The Handbook of Discourse Analysis

Language and Medicine 477
the communicative functions of particular variables (tense, active vs. passive voice,
exponents of modality, hedging devices, connectives, negatives, interrogatives) within
each one. A secondary agenda of the research by this group is pedagogical/ESLoriented,
i.e. to help nonnative medical students to recognize the discursive conventions
of genres of medical English and to write well-structured texts. Also ESL-oriented
are Van Naerssen’s study on the lexicon, syntax, and discourse organization of
the medical record (1985) and Pettinari (1983) on the use in surgical reports of distinct
constructions for introducing “thematic” and “non-thematic” information (defined in
terms of relevance, from the surgeon’s perspective, to the goal of the surgical event).
2.3.2 Case histories
Among written genres of medical discourse, the case history has garnered the most
attention, by far, and elicited the loudest call for reform – of its language as well the
approach to medical practice that it reflects. 14
The case history follows a ritualized format involving the frequent use of certain
words, phrases, and syntactic forms, and a characteristic discourse organization.
It includes information on how the patient’s condition was noticed and diagnosed,
how the condition has been treated, and how the patient responded to treatment.
Psychosocial aspects of the case are presented (if at all) only after the medical problems
have been discussed. The “problem-oriented medical record” favored by most
teaching hospitals today (Weed 1970) organizes this information into four macrocategories,
hygienically abbreviated SOAP: Subjective (the patient’s statement of his
or her condition), Objective (the physician’s observations of the patient’s condition),
Assessment, and Plan.
Significant in this model is the fact that patients’ accounts are set apart and relegated
to the domain of the “subjective” – a negatively valued category in the world of science
(see below) – and their observations are typically introduced using nonfactive predicators.
Patients “state,” “report,” “claim,” “complain of,” “admit,” or “deny” (see the
excerpt below); 15 physicians “note,” “observe,” or “find” (Anspach 1988: 368) – factive
predicators that put a stamp of truth/objectivity on the information that follows. Writers
of case histories tend to present information obtained from physicians (themselves or
others) as factual, while treating information from patients as “an account” (Anspach
1988: 369; cf. n. 31 below). This is presumably done unconsciously; the “evidential” 16
skewing is an artifact of the linguistic conventions of the genre. The example below is
the history portion of the hospital admission summary (written by a resident) of a
patient admitted for obstetrical care (from Anspach 1988: 373–4, my emphasis):
E. HISTORY (OB) DATE OF ADMISSION:
11/07/84
The patient is a 21 year old Gravida III, Para I, Ab I black female at 32 weeks
gestation, by her dates. She states that she has been having uterine contractions every
thirty minutes, beginning two days prior to admission. The patient has a history of
vaginal bleeding on 10/23, at which time she reports she was seen in the ______
Emergency Room and sent home. Additionally, she does state that there is fetal movement.
She denies any rupture of membranes. She states that she has a known history
of sickle-cell trait.