Lingua Franca and Beyond

Section Editor:
Maria Kotowska-Hggstrm
maria.koltowska-haggstrom@
propermedicalwriting.com

Welcome to Lingua Franca and

Beyond
Writing is something that I have
always loved. Actually, as a teenager I would have studied literature, but I changed my mind at
the last year at school. I became a
paediatrician instead for a few
years but then little by little, my career turned
towards writing, precisely medical writing. However,
I am not a native English speaker I am Polish. My
mother tongue does not even belong to the Germanic
languages, and my language roots are completely
different. This difference and my overall background
made me think that I would never be able to write
medical papers in English. Then life started to create
a different scenario: I discovered EMWA, a bunch of
open and friendly people. Laura Collada, who is
EMWAs Public Relations Officer, convinced me to
start as administrator of the EMWA discussion group
on LinkedIn, and Phillip Leventhal, the Editor-inChief of Medical Writing, encouraged me to become
editor of a new section for medical writers like me,
who either write in English as a second language or
who write in languages other than English.
I feel strongly that Medical Writing needs a section
for non-native speakers. Interestingly, I had already
been thinking quite a bit about what it means to be a
non-native English-speaking medical writer. Does it
only mean problems with expressing thoughts correctly or using funny language constructions that
make people laugh? Yes, of course, being a
medical writer is a lot about having a good
command of English, which we, non-native
English speakers, must work hard to attain.
While preparing to write this editorial, I Googled a
bit for various combinations of non-native Englishspeaking, medical writing, scientific writing,
and so on. Surprisingly, almost all hits related to
grammar, vocabulary, punctuation in summary,
to linguistic problems. There were few blogs where
people shared their experience in writing or
advised how to improve English writing skills.
I found no links about what it means to be nonnative English-speaking medical writer.

46

The European Medical Writers Association 2015

DOI: 10.1179/2047480614Z.000000000262

Is it only about language? Definitely not. To me,

overall, being a medical writer means understanding science and being able to structure often complicated research concepts in a comprehensible way. It
also means being able to communicate with the
authors and grasping their ideas. Lastly, while
trying to answer my question, I realised that one of
the main tasks of medical writers is to help researchers publish their results and communicate their key
messages. Here, the difference between non-native
and native English-speaking medical writers comes
in. Very often, those researchers are non-native
English speakers who write poorly in English and
who therefore translate their texts, word by word,
into English. Language per se is a cultural notion,
reflecting mentality and the way of thinking, and
therefore knowing the mentality and the way of
thinking is often critical for understanding and
translating texts into proper English.
Eventually, I realised that being a non-native
English medical writer has advantages, for example,
having the same cultural and linguistic background
as those whose texts are edited, and thus understanding much more easily what the authors intended to
say. It does not mean, though, that we can manage
to make it all happen on our own. We often work
closely with our native English-speaking colleagues.
Working internationally means working in teams.
So what about medical writers who dont write in
English? Everything that I have written so far is about
medical writing in English, but many articles are
written in our native languages. This aspect must
not be forgotten. I am sure that we will read more
about our experiences in writing in other languages.
Although I dont know how this section will
evolve, I know what I want this section to be: a
forum for us, the non-native English-speaking
medical writers, where we can tell each other
about our work experiences, our thoughts, and our
funny stories. I also want us to be able to share
our experiences working with clients from different
languages and cultures and our thoughts on the
international medical writing community.
Finally, I am pleased to introduce the first article
in this section. Rossella Ferrari from Milan, Italy
shares with us her thoughts on cultural and linguistic differences that impact the way we write.

Medical Writing

2015

VOL.

24

NO.

Ferrari Medical writing for non-native English speakers

If you would like to share your experiences

and knowledge with other non-native Englishspeaking medical writers, please contact me at
[email protected].
Everybody is welcome to help make this section
interesting reading.

Acknowledgements

Medical writing for non-native

English speakers: Burden and
opportunity

American and British authors served as the control

group for a sample of 120 articles that were analysed
without the knowledge of the authors nationality
and cross-checking. Overall, the control group had
almost the same acceptance rate (30.4%) and
overall error rate as the test group. No direct
relationship between acceptance rate and number
of language errors was detected even if the badly
written articles clearly correlated with a high rejection rate.
The structure of manuscripts, cultural errors,
grammar and style, and wording are often identified
as the main key issues for NNEs.8 Stylistic differences between American and British English add
further difficulties for NNEs, particularly when a
manuscript has to be submitted to a British or
American journal. Besides, the definition of a
grammar error is not always simple as, for
example, in the use of tense in the discussion
section of original articles.7
To extract and disseminate all the relevant scientific information and evidence, including that coming
from countries with NNEs who have published in
their mother tongue, a bilingual online publication
system has been proposed as a first step to overcome
language barriers in global scientific communication. Establishing a bilingual society in each
European country seems to be the best or the only
solution to the problem, but, although theoretically
acceptable, reaching this objective may be time-consuming.9 Since not every medical writer is in the
lucky position of having an English professional or
colleague who can revise their manuscript, as long
as a society becomes bilingual, most NNEs basically
have to count on themselves for this task.

The amount of information transmitted in a particular language makes it what we define as the
language of science,1 and the dominance of the
English language (the lingua franca) in science has
been long established.24 However, if we consider
the life science peer-reviewed journals, currently
non-native English-speaking authors contributed
about 50% of publications,5 a trend that continues
to increase.
The circumstances and opportunities of medical
writing in English are mainly related to manuscript
publication (original or review articles) but not only.
Other tasks to complete include training manuals
for international sales task forces, PowerPoint presentations, international meeting reports, and fact
sheets.
For non-native English speakers (NNEs) involved
in medical writing, the challenge consists not only of
speaking a second language (English) but also
adding a third language, that is, the biomedical
language, which gives rise to further difficulties.6
As Italian is my native language, in this article I
have tried to focus on several aetiological factors
that give rise to hurdles in medical writing in
English; I present practical suggestions wherever I
have found them in the literature together with
some of my personal reflections. In this approach,
some hints coming from scientific writing are suitable even for medical writing in English. I have
also benefited from several contributions made
by applied linguistic researchers, who have conducted studies in the use of English for academic
purposes.

Needs to meet
In terms of publication success, historically, the rate
of acceptance of manuscripts originating from
NNEs is lower than from native English speakers
(NEs), however this depends on the specific
medical area and varies over time. In 2002, an
Italian survey was conducted of publications in the
journal Cardiovascular Research.7 A group of

Medical Writing

2015

VOL.

24

NO.

I thank Amy Whereat and Philip Leventhal for help

editing this text.
Maria Kotowska-Hggstrm
[email protected]

Structure
The organisational strategy needed to publish a
manuscript may be one of the major opportunities
to improve writing in any native language. Correct
structures are the undeniable condition for clear
communication because they improve the readability of our texts. For example, a sentence usually
starts by creating perspective and then moves on
to convey new information in the next stress position (at the end of the sentence): this is a rhetorical

47

Ferrari Medical writing for non-native English speakers

English emphasis pattern. The proximity of subject

and verb immediately states the essence of information; connector devices create a cohesive flow of
information and coherence through paragraphs.
This is some of the most fundamental advice to
ensure correct text organisation.1012
Organising the structure of a text meaning the
information flow with cohesion and clarity
compels us to provide a logical and sequential order
to the ideas we intend to communicate.13 Yet, as linguistic researchers state, the organisational capabilities
and practices are quite different between cultural
groups because of different patterns or approaching
modalities of the ideas to be presented. This means
that different writing structures are linked to different
thought patterns: the English pattern is a straight line
of sequence, from introduction through to conclusion,
whereas the pattern is circular for Asians, underlying
an indirect style of presentation of ideas, and the
arrangement is a zigzag trajectory for Latin people
(Romance style), with the intent of encompassing all
the aspects of an issue.14
These spontaneous aptitudes of NNEs must be
changed in the English pattern to adapt the manuscript for the academic audience. In effect, a more
organised sequence of ideas allows not only better
control of the logical links between arguments but
also more concise text and relevant information to
be transmitted.
Cultural errors
A non-linear structure for scientific articles or discourses can provoke cultural errors, as linguistic
researchers tell us. In the English linear structure,
themes are presented by a succession of deductions
in which one idea is directly linked to the next. Each
paragraph begins with the general knowledge or the
previous text, then introduces and develops new
information, and ends when a new paragraph,
with other information, is needed. The text structure
should be planned by a hierarchy of importance to
spell out the main idea and its subtopics or other
ideas. The same key words and pattern of sentences
are preferable and effective for showing similarities
and differences in the manuscript sections
(Introduction, Methods, Results and Discussion);
indeed, limited key terms facilitate the readability
for readers and reviewers.13
Usually, NNEs lack in subordinate sentences,
which leads to an undifferentiated or non-hierarchical text structure. The management of defining and
non-defining relative clauses may be different in
English from other languages and it is often a
source of concern for NNEs.

48

Medical Writing

2015

VOL.

24

NO.

The use of a preposition in the continuum from

possibility or probability to certainty, and from
specificity to generality, is qualified by means of
the modality system, which encompasses an array
of devices coming from all the grammatical categories and the syntactical and organisational structure of sentences; this is often a critical area for
NNEs. In the analysis of manuscripts prepared by
NNEs, the incorrect use of the (the definite article),
due to its modality function, constituted the most
frequent mistake, followed by grammar (tense)
and sentence structure errors.
Apart from lexical devices such as mitigators, the
hedging use of passive voice is also common in the
Italian language. Mitigators like hardly, to a
certain extent, almost are markers of politeness,
essential to know and interiorise.
Discourse markers such as connectors or conjuncts ensure the correct flow in an organised structure, providing integration and interconnection
among concepts, but their use is minimal; for
example, yet and still (two important signals)
are nearly absent in manuscripts prepared by
NNEs.13 The classification of conjuncts and their
use in different contexts may also lead us to reflect
on their correct use in our native language.
Grammar and wording
Grammar errors refer to the use of overly long and
complex sentences, or unnecessary words, and the
preferable use of verbs instead of corresponding
nouns, positive statements compared with negative
ones, the use of passive in place of active voice
whenever possible, for example, in the Results
section of original articles. In addition, false
friends and other linguistic transfers are constant
threats for NNEs during the writing process, particularly in translation tasks.
Other than grammar errors, limited vocabulary
and register choices are among the most risky features of writing for NNEs. Wording in English is a
challenge sometimes because of its richness of synonyms; nuances of definition or meaning are significant hurdles to overcome. Even Samuel Johnson,
the author of the first Dictionary of the English
Language in 1755, in his comments about some
aspect of the language, identified the vast number
of phrasal verbs as a remarkable problem for
people who try to learn English.15
Three main categories of wording (lexical) errors
have been recognised: (a) confusing words, (b)
unnecessary words, and (c) inaccurate words.7 In
terms of jargon, specific for each discipline, the use
of a small number of words has been proposed in

Ferrari Medical writing for non-native English speakers

some linguistic studies to pinpoint recurrent keywords and lexical structures.16

In the difficult situation of quickly finding the
most appropriate words in a discourse, patchwriting
has to be pointed out as the wrong method.
Patchwriting is a term that describes a writing
process for academic purposes based on weaving
original and borrowed texts, and it seems to be
typical of some NNEs. Patchwriting should be
regarded as different from plagiarism,17 given the
absence of clear intent to reproduce original
ideas.18 Paraphrasing or re-writing is challenging
for NNEs, so patchwriting may be very tempting.
Some NNEs found this habit suitable to meet cognitive needs, drafting their manuscripts not only for
wording or lexical structure but also for English
language style.1619 Moreover, patchwriting also
seems to be caused by cultural values or lack of
understanding as, for example, in Japanese
universities.20
For a literature review, as an example, the text
sources must be well understood, allowing for re-elaboration and integration, preserving the original
meaning and avoiding any kind of plagiarism or
patchwriting. Although for NNEs this fundamental
process is more difficult and time-consuming
than for NEs, the acquisition and re-elaboration
of the text imply that the content becomes
temporarily ours so that we can convey it with our
own expressions: rephrasing or summarising or both.

Resources
During recent years, the market has boomed for
dedicated short training courses or seminars; these
ensure effective writing skills, which allow manuscripts to be successfully reviewed by editors and
the manuscripts published. However, it is difficult
to believe that this works.
In my opinion, continuous basic English language
training is relevant for maintaining (or increasing)
our linguistic platform. In addition, we can keep
up-to-date through medical and scientific writing
courses of high quality and effectiveness (if available), regular visits to selected websites and literature (e.g.: EMWAs Medical Writing, the Journal of
English for Academic Purposes), and specialised
books.
Given the high level of commitment required, the
strength of our determination in carrying out this
feat is also fundamental.

Conclusions
Medical writing in the English language for NNEs is
demanding, but I think it is worth making the effort

Medical Writing

2015

VOL.

24

NO.

and taking all possible opportunities for improving

our writing skills. Further, a good English level
enables us to exchange experiences with colleagues
from other countries and to take the opportunity
to get up-to-date. Therefore, the most convenient
solution is a to do list based on a precise personal
strategy, to choose and follow a precise training trajectory, and to capitalise on the burden of improving
the structure of all our medical texts: a clear text
structure reflects clear ideas.
In addition, linguistic and cultural diversity can
provide a significant contribution to the medical
writing community by offering different visions,
always keeping in mind that language is a tool (or
system) to clearly communicate and to give voice
to scientific research data, evidence, and ideas that
are worth communicating.

Acknowledgements
I thank Barbara Grossman and Philip Leventhal for
the editing of this manuscript.
Rossella Ferrari
[email protected]

References
1.

Benfield JR, Howard KM. The language of science.

Eur J Cardiothorac Surg 2000;18(6):642648.
2. Vasconcelos SMR, Sorenson MM, Leta J. Scientistfriendly policies for non-native English-speaking
authors: timely and welcome. Braz J Med Biol Res
2007;40(6):743747.
3. Fergusson G. The global spread of English, scientific
communication and ESP: questions of equity, access
and domain loss. Iberica 2007;13:738.
4. Langdon-Neuner E, Berghammer G. The Write Stuff:
the importance of language for medical writers.
Panacea 2010;XI(32):132136.
5. Benfield JR, Feak CB. How authors can cope with the
burden of English as an international language. Chest
2006;129:17281730.
6. Budgell B. Centre for Biomedical and Health
Linguistics: helping non-native English speakers get
a grip on the lingua franca of science. Write Stuff
2010;19(4):297299.
7. Coates R, Sturgeon B, Bohannan J, Pasini E. Language
and publication in cardiovascular research articles.
Cardiovasc Res 2002;53(2):279285.
8. Pagel WJ, Kendall FE, Gibbs HR. Self-identified publishing needs of non-native English-speaking faculty
and fellows at an academic medical institution.
Science Editor 2002;25(4):111114.
9. Meneghini R, Packer AL. Is there science beyond
English? EMBO 2007;8(2):112116.
10. Bower JR. Four principles to help non-native speakers
of English write clearly. 2011;20(1):8991.
11. Heseltine E. Teaching scientific writing to non-native
English speakers. Med Writing 2013;22(1):1316.
12. Neilson F. Teaching scientific writing using the learnercentred approach. Med Writing 2013;22(1):2325.

49

Ferrari Medical writing for non-native English speakers

13. Kourilova-Urbanczik M. Some linguistic and pragmatic considerations affecting science reporting in
English by non-native speakers of the language.
Interdiscip Toxicol 2012;5(2):105115.
14. Kaplan R. Cultural thought patterns in intercultural
education. Lang Learn 1966;16(1):120.
15. Gooden P. The story of English. How the English
language conquered the world. London: Quercus;
2009.
16. Cooke R, Birch-Becaas S. Scientific writing assistance
for non-native speakers of English: shifting right on
the interactivity spectrum. Rivista Canaria de
Estudios Ingleses 2009;59:89100.

See page 58 for the answers.

50

Medical Writing

2015

VOL.

24

NO.

17. Li Y. Text-based plagiarism in scientific publishing:

issues, developments and education. Sci Eng Ethics
2013;19:12411254.
18. Cameron C. Publication ethics and the emerging
scientific workforce: understanding plagiarism in a
global context. Acad Med 2012;87(1):5154.
19. Academic Writing in English. Lund University [cited
24 July 2014]. Available from: http://awelu.svr.lu.se/
sources-and-references/how-to-give-references/
paraphrasing.
20. Wheeler G. Plagiarism in the Japanese universities:
truly a cultural matter? J Second Lang Writing 2009;
18(1):1729.