Rhetoric of health and medicine

The rhetoric of health and medicine refers to both the study and application of persuasive language and symbols in health and medicine. It is an interdisciplinary subfield of rhetoric, with practitioners hailing from disciplines such as English studies, communication studies, and health humanities. Academic researchers in this field use a wide variety of research methods. Some researchers work closely with health care professionals, serving as co-investigators on grant-funded medical research projects or as coauthors on research-related documents. These researchers’ tasks may include studying audience response to specific health-related messages or conducting usability testing on health information systems. Other researchers take a broader critical approach that is more aligned with health humanities. As rhetorical critics, such researchers can offer distinctly non-medical perspectives on topics such as power and inequality in the context of health care communication. In addition to exploring these areas of academic focus, students in the rhetoric of health and medicine can also find professional opportunities in medical writing. These professionals write, edit, and develop materials about subject matter related to medicine and health. They might also help health professionals write documents, or they might advocate for the public by explaining complicated health issues in language that non-experts can understand. The documents that medical writers create might include educational handouts for patients, legislative reports for government agencies, grant proposals for research scientists and institutions, or promotional literature for the pharmaceutical industry.

History of the field and key scholars
The rhetoric of health and medicine is tied to the emergence of rhetoric of science in the early 1970s and 1980s. Contemporary theorists such as Kenneth Burke, Michel Foucault, Thomas Kuhn, Bruno Latour and Steve Woolgar, laid the theoretical groundwork for this early interest in the persuasive dimensions of scientific language. In the 1990s, the rhetoric of health and medicine emerged more clearly as a subfield distinct from rhetoric of science. This development came about through the work of scholars like Celeste Condit who raised questions about the historical and rhetorical dimensions of issues like abortion and genetics. The field also saw the rise of disability studies and illness narratives, with Lennard Davis’ Enforcing Normalcy: Disability, Deafness, and the Body; Arthur Frank’s Wounded Story Teller: Body, Illness, and Ethics; and Steven Epstein’s Impure Science: AIDS, Activism, and the Politics of Knowledge. In the early 21st century, scholars began to pay increasing attention to various topics in the rhetoric of health and medicine. J. Blake Scott’s 2003 book Risky Rhetoric: AIDS and the Cultural Practices of HIV Testing used contemporary and classical rhetorical theories to explore health policy around HIV testing and prevention. In 2005, Judy Segal’s Health and the Rhetoric of Medicine gained recognition for its use of key rhetorical principles to explore health conditions and medical solutions. In 2010, Lisa Keränen’s Scientific Characters: Rhetoric, Politics, and Trust in Breast Cancer Research addressed issues of research viability and relationships among scientists, patients, and advocates. Kimberly Emmons’ work on the rhetoric surrounding depression, Black Dogs and Blue Words: Depression and Gender in the Age of Self-Care, was published the same year. Several communication journals, including Journal of Business and Technical Communication, Technical Communication Quarterly, and Present Tense have also recently published special issues on themes related to the rhetoric of health and medicine.

Pharmaceutical rhetorics
Pharmaceutical rhetorics are the persuasive language and symbols that pharmaceutical industry professionals use in their communication with regulatory agencies, consumers, physicians, and other stakeholders. Scholars who study this topic have found that the language used to define, describe, and regulate pharmaceuticals has just as much influence on public understanding and perception as do the drugs’ chemical makeup. Information about pharmaceutical products is highly regulated and is filtered through many channels as it moves from scientist to consumer. Studying and trying to improve the rhetorical processes involved in pharmaceutical information as it moves from policymaker, to drug maker, to seller, to health care provider, to patient and consumer is a key concern of rhetorical scholarship on this topic.

Rhetoric of mental health
The rhetoric of mental health considers how language functions in the production of knowledge on topics such as mental and psychological disorders, chemical imbalances in the brain, and variations on what are considered normal mental faculties. The $100 million Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, introduced by the Obama administration in 2013, is testament to brain science’s and mental health’s emerging place in medical science and public policy debate. Neurorhetoric, which means the study of how language is used in the creation, distribution, and reception of science about the brain, has recently become an important topic in medical rhetoric and composition studies, as well as in popular science publications targeted at non-scientists. Information and texts relevant to the rhetoric of mental health include psychotropic pharmaceutical regulations, their production, prescription, advertising, and consumption, and scientific and popular discussions about major depressive disorder, bipolar disorder, obsessive-compulsive disorder, schizophrenia, autism, and other mental disorders. The Diagnostic and Statistical Manual of Mental Disorders (DSM, now in its 5th edition) is a central text to the study of clinical descriptions, diagnostic, and prescription procedures of the mental health profession.

Patient narrative
Patient narrative is the clinical story of a person’s past and present medical history documented by a medical clinician. The patient narrative can also be referred to as the medical history, the History and Physical (H & P), or the clinical narrative. The H&P includes a Subject, Objective, Assessment, and Plan (SOAP note), which summarizes the patient’s narrative or history of medical illness, objectively reports the patient’s clinical data and lab results, assesses diagnoses and prognoses, and oftentimes suggests a plan of action or recommendations about how to address the patient’s clinical situation. As part of the American Recovery and Reinvestment Act of 2009, the government enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act, which mandates that health providers transition from handwritten (typed) patient narratives to the electronic patient narrative in forms that might include the electronic medical record (EMR) or the electronic health record (EHR). (An EMR is controlled by the clinic or hospital system, whereas the EHR is controlled by the patient). The EMR and EHR are of interest to communication scholars because they economize the words and space of the traditional patient narrative into a structured system of navigation screens and checkboxes where the patient data is captured through a set of ICD-10 codes that identifies specific medical diagnoses, illnesses, procedures, and treatments.

Rhetorics of alternative medicine
The Rhetoric of alternative medicine differs from traditional medical rhetoric in its emphasis on the persuasive aspects of language related to holistic or other nonstandard approaches. Some of these alternative medical practices include acupuncture, massage therapy, and chiropractic care. Rhetorical scholars recognize biomedicine’s emerging acceptance of alternative medicine, called integrative or complementary medicine. Scholars further explore alternative medical practitioners’ claims that they take a holistic approach to medical treatment, assessing a person’s body, mind, and spirit, rather than just treating a disease.

Patient-physician communication
Starting with references to medical care in ancient Greece, Plato’s “Dialogues”, expressed that physician-patient communication did not include any “lively interactions” between the physician and patient. In the Age of Enlightenment, Dr. John Gregory began to emphasize patient-physician communication by introducing the idea of preventative care for “gentleman of a liberal education.” Few found his suggestive style of care useful and the view that “physicians must assume sole responsibility for protecting the ignorant public from its folly” lived on for some time. As late as the 1980s, the American Medical Association still had not incorporated regulations into their Code of Ethics that required physicians to incorporate patient opinion into the decision-making process. It was not until 1996 when the Health Insurance Portability and Accountability Act (HIPAA) was created to protect patient rights and privacy. This law was intended to assure patients that their wishes, in relation to treatment decision-making processes, would be considered.

Professional opportunities
For students who take a more applied approach to health and medical rhetoric, there are an increasing number of employment opportunities in industry, government, and nonprofit organizations. Such opportunities fall into two broadly defined categories: service and advocacy.

Service
Service is a situation in which a communication expert helps a healthcare professional be more effective in his or her communication efforts. This might mean the communicator is paid to assist with a task like grant writing, editing, or authoring a medical document. Medical transcriptionists, represented by the Association for Healthcare Documentation Integrity (AHDI), provide another form of professional communication in medical discourse. The AHDI is the world’s largest non-profit organization representing individuals and organizations in healthcare documentation. By ensuring documentation’s accuracy, privacy, and security, they aim to protect public health, increase patient safety, and improve quality of care for healthcare consumers. Other professional medical writing associations like the AHDI include American Medical Writers Association (AMWA) and the International Academy of Nursing Editors (INANE).

Sometimes these medical authors are considered “ghostwriters,” or paid writers who write a communicative piece but are not formally acknowledged as a text’s author. Karen L. Wooley says that the difference between a professional medical writer and a ghostwriter is that professional writers must adhere to ethical guidelines, while ghostwriters may not be held to these guidelines. While authors control the content when working with a professional medical writer, Wooley says that ghostwriters may try to take control of the content away from the author and hide certain facts, like where a project’s funding comes from. Researchers such as Elliott Moffatt are concerned that medical ghostwriting, especially in the context of pharmaceutical research, is dangerous to public health. Possible dangers can include misrepresenting the data and subtly influencing the way clinicians and patients perceive the data.

Advocacy
Advocacy in medical rhetoric is a situation in which the communicator addresses a health-related topic, empowering the citizens of a community to understand how that issue impacts them. This type of health communication enables the public to understand a health issue more thoroughly, providing them with the tools necessary to challenge or change existing power structures within their own communities. Advocacy is often associated with risk communication, the process of explaining natural disasters, human-made hazards, and behavioral practices to the public in a way they can understand. Theorists such as Don Nutbeam propose a need for advocacy and say that health literacy, or people’s ability to access and make decisions with health information, is an important part of empowerment. Nick Pidgeon and Baruch Fischhoff say that communicating complex medical or health information to the public is difficult because past scientists failed to base their communication on solid principles and evidence. Based on these past failures, Pidgeon and Fischhoff argue that a simpler and trustworthier model of science communication is needed. In response to this issue, Jeffrey T. Grabill and W. Michele Simmons propose that technical communicators can provide advocacy because they have both good writing skills and an ability to understand and convey information to patients.

Metaphor and analogy
Metaphor and analogy are important in scientific communication because they make new ideas understandable to both expert and nonexpert audiences. Disease, for example, which is difficult to comprehend on both large scale and a microbiological scale, is often communicated through metaphor and analogy. When a public health campaign “wages war” on cancer, or a microbiologist describes a virus as “attacking” a cell, these forceful words create a war-like metaphor for understanding the way disease works at both a macro and a micro level. Notable work in this area has been done by Judy Segal, who chronicles the impact of five biomedical metaphors in her book Health and the Rhetoric of Medicine, including ‘‘medicine is war,’’ presented very briefly above, ‘‘the body is a machine,’’ ‘‘diagnosis is health,’’ ‘‘medicine is a business,’’ and ‘‘the person is genes, ’’ all of which have had academic, cultural, and social impacts on the way medicine is practiced and understood. Monika Cwiarka has also questioned the use of laboratory mice in behavior-based studies, asking whether certain behaviors observed in mice can be considered analogous to those observed in humans. Another important recent study is Gronnvoll and Landau's research to determine how the public uses metaphor to understand genetic science.

Kairos
Kairos is a rhetorical term that refers to the opportune moment for a rhetorical event to occur. In plain words, it is the "moment" mentioned in the phrase: "I should have said something, but the moment has passed." Shifts in scientific and medical beliefs have also been grounded in kairotic events. Changes that occurred over the course of the 20th century in medical advice about infant feeding provide one example of a topic that has been studied from the perspective of kairos. Also, consider the case of tonsillectomies. During the 1930s, over 50% of children in the United States in Britain had tonsillectomies. However, post-World War II studies concluded that tonsillectomies negatively affect the ability of the body to fight off disease. The conclusions of these studies may not have been the only reason for a decrease in performed tonsillectomies, but they do provide an interesting example of how kairotic elements can impact medical practice.

Stasis
Consider a hypothetical conversation between two parties about health care reform. One party may wish to argue the moral necessity of health care reform while the other party wishes to argue that health care reform is economically infeasible. Until both parties agree on the issue at hand (whether it be the economic or moral considerations of health care reform), resolution of the argument cannot take place. Once the parties have agreed on the issue at hand, they have achieved rhetorical stasis. The idea of first agreeing to the issue at hand is central to any discussion between rational people. One example of how the stasis concept can apply to health and medical rhetoric is provided in a recent article by Christa Teston and Scott Graham. These researchers applied the rhetorical concept of stasis to medical discourse by reviewing the FDA discussion on Avastin as a treatment for metastatic breast cancer. They concluded that the absence of stasis resulted in miscommunication between the interested parties. The FDA could have achieved stasis, these authors conclude, by first reaching consensus on the following questions: What counts as clinical benefit? What kinds of evidence would be deemed meaningful?