Medical Writing from Antiquity to the Creative Commons

An old new profession dedicated to understanding and clarity of thought

Introduction

Medical writers, also referred to as medical communicators¹ compile, analyze and interpret clinical findings, scientific evidence and regulatory data and other related subject matter with the aim of presenting them in a professional, understandable, concise form for dissemination within the medical, regulatory, pharmaceutical and healthcare industries. The forms of presentation include clinical submission documents, educational materials, prescribing information, patient information material, press releases, journal articles, product, brochures, newsletters, press releases and even radio, television or video scripts. Medical writing is subject to similar ethical codes as in the medical community. It is the mission of medical writers to convey knowledge in a concise, unambiguous style appropriate to the target audience. Medical writers are typically employed by Contract Research Organizations (CRO), the pharmaceutical and medical device industry. Many also work on a freelance basis.

The global medical writing market

Between 2002 and 2008, the medical writing market more than doubled, expanding from $300 to $694 million.² By 2019, more recent forecasts are projecting a 10% rate of compound annual growth in CRO, the healthcare communication market where most medical writers are employed.³ Given this upward trend, we are looking at a billion dollar market moving towards the end of the decade.

Physicians writing on medical topics or expert writers compiling medical data?

The practice of medical writing dates back to Antiquity. The first medical writer documented in history is the mythical God Thoth who was worshiped in Egypt as the inventor of writing between 6000 – 30 BC. As legend has it, Thoth is said to have created himself through the power of language. His writings, presumably on papyrus scrolls, also concerned medicine, the body and diseases. This Egyptian god was the first documented scribe who processed medical – then hidden – knowledge, by virtue of which he became “an infallible judge capable of rendering just decisions.”⁴

Asclepius – holder of secret knowledge

In our civilization, the better-known tutelary god of medicine is Asclepius, also written as Aesculapius or Asklepios. His snake-entwined staff is used as a symbol for physicians throughout the western world. Asclepius, too, possessed secret medical knowledge imparted to him by that symbolic snake. These facts are not only interesting from an historical perspective, but also from a knowledge-related one. The expert knowledge held by these and other gods was secret, hidden – i.e. not accessible or understandable to mere mortals.

The Hippocratic Oath – a paradigm shift?

By 400 BC, written principles of medicine had been “abstracted” by Hippocrates of Cos, the most famous physician in antiquity. His oath set out the guidelines for the practice of medicine and medical writing still valid to this day. This oath was the advent of a code of behavior for professionals, but Hippocrates’s promulgation of this thought-style also might be said to mark a paradigm shift in that the responsibility for knowledge was shifted to the possessor of that knowledge – the physician – in relation to its recipient – the patient.

Thought-styles in writing medicine

The great Roman medical scholar Galen lived from c. 129 – c. 200. A prolific writer, authoring more than 500 books, Galen compiled and systemized Greco-Roman medicine, physiology, and anatomy. He applied a cause-related approach or systemized-teleological thought-style to his subject matter, for example, by applying anatomical knowledge to explain the body’s structures in terms of their function.⁵ Circa 1030, the Persian philosopher and physician Avicenna wrote the Book of Healing and the Canon of Medicine. The Avicenna thought-style can be characterized by comprehensiveness, enlightenment and innovation, overriding that of Hippocrates and Galenus in both theory and practice.⁶ This will be called the canonizing-educational thought-style.

Paracelsus – a thought revolutionary of the Renaissance

For Paracelsus, who lived from 1493–1541, the doctrine of medical writing practiced by the likes of Galen and the famous Persian medical philosopher Avicenna (c. 1030) had become too dogmatic. Called the “Luther of Medicine” because he defied the schools of Galen and Avicenna dogma and burned their books, Paracelsus condemned all medical teaching not based on experience. As a lecturer in medicine at the University of Basel in Switzerland, he incensed the authorities by inviting the public to attend his lectures.⁷ This openness of medical knowledge was not looked kindly upon by the powers that be.

Thought-styles in medical English – now we’re getting somewhere

The advent of 17th scientific writing was reflected in early modern medical texts by a differentiation between scholasticism and empiricism. Vernacularization, i.e. the transposition of texts from Latin, then the higher-status language, into the vernacular. The knowledge of medicine was now systematically made available in more common terms. This was the start of the trend to replace the use of Latin by the use of English. Today, the layperson may still be stumped by the medical terms overladen with Latin or Greek. This in part stems from the fact that English back in the time of vernacularization did not yet have the terminological means or stylistic and grammatical conventions needed to express more complex theories and their interconnections.⁸

Tipping the scales – blinded peer review comes of age

In 1731, the blinded peer review as we know it today was described in the preface to the French edition of Medical Essays and Observations.⁹ Leading into the next century, early modern medical English had broken through as the language of science and a reflection of the “scientific outlook” in England.¹⁰ By the 19th century, modern medical writing had incorporated “inquiry” as a thought-style within the new medical disciplines.¹¹
Medical writing based on highly rigorous peer-review, a stringent editing process and scientific accuracy and excellence are synonymous with the New England Journal of Medicine, founded in 1812 as the New England Journal of Medicine and Surgery and the Collateral Branches of Science, which celebrated its 200 year anniversary in 2012 as the oldest continuously published medical periodical in history.

Making structured sense of it all – The Cochrane Collaboration

In 1972, the year that the American National Standards Institute established the introduction, methods, results, and discussion format, dubbed IMRAD, as the standard for reporting research, Professor Archibald Leman Cochrane, pioneer of modern epidemiology, published his pivotal work Effectiveness and Efficiency: Random Reflections on Health Services. Therein, he stressed the importance of using evidence from randomized controlled trials. Over 20 years later, the Cochrane Collaboration was founded in his name; its aim was to promote health decision-making based on informed high-quality, relevant evidence. Now we had our systematic reviews and meta-analyses to make sense of all the data medicine keeps generating. In 1984, the Annals of Internal Medicine introduced the structured abstract and in 1997, the Consolidated Standards for Reporting Trials (CONSORT) statement set the standard for reporting randomized controlled trials.

“Burn your textbooks” – the next revolution?

Parallel to the developments advanced by the epidemiologist Cochrane, David L. Sackett – the father of evidence-based medicine and our next medical writing revolutionary – was working on the first edition of his seminal work Evidence-based medicine: How to practice and teach EBM, published in 1997. Sackett et al. began telling medical students how to “ask answerable questions” and teaching them to integrate the best research evidence with clinical expertise and patient values. The authors literally told their readers: “burn your (traditional) textbooks”. Pushing up and down on the chest of the drowning library of anecdotal medical tomes, they advocated weeding out the “smelly” useless parts of old textbooks, while compiling the new and more recent evidence as a basis for decision-making. This was the same year that the National Center for Biotechnology Information (NCBI) launched the online portal PubMed, aimed to advance science and health by providing access to biomedical and genomic information.

More and more open thought-styles – have we come full circle yet?

The year 2001 saw the establishment of both the Public Library of Science (PloS), a nonprofit Open Access publisher founded “to accelerate progress in science and medicine” and of the Creative Commons, a portal that allows authors to legally share knowledge and creativity in the public domain. This will be called the Open Access thought-style.

Conclusion

Common to all thought-styles characterized by the historical figures across the millennia to the present day is the continuing attempt to structure the presentation of observed and gathered knowledge in a systematic manner. The main emphasis in this evolution has been a striving to achieve an unambiguous, concise and understandable style that improves on pre-existing methods.
The evolution in medical writing styles continues to this day as reflected by the trends in the prevalence of systematic reviews, evidence-based medicine and the guideline-driven compilation of clinical data. Obviously, thanks to the Internet and Google, we are now all able to share medical information and knowledge. However, that does not always make the information and knowledge we share more understandable or less impenetrable. Indeed, with the advent of the globalization and digitization of knowledge conveyance in the English language, particularly by non-native speakers, comes the risk that obfuscation of the true meaning of knowledge intended to be conveyed will grow. This may be a setback to the reasoned presentation of data if not counteracted by upholding a prescription for proper grammar and clarity of speech. Modern-day medical writing is designed to uphold these values.

Table 1. Medical Writing Milestones

c. 6000 – 30 BC I Thoth I Ibis-headed God worshiped in Egypt; mythical inventor of writing and patron god of physicians
c. 500 BC I Aesculapius or Asklepios I Tutelary god of medicine and healing who, by healing a snake, was given medical knowledge regarded as a sacred secret ¹²
c. 400 BC I Hippocrates of Cos I Most famous physician of antiquity, promulgates his Oath as guidelines for the practice of medicine
c. 25 BC–50 AD I CelsusI Writes De Re Medica encyclopedia of medicine, book seven De medicina survives¹³
c. 100 I Rufus of Ephesus I Writes oldest surviving anatomical text On the Names of the Parts of the Human Body
c. 170 I Galen I Prolific physician, writer and systemizer of Greco-Roman medicine, applied a teleological approach, or doctrine of final causes, to his subject matter¹⁴
c. 1030 I Avicenna I Persian philosopher, writes the Book of Healing and the Canon of Medicine
c. 1300 I Taddeo Alderotti I Writes Consila (medical case book) with first modern case histories
1363 I Guy de Chauliac I Physician to Pope Clement VI, writes Inventarium sive Chirurgia Magna, monumental surgical encyclopedia of the Middle Ages
1375 -1500 I Middle English Medical Texts I Vernacularization of science, transition from Latin to English terminology
1493–1541 I Paracelsus I Called the “Luther of Medicine,” because he defied Galenic and Avicenna dogma, condemning all non- experience based medical teaching
1500 -1700 I Early Modern Medical Texts I “Triumph of the scientific outlook in England”¹⁵
1542 I Vesalius I Writes De Humani Corporis Fabrica
c.1600 I Scientific English I First comes into being
1665-1731 I Journal des scavans  Proceedings of the Royal Society. I First scientific journals published, the latter establishing a form of peer review as a requirement for publication
1700 -1800 I Late Modern English Medical Texts I Incorporates modern approaches to medicine with “enquiry as a thought-style”
1812 I New England Journal of Medicine (NEJM) I Founding of the oldest continuously published medical journal
1859 I Louis Pasteur I Adds the methods section to scientific articles, precursor to IMRAD format
1900 I George M Gould I Writes Suggestions to Medical Writers The Philadelphia Medical Publishing Company.
1940 I American Medical Writers Association (AMWA) I Founded to promote excellence in medical communication
1957–1962 I Journal of the American Medical Association (AMA) I Began to routinely include abstracts with its articles, AMA Manual of Style published
1972 I Archibald Leman Cochrane I Professor and pioneer of modern epidemiology, publishes pivotal work Effectiveness and Efficiency: Random Reflections on Health Services, stressing the importance of using evidence from randomized controlled trials
1972 I American National Standards Institute I Establishes IMRAD as standard for reporting research
1979 I Uniform Requirements for Manuscripts Submitted to Biomedical Journals I Introduced by the International Committee of Medical Journal Editors (the Vancouver Group)
1989 I European Medical Writers Association (EMWA) I Founded as a network of professionals to represent, support and train medical communicators in Europe
1984 I Arnold S. Relman, M.D I Suggests in NEJM that authors routinely acknowledge funding, marking the birth of financial conflict of interest statements
1984 I Structured abstract I Introduced by the Annals of Internal Medicine
1993 I Cochrane Collaboration I Founded to promote health decision-making informed by high-quality, relevant evidence, named after Professor Cochrane
1997 I CONSORT Statement I Guideline for reporting randomized controlled trials issued
1997 I Evidence-Based Medicine I David L. Sackett, W. S. Richardson, W. Rosenberg, and R. B. Haynes publish the first edition of their seminal work aimed to integrate the best research evidence with clinical expertise and patient values
1997 I PubMed I Launched by the NCBI to advance science and health by providing access to biomedical and genomic information
2001 I Public Library of Science (PloS) I Nonprofit Open Access publisher founded “to accelerate progress in science and medicine”
2001 I Creative Commons I Founded to legally share knowledge and creativity

AD, Anno Domini; BC, before Christ; c., circa; CONSORT, Consolidated Standards for Reporting Trials; IMRAD, Introduction, Methods, Results and Discussion, NCBI, National Center for Biotechnology Information

Citations

¹ http://www.amwa.org/about_med_communications
² as reported by the CenterWatch Monthl
³ http://emedicalminds.com/2016/10/13/outsourcing-of-medical-writing-services-to-india/
⁴ Mark_JJ_206_Thoth.doc
⁵ http://galen.bbaw.de/survey/literature?set_language=en
⁶ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3558117/#CIT0008
⁷ https://www.britannica.com/biography/Paracelsus
⁸ Irma Taavitsainen – Corpus
⁹ Lang 2010
¹⁰ Irma Taavitsainen – Corpus
¹¹ Irma Taavitsainen – Corpus
¹² http://www.theoi.com/Ouranios/Asklepios.html
¹³ Mark Cartwright: https://creativecommons.org/licenses/by-nc-sa/3.0/
¹⁴ http://galen.bbaw.de/survey/literature?set_language=en
¹⁵ Taavitsainen

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