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From the Division of Cardiothoracic Surgery (Dr. Benfield), David Geffen School of Medicine at UCLA, Los Angeles, CA; and the English Language Institute (Ms. Feak), University of Michigan, Ann Arbor, MI.
Correspondence to: John R. Benfield, MD, David Geffen School of Medicine at UCLA, 11611 Terryhill Place, Los Angeles, CA 90049; e-mail: j.benfield{at}verizon.net
Key Words: English • language barrier • medical writing • writing
Background
English is the language of the most widely read and quoted medical journals. This poses a challenge for many authors whose native language is not English. Such authors struggle with the English language burden just as native English-speaking professionals are challenged by language barriers in countries where another language is spoken.1 Given these linguistic challenges, English as an international language (EIL) authors tend to believe that their manuscripts are significantly less likely to be accepted than manuscripts from native speakers. In reality, at least 50% of the publications in many of the best peer-reviewed journals are contributed by EIL authors. For example, from 2003 to 2005, the Journal of Thoracic and Cardiovascular Surgery received 59 to 63% of its manuscript submissions from EIL authors (P. Fried, MBA; personal communication; January 2006) and the experience of the Annals of Thoracic Surgery was essentially the same (H. Pusztay, BA; personal communication; January 2006). For both journals, the acceptance rates of EIL-authored manuscripts is essentially the same as that for native speakers.2
EIL author manuscripts often do require more work from reviewers and editors than manuscripts from native speakers. For example, the EIL author manuscripts for which we studied the review process in detail required significantly more revisions to achieve clarity of expression compared to similar manuscripts from native speakers during the same period of time.2
We believe that the privilege of being native English speakers comes with a responsibility to help EIL colleagues with their English.3 Accordingly, within the past 5 years we have conducted 15 interactive workshops for EIL cardiothoracic surgeons along with 3 similar sessions for other surgical specialties and for gastroenterologists in the United States and Japan.
All interactive sessions that we presented had curricula that were specific to the specialties we were addressing. The examples we used as the basis for exercises that the EIL participants completed were drawn from EIL manuscripts and from written comments from reviewers and editors. All curricula were jointly prepared by a peer (J.R.B.) and an English for academic purposes language professional (C.B.F.). Dr. Benfield was a clinically active faculty member for 36 years in academic surgery. He has served on eight editorial boards, including 15 years as associate editor of the Annals of Thoracic Surgery, and as editorial consultant to 11 publications, including CHEST and the New England Journal of Medicine. Ms. Feak teaches at the English Language Institute of the University of Michigan. She has coauthored two books about academic writing and is on the editorial board of the journal English for Specific Purposes. She has worked as an EIL teacher for 22 years and has served as consultant for the US Department of State. Both authors brought different strengths to the audience during the interactive sessions of instruction, as indicated by the written evaluations provided by the audience.
During preparation of learning exercises, the language professional and the peer regularly worked independently to revise problematic sections of EIL manuscripts or publications, thereby creating the opportunity to compare the editing by the language professional with that of the peer. This process confirmed the contention of Parkhurst4 that "feedback given by... writing teachers... addresses... problems of form and/or presentation, whereas... the feedback of (subject) experts... focuses on ideas and content... ." We further explore this difference through the example below.
Illustrative Comparative Writing and Editing
The following shows an EIL author’s beginning of an article and independently proposed revisions by a language professional and a peer. The examples provided below are based on manuscripts of EIL authors provided to the authors of this article for the purpose of facilitating preparation for interactive workshops that were conducted during the meeting of the Society of Thoracic Surgeons in Chicago, IL, January 30–31, 2006.
EIL Author Draft
Despite of the intricate modification in the surgical management of the perimembranous ventricular septal defect (VSD), the postoperative prevalence of the complete right bundle branch block (CRBBB) had remained high with values ranging from 20 to 62%. The underlying concept of the conventional suturing method for this particular subset of VSD has evolved on the basis of the currently accepted view of the conduction system.
Language Professional Draft
The conventional suturing method for patch closure of perimembranous VSDs is based on our current understanding of the conduction system and involves placing the stitches approximately 5 mm away from the posterior-inferior rim of the defect. The goal of this approach is to... (What is the goal? Is it to protect or preserve something? Something else?).
Peer Revision Draft
Despite improvements in the suturing method for closure of perimembranous ventricular septal defects (VSD), the postoperative incidence of complete right bundle branch block (CRBBB) has remained from 20 to 62%. Conventionally, stitches have been placed away from the posterior-inferior rim of the defect, hoping thereby to avoid the bundle of His in its left ventricular course.
The reformulation written by the language professional clearly differs from the drafts of the surgeons, who began by focusing on the unacceptably high incidence of the complication when the conventional suturing method was used. The language professional instead proposed beginning with the information given in the second sentence about the conventional suturing method because she assumed this was common knowledge. Her proposed strategy was to delay the statement of the problem until later in the introduction. She employed the often-used strategy of starting with information already known to readers. In the next sentence, she suggested that the author explain why the conventional method had been used, but she had to resort to queries to the author (in italics) rather than to a more concrete suggestion because she lacked subject knowledge.
The language professional perhaps demonstrated better mastery than the peer of the use of language to achieve a particular rhetorical effect. The peer, however, followed the EIL author’s draft more closely but was able to "read between the lines" of the original as a result of his subject matter knowledge. In the first sentence of his reformulation, he suggested replacing the author’s term intricate modification with the term improvements. Furthermore, he suggested that the author’s term surgical management (a generality) be replaced with the term suturing method (a term specific to the message of the article). The peer also omitted the term high with values ranging because he understood that this phrase was redundant in light of the numbers the EIL author quoted immediately thereafter. In the second sentence, the peer was also able to explain that the goal of the conventional suturing method was "to avoid the bundle of His in its left ventricular course."
Although peers and language professionals bring different skills and perspectives to the revision process, convergence is common. We found that when content seemed fine to both of us but the focus or emphasis were unclear, our independently suggested revisions usually coincided nicely. The following three versions from the first section of a conference abstract reveals that the peer and the language professional each made quite similar changes that greatly improved the EIL author’s original abstract.
EIL Author Draft
Background:
We reviewed the patients who underwent tricuspid valve replacement (TVR) to compare the long-term clinical results of bioprosthetic valve with mechanical valve in tricuspid position.
Language Professional Draft
Background:
The choice of a bioprosthetic vs a mechanical valve in tricuspid valve replacement (TVR) continues to be debated. We reviewed the long-term clinical results of TVR involving these two valves.
Peer Revision Draft
Background:
Tricuspid valve replacement (TVR) has been accomplished with mechanical and bioprosthetic valves. The relative long-term merits of the two types of valves are incompletely known.
In the above, the EIL authors simply stated the nature of their research, while the language professional and peer thought that the background could be strengthened by highlighting a need for the research. In the peer’s draft, this was accomplished by stating that the relative merits of the two valves were unknown, while the language professional went so far as to suggest that the choice of valve, rather than the merits of each, was a source of debate.
Explication
Does the choice of the right words and phrases really matter? Winston Churchill and Mark Twain thought it did.5 According to Johnson,5 Twain proclaimed that "the difference between the almost right word and the right word is really a large matter—it’s the difference between the lightning bug and the lightning." Also, in his famous speech of 1940, Churchill said "Let us therefore brace ourselves to our duties and so bear ourselves that if the British Empire and its Commonwealth last for a thousand years, men will still say, ‘This was their finest hour.’" Johnson5 states, "Try substituting another word for finest in the last sentence. ‘This was their best hour?’ ‘Most noble hour?’ ‘Most courageous hour?’ Nothing else serves as well as finest. You can hear the lightning crackle."5 In science, it is important for all authors to be able to express themselves fully. Good scientific publication demands accuracy, completeness, and the power of analysis and interpretation.
Take-Home Messages
In order for the revision process to move beyond the simple goal of "fixing" a text to a process in which EIL authors are developing their writing skills on the way toward becoming independent writers, input from both a language professional and an experienced peer is important. The language professional should ideally be a schooled and experienced applied linguist, and the peer a specialist in the subject matter of the manuscript.6 This ideal is difficult to achieve, in part because EIL authors may only have access to native English-speaking "amateurs." Also, peers who are specialists in the discrete subject matter may be difficult to find. However, making the ideal available to a significant number of EIL authors is a realistic goal for the future. In the meantime, the following is our "take-home message."
Footnotes
Abbreviations: EIL = English as an international language; TVR = tricuspid valve replacement; VSD = ventricular septal defect
Received for publication March 31, 2006. Accepted for publication March 31, 2006.
References
This article has been cited by other articles:
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  S. J. Welch Avoiding Common Problems During Online Submission of Manuscripts Chest, May 1, 2007; 131(5): 1591 - 1594. [Abstract] [Full Text] [PDF]
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