where narrative provides an approach to the strict empirical formats they must use in ways which make them more flexible and persuasive. We begin with a theoretical framework for teaching narrative in science and medical research writing in the strict IMRAD (introduction, methods and materials, research and discussion) and in grant-writing, demonstrate the idea of narrative in pedagogical practice, and end with a brief discussion of the implications of using narrative in medical research writing.

Introduction

In recent years, the place and value of narrative in healthcare and the practice of medicine has been clearly established. Studies in patient-physician interaction (Kleinman 1988, Hunter 1991) and in clinical practice (Mattingly 1989, 1998) have explored the ways in which storytelling provides a basis for understanding and surviving illness. But narrative is often regarded as outside the province of medical research writing; as it has been traditionally taught, medical research writing is a domain where language is spare, strict and disciplined, figurative language is nearly non-existent, formal organization and brevity dictate structure and "narrative voice hardly occurs" (Eisenberg 1992, p. 58). In short, it has been argued that medical research writing, especially as portrayed in trade journals, research reports and grant-writing belongs in an arena where no narrative structure is present and no identifiable narrative voice is telling the story. Viewed in this light, medical and scientific research seems a formal discipline, cool and far removed from the chaotic tangle of human endeavor. But if this is the view customarily held by medical and professional writers, it is strangely at odds with the way in which many doctors and scientists view both their work and their writing. In actuality, medical science and research writing are full of storytelling. In several genres common to medical research writing the use of narrative is apparent and it is useful to explicate how healthcare practitioners as well as communication professionals such as writing instructors can teach narrative as an effective means of communicating issues in science and medicine.

In recent years, rhetoricians have emphasized how the conventions of scientific texts operate to define scientific work as a collective, cooperative inquiry. Such a definition combines elements of Aristotelian and contemporary rhetoric. Gross (1990) provides a more contemporary rhetoric that includes both logic and dialectic. Also, departing from Aristotle's differentiation between dialectic and rhetoric, Pera (1991) views scientific rhetoric as "the set of those persuasive, argumentative techniques scientists use in order to reach their conclusions" (p. 35). Such definitions reflect the assumption that writing scientific research cannot be a depersonalized and objective rendering of observations. They also suggest that research reporting may contain elements of narrative. A rhetorical approach to narrative provides a basis for understanding medical research writing in terms of storytelling. Rather than looking at story or narrative merely in terms of the elements emphasized in fiction, such as character, theme and symbol, a rhetorical approach to narrative focuses on elements such as the narrative's teller, the techniques employed, the story itself, the audience and purpose of the narrative (Phelan 1996). All of the rhetorical elements of narrative are present in medical research writing; they are also bound by particular conventions just as fictional narratives are. Although medical research narratives serve audiences accustomed to empirical foundations and frameworks in the reporting of information, they also tell stories whose purposes are to present ideas and observations and engage audiences by employing the rhetorical elements of storytelling.

Theoretical Framework

A literature review of the sociology and rhetoric of science from the early work of Popper (1959, 1962) to Latour & Woolgar (1979) to Bazerman (1983, 1988) indicates a shift in emphasis from researching the relations between the general public and the social institution of science to the social context of scientific writing by exploring how the social context influences the writing process and product. For instance, Latour and Woolgar's (1979) study provides an instance of scientists working within "proper science." Derived from extensive observations of a biochemistry laboratory, they suggest that laboratory activity is a rhetorical process of inscription, whereby research findings are documented in such a way so as to persuade the scientific community that the scientific observations are truths.

Research by Knorr and Knorr (1978) illustrates how laboratory work is intended to be persuasive and, when documented, its purpose is to establish the value of a scientist's research within a particular community or communities of readers. Interestingly, Knorr and Knorr use a market-economy metaphor to describe the purpose of such documentation. For instance, the text must first reconstruct the market, define the market needs, and then identify the research to be reported as the appropriate vehicle for satisfaction of those needs. In short, it must construct a good story that meets the needs and expectations of specific audiences. The idea that storytelling is part of scientific and medical research writing is hardly a new one. Physicians and medical researchers often refer to the need to be able to tell a good story in presenting their work to larger audiences. For instance, one senior scientist in Bekins' (2000) study noted that

   Part of getting funding is being able to tell stories well.
   Why do you need this money? The people who can't tell you in some
   coherent way they might have good ideas, they may be in a good
   laboratory--if they can't tell you what their vision is or how they
   are going to approach a problem ... in some interesting way, they're
   not going to get paid a lot. (p. 132)

Narratives serve many ends, and among their psychological and sociological functions are those of world-building and of discovery and exploration. All these functions are embodied in science itself and, hence, in medical research writing. The movement present in plot produces a dynamic experience for the reader because the narratives move through time and engage the reader's intellect, emotions and judgment. Just as in fiction, in medical research writing, if the story is told well, the tension created by plot/movement is resolved, the reader intrigued, and the story comes to a satisfactory end. In science and medical research writing that end may be gaining new knowledge, confirming existing knowledge, generating new ideas, or on a more pragmatic level, earning publication, winning a grant or passing on specialized knowledge to a wider audience of health care providers. Such writing involves a bit of "marketization'" (Hyland, 2000)--the promotion of oneself through discourse in structured and selective content, reflective of the common ground between the writer and the discourse community. Whether writing a research report or a grant proposal, the author becomes a maker of meaning, a teller of stories. Each provides insight into the strategic balancing act medical researchers seek to attain between reporting originality and telling a good story that catches the reader's attention.

Narrative as Pedagogical Framework

To teach students and scientists to write, we need to recognize how narrative works even in the formulaic structures of science writing. A rhetorical approach to story demonstrates clearly that written medical discourse, even in its strictest formats, uses the essential elements and techniques of storytelling. Re-framing medical research writing in terms of story/narrative helps writers understand the techniques, structures and purposes of the writing tasks which their discipline presents them with. This means a careful analysis of the rhetorical elements present in medical research writing: narrative voice, audience and plot.

Narrative Voice

Although conventional pedagogy insists that there is no narrative voice present in medical research writing, all stories have tellers. In science writing, narrative voice generally follows well-established conventions. The storyteller's voice does not impose itself between the audience and the story, choosing instead to foreground facts and ideas, rather than point of view. Thus, narrative voice wears the mask of the observer, even though, like all narrative voices, the teller makes constant choices about what is told and what is withheld, what is foregrounded and what is backgrounded, and in what order events and data are presented. Traditionally, this has been done through the use of impersonal, passive voice forms which eliminate the explicit presence of a storyteller. (Harding & O'Barr, 1997) However, recently medical and scientific writers have achieved the desired effect through the use of a collective "we" and the use of active voice forms, thereby speaking directly to the audience and also allowing the sense of story to emerge more clearly. For example, in a research report in microbiology, the lead writer uses "we" and refers to "our group." This shift away from the impersonal passive also means that verbs move from passive to active mode ("we evaluated," "we compared," "we synthesized") so that while the passive voice is maintained in the Materials and Methods section, as is the convention in laboratory studies, the use of the collective voice allows the writer to maintain the sense of the human activity involved in a medical research laboratory (Kern et al., 2001). Learning to tell the story in a voice that maintains a necessary measure of formality and authority and at the same time, speaks engagingly to audiences whose backgrounds may vary widely is an important skill for both medical researchers and professional writers. By comparing the ways in which narrative voice is created and sustained both in research articles and in those texts written for a wider audience of health care providers and lay people, our students may learn how to shift narrative voice to accommodate various audiences.

In science writing, the storyteller's voice must be straightforward, reliable and sell-aware; there can be no naive narrators here. Unlike narrative voice in fiction, this voice reflects a commitment to truth based on two assumptions: first, that there are truths to be found in the story being told; and second, that it is the ethical responsibility of the storyteller to present the facts that embody those truths as clearly as possible. Those two assumptions also shape the scientist-storyteller's choice of language and of tropes like metaphor, for example. Figurative language is rare in reporting quantitative research because language must be both precise and powerful as it deals with the concrete and particular in its descriptions. But in writing medical research for wider audiences, in grant proposals and research reports, analogy and metaphor can create familiar ground for an audience unfamiliar with the material and can be powerfully persuasive in creating a narrative. To demonstrate the uses of figurative language, we ask our students to analyze rhetorically both the professional and public writing of medical doctors and researchers like Dr. Lewis Thomas (1974) and psychiatrist Dr. Oliver Sachs (1998). Thomas, an eminent physician, writer, and biologist, and a regular contributor to the Journal of the American medical association (JAMA) and Sachs, a British-trained neurologist now living in New York, whose books deal with neurological conditions and the neurophysiological mechanisms causing them, are both excellent writers. Their work, intended for both a professional and lay public, makes extensive use of narrative techniques. Class exercises in rhetorical analysis based their work provide our graduate students on both medical research and professional writing tracks multiple examples of how such tropes can be used to explain complex medical and scientific concepts.

Every process of investigation involves emotions: curiosity, puzzlement, frustration, disappointment, excitement, wonder and even awe are all present in the course of any medical study. Of course, the idea of emotion in a medical article will be immediately rejected by an objective, de-personalized view of science writing. While it is true that medical narratives may deliberately background these emotions, it is disingenuous to assume that discovery and exploration do not evoke emotion and that any account of these activities does not embody these emotions. We see this in the work of Thomas and Sachs, which captures the emotional charge of the process of scientific discovery.

Audience

An understanding of audience is crucial to any narrative. In medical research writing, the writer has a distinct advantage over the fiction writer because audiences for medical articles self-select to a high degree. A group of molecular biologists preparing an article on their latest study know that the overwhelming majority of their readers will consist of peers, colleagues, and students already interested or actively involved in similar areas. This means that they can assume a high degree of interest in the subject matter, a reasonable amount of background knowledge and experience in the area, and similar levels of education and training in their audience. For instance when applying for grant monies, scientists often communicate both formally and informally to establish relationships with their professional communities, building consensus among their colleagues in an effort to gain visibility and credibility for their research. Myers' (1985) research on the grant writing practices of two biologists illustrates such communication practices and provides a vivid example of the role narrative plays in medical research writing. Through interviews and textual analysis of proposal drafts, Myers shows how the participants come to two different strategies for presenting themselves in their proposals (neither too meek nor too assertive) and for making claims about their work. To varying degrees, both writers made extensive revisions to the proposal drafts in an attempt to (re)situate their work within the accepted norms of the larger community.

Plot

Bazerman (1988) has suggested that writers' "interests are best served by developing standards for public argument and adhering to them" (135). In the case of writing medical research, a variety of healthcare audiences are well served by the familiar structure of the research report, which can facilitate the ease with which research stories can be absorbed. This format consists of four sections--introduction, methods and materials, research and discussion--and is commonly referred to as the IMRAD format. The IMRAD format will point immediately and clearly to the purpose of a research narrative. Because both lay people and healthcare personnel encounter the IMRAD format very early on in their undergraduate educational process in writing lab reports for required classes in biology, the structure provides a wide variety of audiences with a familiar pathway into the narrative of medical research. At the center of all narrative is plot, observes Aristotle. He views narrative as a sequence of events, ideas, and/or thoughts that produce a rhythmic movement, and arrive at a satisfactory end (1997). His description here could easily characterize the movement we find in the sequence of ideas, events and observations that forms the introduction, methods, results and discussion of the IMRAD format discussed above. Each section of the IMRAD format contributes to the movement (plot) required of a successful story. For example, the introduction section of the report must background the study and delineate the question with which the study is going to be concerned, much in the same way that the opening of a story introduces the situation and the complications which will drive the plot forward.

The material in the introduction section of the IMRAD format must also catch the reader's attention and produce a sense of curiosity and interest about the story that will keep the reader engaged. The introduction needs to present not merely the facts of the background story, but must also convey a sense of the importance or urgency of the questions to be answered by the study. Plot movement comes not only from the use of rhetorical techniques, but also from the tensions between writer and reader that arise from substantive gaps in knowledge that the writer, who is presenting a story of discovery or new knowledge, writes to resolve (Phalen 1996). The idea of plot, while it originates in narrative, is also implicit in the work of John Swales, who has identified the movement within the introductory section of medical formats in terms of "moves" (Swales 1990). These moves are not meant to be sudden shifts from one idea to the next like adversarial moves in a game of chess. Rather, they are plot moves, flowing smoothly together to carry the reader along a narrative track. The idea of narrative "moves" serves writers not only as an analytical tool, but also as a useful practice in creating scientific and research narratives, allowing an easy transition from writing theory to the practice of writing itself.

Implications for teaching medical/science writing

In our classroom practice, we have found that emphasizing narrative in science writing generates renewed interest in taking on the writing tasks which can often seem an onerous but necessary part of science and medicine. When we asked students in a scientific/medical research writing class to read research articles in their areas (microbiology, organic chemistry and cell biology) and then re-cast the information in terms of story, we found that not only were they able to do so, but they were surprised to discover that the information they found fit so easily into the framework of narrative.

Writing, for medical researchers, healthcare personnel and scientists, is critical to the development and dissemination of their work, as it is to a wide range of healthcare providers and laypeople. We have found that using narrative as a paradigm for medical research and science writing eases the task for many writers. Researchers and scientists are able to understand both their work and their writing as part of an enterprise that goes well beyond labs, hospitals and consulting rooms. Technical writers who are translating medical research for wider audiences of lay readers find that their perception of medical and scientific research is strengthened by an understanding of how narratives are embodied in research reports. Writing and reading medical research as storytelling not only makes the task easier and more interesting for the writer, but also produces texts that are more comprehensible for a variety of audiences.

References

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Jane Robinett, San Diego State University Linn K. Bekins, San Diego State University

Robinett is Associate Professor in rhetoric and writing studies and Bekins is Associate Professor and a consultant specializing in technical and scientific writing.