Medium, meaning and modals: the complexity of patient-focussed language

We are delighted to publish this blog post by guest blogger Catherine Richards Golini. Catherine, who is based in Switzerland, is an expert teacher in the field of English for healthcare, medicine and general science. She has an MA in Applied Linguistics from Birkbeck College, University of London and is completing a PhD at the University of Swansea on the subject of ‘A corpus driven lexico-grammatical analysis of patient information for radiography’. Catherine is the president of EALTHY, the European Association of Language Teachers for Healthcare and is a reviewer for the journal ‘English for Specific Purposes’. Here, she explores some of the nuances of healthcare communications developed for patients, and why using short and simple words may not always results in clear communications.

Medium, meaning and modals: the complexity of patient-focussed language

When we consider vocabulary in relation to healthcare information, it is natural to think of terminology – medical terms used by professionals and not used or well-understood by patients. As my doctoral research has uncovered, however, this is just part of the story.
Vocabulary has always fascinated me and the more I considered patient information, its importance in patient empowerment and the complexities involved in producing accessible, clear information, the more I wondered whether we really knew enough about the kind of everyday words that we take for granted.

Most guides to the writing of patient communication emphasise brevity, both of the sentence and of the word, with some suggesting brevity is fundamental to comprehension: Short words + short sentences = information that is easy to read[1]

Syllable counting and length of words may indeed help – general terms in English are often shorter in length if they do not have Latin or Greek origins – and being succinct and precise is surely a laudable aim in communication for the general public. I believe, however, that it is a mistake to assume that short (+ precise) = clear.

Shorter words are not precise because they are not long, nor are shorter words necessarily understood better by patients. A technical term is just that, irrespective of its length.

It is also – and very much – a question of context. Much depends on how words are used and on who is using them. A word can be technical in one context but not so in another. Protocol means different things in different professions; acute means one thing to a mathematician and quite another to a nurse. Patients unfamiliar with the meaning of contrast in the context of radiography will not understand it, though would not struggle to comprehend the meaning in another context. This is why a definition is almost always given: a kind of dye. Likewise a slice, a seemingly non-complex, one-syllable word that a literacy assessment might well judge to be non-complex, but is the meaning really obvious to a patient having a CT scan for the first time? And what about a blood draw? A compound noun with two, one-syllable words, theoretically it should be easy to process if all we’re doing is counting syllables, though this is not a term in common use in the UK. The question of variety comes into play here, as different terms are used in different varieties of English. Shot and jab, simple, one syllable wordsare two more examples that may well not

be understood by speaker of other varieties of English. In a globalised world, we must also be aware of speakers of English as a second or foreign language who, depending on their language background, may have as many or even more problems with everyday terms than they do with technical or medical terms.

Phrasal verbs, i.e. pop into or look out for, might seem friendly and easy-to-understand but phrasal verbs are notoriously difficult for people who do not have English as their native language while for those with a Romance language as their first language, the technical terms are far less likely to be problematic.

Another important group of words that are non-technical but potentially problematic is modal verbs and these, along with the sub-group of semi-modals (verbs like have to and need to), are used very frequently in patient information to inform and instruct. My research suggests that they are used far more frequently in patient information than in general language and that there is a unique pattern of use, with certain modals being preferred over others. These preferences are likely to be connected to the desire to avoid an overly authoritarian voice, though there also seems to be a relationship with the type of information content. While must and have to are used, it is should and increasingly need to that are the most commonly-used modals for giving instructions and directives.

You should inform the radiographer if you are, or might be, pregnant.

Do we all understand the same thing when we read or hear should?  The meaning of this word ranges from ‘it is advisable’ through to ‘do it!’ or ‘don’t do it!’ Its meaning depends on the content of the message, the context and the participants and their relationship to each other. It also depends on what knowledge the participants bring to the situation and their perception of their role and the role of the other. If I know full well that pregnancy and a CT scan don’t go well together, and I am a native-speaker of English or raised in a country where medicine is patient-centred, I am more likely to interpret should as a directive. I believe that patients who have limited experience of radiography, who are not native speakers, and who have been raised in a society where doctors direct and patient are directed are more likely to interpret this sentence as advisable, but optional.

Then there is have to, which often does not have an equivalent in other languages, being translated with the same verb as must, and need to, which has seen a rapid rise in use in many varieties of English and in both spoken and written language. Is you need to saying the same thing as you must or you have to? Research into the use of should and need to suggests that they are both increasingly used to issue directives in a non-threatening manner, directives that are presented as being for the person’s own good. Friendly directives, if you like. This finding has interesting implications for healthcare communication.

To see whether native speakers and non-native speakers use modals in different way, I conducted a survey of around 90 people, two-thirds of whom were native speakers of the language while the other third spoke English as a second or foreign language.  The vast majority of those who completed the survey were healthcare professionals or training to be healthcare professionals. The native speakers were, by and large, involved in patient information writing and healthcare communication and resident in the UK. The other half were primarily European, with a variety of languages as their L1 including Italian, German, Romanian and Hungarian.  Participants were asked to select a modal verb, from a choice of four, to complete a sentence taken from patient information. The results, which can be seen below, say nothing about how modals are perceived, but in terms of use there seems to be a preference for need to and must from the native speakers and, surprisingly, a clear preference for have to from the non-native speakers. There is little difference in the use of should.


The most surprising result from my survey, however, was the vast range of responses from both groups of participants and for all four of the modal verbs under investigation. Should was selected 11 times by one native speaker participant while three fellow group members never chose it. Must was selected more than eight times by five members of the native speaker group yet nine members chose it only once or less. The same kind of variation was seen in the group of non-native speakers.

The relationship between healthcare communication studies and Applied Linguistics has huge potential and the use of corpora – electronic databases of language – has permitted many aspects of language and communication to be revealed.   Investigating individual preferences for modal verbs, for example, (and other means of presenting directives and obligations), the choices that govern our preferences and our perception of these words when others use them is an area that is not only interesting but can reward with useful, practical outcomes for practitioners and healthcare communication professionals. And be the subject of other blog posts, perhaps.