Importance of language and writing style in a clinical study report

How important is language and writing style in a clinical study report?  I was recently asked this question by a medical writer working for one of my McCulley/Cuppan clients. The writer is dealing with a team that seems to obsess over every word in every draft and the writer is looking for some help in how to address the situation.


Here is my response to the question:


You are asking about lexical and syntactical elements of writing (the third element of writing is grammatical.) 


Lexical pertains to the words (vocabulary) of a language. In the context of clinical research we need to talk about several applied lexicons of scientific phraseology that apply broadly to science and then narrowly to a specific therapeutic area. The admittedly most distinctive feature of any clinical study report is the application of specific scientific and technical prose. So, language is very important in a CSR to avoid lexical ambiguity (why I so love statisticians and their demands for careful use of language when describing statistical observations) in order to allow the reader to derive the intended meaning.


My experience suggests that many people in Pharma think attention to syntactical elements (style) means they are either eliminating ambiguity or improving clarity of message. Rarely is this the case.


You have heard me say before that style does not matter in the type of writing represented in clinical study reports submitted to regulatory authorities in the US and elsewhere.

My position is supported by current discourse theory. Discourse theory states that, as a rule in scientific writing, meaning is largely derived from the precise use of key scientific words, not how these words are strung together. It is the key words that create the meta-level knowledge of the report. Varying style does little to aid or impede comprehension.


What happens is people often chase and play around with the style of document. Largely they are looking to manipulate an advanced set of discourse markers specific for clinical science writing or some subset specific to a therapeutic discipline. Discourse markers are the word elements that string together the key scientific words and help signal transitions within and across sentences. These discourse markers are the elements that provide for style. There are macro markers (those indicating overall organization) and micro markers (functioning as fillers, indicating links between sentences, etc.) Comprehension studies show that manipulating discourse markers--that is, messing with style--in most instances does not influence reader comprehension. It is worth noting that manipulation of macro markers appears to have some impact on comprehension for non-native speakers of English (why it is worth using textual advanced organizers to help with document readability.)


So the net-net is: there is little fruit to be picked from messing with style in a clinical study report. Put review focus on the use and placement of key terms.


This is a bit of a non-sequitur to the question, but a concept I’d like to share. To derive meaning from scientific text, readers will rely on their prior knowledge, and cues provided by the key terms and data they encounter or fail to find in a sentence, paragraph, table, or section of a clinical study report. So what I’d really prefer to get people thinking about is the semantical elements of their documents. Semantics is fundamentally about encoding knowledge and how you as an author enable the reader to process your representation of knowledge in a meaningful way. Semantics is about how much interpretive space you provide to the reader in a document by what you say and equally important, by what you do not say. Of course you cannot get to the point of thinking about semantics unless you see clinical study reports as something more than just a warehouse for data.

Not knowing when good is good enough in writing regulatory documentation has a huge cost

We do not talk much on this blog regarding the use of language or the application of terms in science writing. Principal reason is that much of what we see in regulatory submission documents is genuinely “good enough.” However, others do not necessarily see it that way. I want to share with you how discussions in review roundtables can end up getting focused at really absurd levels of detail with a misapplied sense of establishing quality communication. 

In our consulting work, we try to be disciplined during our document reviews and only comment on language when it truly obscures or alters meaning. Being grammatically perfect in regulatory submission documents is a nice notion, but in practice consumes way too much time and organizational energy and will yield little in terms of outcomes.

We share this point with people all the time...but at times the advice goes unheeded and even worse…at times people just do not know when to move on and address real big concerns in their documents.

A case in point is a situation I observed regarding a long winded discussion in a review meeting over the use of the term “very critical”. The term “critical” in a medical sense means: of a patient's condition having unstable and abnormal vital signs and other unfavorable indicators. In theory, the meaning of critical is a black-or-white proposition without qualifications regarding gradation. Something is either critical or it is not. Therefore there should be no adverbs, like “very” in front of the term “critical” to connote a measureable degree of criticality. In this roundtable review the team got caught up in a 30 minute discussion that involved only two people arguing whether to use the term “very critical” or change it to “critical.”

Being pragmatic, I’d have to say: “Guys what are you thinking? You hold a team hostage for 30 minutes to argue over grammatical accuracy? To argue over something that will not matter when and if read by a regulatory reviewer. There were 10 professionals sitting in the room and 8 did nothing for 30 minutes. Cost of salaries alone is enough argument to say “Forget about it, let’s move on…we cannot afford to argue over such insignificant detail.” When we add in the opportunity cost (what these 10 people collectively could have been doing with their time), then for sure you have to make the argument.

This above episode gets played out time and time again in review sessions all over the pharma and medical device industries and is the reason why I am steadfast in my position that the vast majority of people involved in authorship and review do not know the answer to the question “How do you know when is good, good enough?” The end result is inordinate amounts of time can be applied at the wrong level of detail in reports and submission documents.

Change, change everywhere...yet it all remains the same

Change, change everywhere....yet as far as I can tell, most writing practices used to day to create research reports in the life sciences are the same as those deployed in 1928.


I did a workshop the other day for a group of medical writers looking at aspects of managing documentation projects. I started the session with a photograph taken in a newspaper office in 1928. I suggested to the group that other than the typewriters on the desk, the ways they work are essentially the same as the people posing in that 1928 photo. My comment got everyone’s attention, though I am sure some did not receive well the message. I am quite comfortable with my statement as traditional documentation development practices in the realm of medical writing have remained more or less unchanged for decades.


I explained to the group that much of the medical writing work they engage in is played out exactly the same way it was in 1928. Their current writing world remains one that is largely a work platform where they produce drafts in isolation and then send the drafts out to team members (electronically now unlike paper of the past) who then review in isolation and ultimately return the marked up documents to the authors (exactly like they did in 1928.)


My point to the group was if you really want to change outcomes, then you better think about changing your work practices. Doing things largely the same way will continue to yield the same outcomes. Just because you now have the reviewers grab your document from a server file, or you do round table reviews via WebEx, or you author your report in an enhanced electronic template does not mean you have made a radical departure from how people authored research reports or other documents 20-30 years ago. And I do know that the same weaknesses found 50+ years ago in document products and practices remain today.


You want different outcomes? Then change the practices associated with planning, authoring, and reviewing documents, not merely the tools and the processes you lay on top of practice.

More thoughts on the limited sophistication of documentation practices in the life sciences

I mentioned in this post that I consider the documentation practices for creation of regulatory submission documents in most pharma and medical device enterprises to rather unsophisticated. My position is largely driven by comparing observations of documentation practices to descriptions of varying levels of documentation maturity we have developed. Our descriptors have their roots in the work presented by Joann Hackos in her book: Managing Your Documentation Projects.

Like Hackos, our documentation practices-maturity model is a six point scale ranging from: Level 0 — Oblivious to Level 5 — Optimizing. My observations suggest that the vast majority of regulatory writing falls into the 2.5 range, which is between Rudimentary and Organized/Repeatable.
The Rudimentary documentation organization is one where the vast majority of effort is placed to ensure documentation consistency. All documents are generated utilizing well characterized templates. Document strategic review is largely absent as energy is applied to ensuring structural (that is, grammar and format) accuracy and consistency. Work practices are highly individualized and there is little application of meaningful estimating of document size or time lines.

The belief statements of organizations working at the rudimentary level include the following:

• All writers manage their own projects
• We would like to know more about our reading audience, but nobody takes the time to learn more….so we “suppose” what they want in our documents
• Our users are just like us…….I am a subject matter expert, so every other person educated like me will read documents just like I do
• We talk about what the data means, but we rarely talk about how to represent this meaning in our documents until we are into round table reviews
• We have little concern with how many rounds of review go into creating the final version of a document….we strongly endorse the credo “the end justifies the means”
• Planning document content before actually writing a report is just busy work
• We routinely reverse engineer document development timelines from the stated publication deadline and not from the scale and scope of the intended document
• We care what the customer thinks of our documents, but we do not use any organizationally applied quality standards. Standards are principally driven by teams and their senior reviewers
• File and forget–we do not take time to collectively reflect on documentation work practices practices

The belief statements of organizations working at the organized and repeatable level include the following:

• We have begun to study our document users but see little value in a concerted effort to collect information on how well our documents “satisfice” their needs
• We are surprised or even indignant when we get questions from our regulatory user looking for information that we included in our submission package
• The quality of our document project management is inconsistent, but we are okay with that because that is reality and each project is unique
• We do not see meaningful metrics beyond time for documentation projections…if we meet the deadline, then ways of working had to be good
• Nobody knows what others are doing in the process of review…the only way they know is via what may be discussed during a round table review
• We believe in our described “ways of working” until faced with unexpected situations, then we panic and call for “all hands on deck”
• We can easily get caught up in “process” at the expense of “product”

Now let’s contrast the above with belief statements of organizations working at the optimized level which include the following:

• We always engage in collaborative pre-writing planning of documents to make sure we fulfill strategic purpose of any given document
• We are thoroughly committed to understanding our document users and we work to systematically collect information from them
• We know how big a document will be even before we write it
• We always do end-of-project analysis to collect lessons learned and then disseminate this information across the organization
• We maintain a database of critical documentation work practice parameters and benchmark all documentation projects
• We recognize that accuracy and consistency are just the start of ensuring quality….we have expanded focus to quality of argument and document usability
• We are learning how to be innovative and not let the process control us

Originally published on our Knowledge Management blog

Designing the architecture of the argument in development reports

Kirk Livingston, a teacher and a medical writer working largely in the medical device industry, as well as a fellow blogger at LivingstonContent, shared this comment on my previous post regarding poor rhetorical shaping of arguments in research reports.

There’s a lot of work involved with producing solid, well-reasoned conclusions. Can it even be accomplished as an “authoring team” or is it the work of an individual? Recent research about medical device companies in Minnesota suggests communication teams are chronically understaffed. So–who has time to come to the right conclusions? Thanks for the thoughtful post.

I agree there is considerable work that goes into producing solid, well-reasoned conclusions. I am certain the work can indeed be accomplished by an authoring team. The caveat here is, it can be accomplished as long as the team engages in truly collaborative authorship work practices and makes use of pre-writing planning tools to help shape the argument.

I am not so sure that writing teams are chronically understaffed. I think the real issue here is the limits of interest and skill that team members may have towards the task of writing. As I reflect on 17 years of work associated with the authorship of regulatory documentation, I am convinced adding numbers to the equation will have little bearing on the rhetorical qualities of any given document. Larger writing teams will likely yield only emotional comfort--the notion of safety in numbers.

Producing high quality documents is a function of knowing what you want the document to do for you, a sense of where arguments must be played out in a document, and what writing tools to use in order to get true collaboration and sharpen everyone's focus to achieve the objectives you want to document to support.

Producing high quality documents in the forum of pharmaceutical and medical device research requires understanding how to build out the red thread of logic in a research report. In pre-writing planning it starts with something as simple as building a table that is to be filled in by the authoring team. The table has three columns to be completed by the team:

Primary & Secondary Objectives | Conclusions | Key Data

You then have one row in the table for each objective.

The team's task is then is to build out conclusions about achievement of each objective and what data warrants that conclusion.  A simple but powerful writing tool that helps a team to lend considerable shape to the architecture of the argument that must be represented within a report.


Originally published on our Knowledge Management blog

Effective argumentation often missing from clinical research reports

Much of clinical research reporting associated with regulatory submission strategies must be persuasive writing. In particular, discussions about the significance of study findings and how these findings directly support development claims. To win the point of persuasion, such writing must follow conventions of well-framed arguments that avoid rhetorical flaws.

I've been doing quite a bit of work over the past two months with groups who are responsible for producing clinical research reports. Reflecting back on my work, I find that many involved in authoring or reviewing these documents do not recognize the elements that contribute to effective arguments. They often confuse summaries of study findings as being meaningful conclusions about the significance of research findings.

One of the common rhetorical flaws is that authoring teams are comfortable making broad generalizations and see such generalizations as being solid conclusions and part of well-framed arguments. Broad generalizations seldom stand scrutiny of regulatory review and the generalizations of truly difficult and controversial topics never withstand close scrutiny. Faulty generalizations are easy to spot. For instance terms like......"generally well tolerated;" "suggests relevant differences;" and "may be associated with" appear throughout discussion and conclusion sections of many clinical research reports.

Originally published on our Knowledge Managment blog

4 Books Every Technical/Scientific Writer Should Considering Reading

The following books are ones that "new" technical and scientific communicators should consider reading. The books look at technical writing from different perspectives and will prove useful to the experienced communicator as well.

Metaphor and Knowledge: The Challenges of Writing Science. Ken Baake

Summary: “Metaphor and Knowledge offers a sweeping history of rhetoric and metaphor in science, delving into questions about how language constitutes knowledge. Weaving together insights from a group of scientists at the Santa Fe Institute as they shape the new interdisciplinary field of complexity science, Ken Baake shows the difficulty of writing science when word meanings are unsettled, and he analyzes the power of metaphor in science.” (partial text available from Google Books)

What Writing Does and How It Does It: An Introduction to Analyzing Texts and Textual Practices. Charles Bazerman, Paul Prior, editors

Summary: “In What Writing Does and How It Does It, editors Charles Bazerman and Paul Prior offer a sophisticated introduction to methods for understanding, studying, and analyzing texts and writing practices. This volume addresses a variety of approaches to analyzing texts, and considers the processes of writing, exploring textual practices and their contexts, and examining what texts do and how texts mean rather than what they mean. Included are traditional modes of analysis (rhetorical, literary, linguistic), as well as newer modes, such as text and talk, genre and activity analysis, and intertextual analysis.” (full text)

Technical Writing: Process and Product. Sharon Gerson and Steven Gerson

Summary: “Technical Writing: Process and Product guides readers through the entire writing process—prewriting, writing, and rewriting—developing an easy-to-use, step-by-step technique for writing the types of documents they will encounter on the job. The authors' reader-friendly style engages readers in the writing process and encourages hands-on application. Discusses prewriting, writing, and rewriting in relation to ethics, audience identification, electronic communication, and the role of technical writing in the workplace. For anyone looking to utilize more effective written communication in their jobs.” (summary and e-learning resources available at publisher's website)

Professional and Technical Writing Strategies: Communicating in Technology and Science. Judith VanAlstyne and Merrill D. Tritt

Summary: “Comprehensive and easy-to-read, this award-winning reference for those in technical, engineering, and scientific fields emphasizes practical writing. Its presentation and applications offer simple guides that users can easily emulate. It combines instruction, sample papers, exercises and writing projects for manuals, correspondence, research and publication articles, and oral technical communications.” (summary)

Originally published on our Knowledge Management blog