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«Limited Forensic Assessability of Soft Tissue Injuries. Contrastive Terminological Analyses of Hungarian, Austrian and German Medical Diagnostic ...»

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University of Pécs, Faculty of Health Sciences

Head of the Doctoral School:

Prof. Dr. József Bódis

Rector and Member of the Hungarian Academy of Sciences

Limited Forensic Assessability of Soft Tissue Injuries.

Contrastive Terminological Analyses of Hungarian, Austrian and

German Medical Diagnostic Reports

PhD Dissertation

Katalin Fogarasi

Head of the Doctoral Programme:

Prof. Dr. Gábor Kovács L. Regular Member of the Hungarian Academy of Sciences

Supervisors:

Dr. Gábor Rébék-Nagy, Head of the Department of Languages for Specific Purposes, Faculty of Medicine, University of Pécs (Hungary) Prof. Dr. Thomas Riepert, Deputy Head of the Department of Forensic Medicine, Medical Center of the Johannes Gutenberg-University of Mainz (Germany) Pécs 2012

TABLE OF CONTENTS

PREFACE………………………………………………………..…………………. 01 1. INTRODUCTION………………………………………………………………….. 02 1.1. Writing medical reports…………………………………………………………… 02 1.2. Audience of reports………………………………………………………………... 02 1.3. Medical diagnostic reports on injuries (MDRI)……………………...…………… 02 1.4. Linguistic approach to MDRI…………………………………………….…….….. 03 1.5. Professional communication in medicine…………………...……………………… 03 1.5.1. Principles of effective communication…………………………..………………… 03 1.5.2. Language for Specific Purposes (LSP)………………………….………………….. 04 1.5.3. Layers of Languages for Specific Purposes (LSP)…………………………………. 05 1.6. Genre analysis in medicine ………………………………………………................ 06 1.6.1. Concepts of discourse and genre. ………………………………………………….. 06 1.6.2. Discourses and genres in medicine ………………...…………………………......... 07 1.7. The genre of medical diagnostic report (MDR) on injuries ……………………….. 09 1.7.1. Generic characteristics

1.7.2. The forensic discourse in the continental and the Anglo-Saxon legal system........... 10 1.7.3. The role of MDRIs in the forensic discourse of Germany, Austria and Hungary..... 10 1.7.4. Terminology depicting injuries in Germany, Austria and Hungary……………..….12 1.7.5. Forensic problems with ambiguous MDRIs and their possible consequences……...13 1.7.6. Linguistic analyses previously conducted on the terminology of forensic medicine.14 1.8. Terminological analysis in medicine ………………………………………….….... 14 1.8.1. Theory of terminology …………………………………..………………................. 14 1.8.2. Quality criteria of LSP and terminology: unambiguousness versus synonymy ….... 12 1.8.3. Determinacy and indeterminacy

1.8.4. Medical terminology………………………………………………………………... 18 1.8.5. Analysis of genre-specific collocations or lexico-grammatical patterns ……...........19

–  –  –

2.1. Description of the genre MDRI…………………………………………………….. 22

2.2. Interdiscursivity in MDRIs………………………………………………….……… 22

2.3. Contrastive terminological analysis………………………………………………… 22

2.4. Hypotheses………………………………………………………………………….. 23

3. MATERIAL AND METHODS…………………………………………………….. 24

3.1. Sources of forensic files……………………………………….…………………… 24

3.2. Exclusion and inclusion criteria……………………………….…………………… 24

3.3. Methods of collecting forensic files…………………………..……………………. 25

3.4. Macro- and microstructure of the corpus……………………..……………………. 25

3.5. Methods of statistical analysis……………………………………………………… 26

3.6. Difficulties of creating a well-balanced corpus pertaining to file numbers…..…… 28

3.7. Methods of corpus analysis…………………………………………………………. 28

3.8. Methods of collocation analysis……………………………………………………..29

4. RESULTS……………………………………………………………...…………… 30

4.1. Results of general statistics…………………………………………...…………….. 30 4.1.1. Cause of injuries………………………………………………………..………….. 30 4.1.2. Primary treating doctors……………………………………………..……………… 31 4.1.3. Registration of the exact time of treatment…………………………….…………… 31 4.1.4. Registration of the consumption of alcohol and narcotics………….……………… 32





4.2. Assessability of MDRIs by the expert opinions……………………………………..32

4.3. Terms describing soft tissue injuries……………………………………..………….33

4.4. Terms for soft tissue injuries in the Hungarian sub-corpus………………..……….. 34 II 4.4.1. Terms depicting soft tissue injuries in parts A and B of the Hungarian MDRIs……..…………

4.4.2. Comparison of terms in parts A and B of the Hungarian MDRIs……….………… 35 4.4.3. Comparison of Hungarian and Latin diagnoses (B) in the Hungarian sub-corpus… 35 4.4.4. Terms used in Hungarian expert opinions (C)………………………..…………….. 36 4.4.5. Regional differences in the use of terms in Hungary……………………………….. 39

4.5. Terms describing soft tissue injuries in the Austrian sub-corpus………...………… 39 4.5.1. Terms depicting soft tissue injuries in parts A and B of the Austrian MDRIs……………………

4.5.2. Comparison of terms in parts A and B of the Austrian MDRIs……………………..39 4.5.3. Terms used in Austrian expert opinions (C)…………………………...…………… 40 4.5.4. Regional differences in the use of terms in Austria………………………………… 42

4.6. Terms describing soft tissue injuries in the German sub-corpus…………...………. 42 4.6.1. Terms depicting soft tissue injuries in parts A and B of the German MDRIs……………………

4.6.2. Comparison between terms in parts A and B of the German MDRIs…………….…43 4.6.3. Terms used in German expert opinions (C)……………………………………...….44 4.6.4. Regional differences in the use of terms in Germany………………………………. 45

4.7. Comparison between the use of terms in Austrian and Hungarian MDRIs………… 47

4.8. Comparison between terms in the Austrian and German MDRIs………………….. 49

4.9. Comparison between terms in the Hungarian, Austrian and German MDRIs………51

4.10. Correlation between injuries in descriptions (A), diagnoses (B) and expert opinions (C)…………………………………………………………………….……52 4.10.1. Correlation between described (A) and diagnosed (B) injuries in Hungary, Austria and Germany……………………………………………………………….. 52 4.10.2. Correlation between described (A) and assessed (C) injuries in Hungary, Austria and Germany………………………………………………………..……… 53 4.10.3. Statistical correlation between diagnosed (B) and assessed (C) injuries in Hungary, Austria and Germany……………………………………..……………… 54

–  –  –

4.11. Synonymous groups of unidentifiable injuries in A, B and C……………..……….. 55 4.11.1. The synonymous group ‘tenderness on pressure’ in parts A, B and C of the files…. 56 4.11.2. The synonymous group ‘bruise’ in parts A, B and C of the files……….………….. 57

4.12. The largest synonymous group ‘lacerated wound’ in parts A, B and C of the files... 58

4.13. Registered characteristics of soft tissue injuries……………………………………. 58 4.13.1. Registration of size………………………………………………………….……….59 4.13.2. Registration of numbers of injuries……………………………………………...…..61 4.13.3. Registration of shape………………………………………………………..……….62 4.13.4. Registration of further characteristics of injuries……………………………...…….62 4.13.5. Distribution of the characteristics in descriptions………………………………..…. 65 4.13.6. Influence of recorded characteristics of injuries on the assessability of MDRIs..…. 65

4.14. Registration of the exact location of soft tissue injuries………………….………… 66

4.15. Registration of location……………………………………………………..………. 67 4.15.1. Registration of location in the Hungarian sub-corpus……………………………… 68 4.15.2. Registration of location in the Austrian sub-corpus……………………….……….. 70 4.15.3. Registration of location in the German sub-corpus………………………………… 71

4.16. Lexico-grammatical analysis……………………………………………………...... 73 4.16.1. Lexico-grammatical analysis of the Hungarian sub-corpus………………………… 73 4.16.2. Lexico-grammatical analysis of the Austrian sub-corpus…………………………... 74 4.16.3. Lexico-grammatical analysis of the German sub-corpus…………………………… 75

5. DISCUSSION………………………………………………………………………. 78

5.1. The genre of MDRI…………………………………………………………………. 78

5.2. Interdiscursivity…………………………………………………………………….. 78

5.3. Subjective symptoms of patients as unidentifiable injuries………………………… 79

5.4. Terms lacking specification as unidentifiable injuries……………………………… 79

–  –  –

5.6. Inconsistent use of nominal collocations…………………………………………… 87

5.7. The role of genre-specific nominal collocations……………………….…………… 89

5.8. Various levels of terminologisation………………………………………………… 90

5.9. Different levels of professionalism………………………………………………… 93

5.10. Important circumstances and characteristics of injuries not registered precisely…. 94

5.11. Forensic assessability………………………………………………………………. 95

5.12. Comparison of the Hungarian, Austrian and German ways of recording injuries… 96

5.13. Need for standardisation

6. CONCLUSION…………………………………………………………………….. 100 REFERENCES

TABLE OF GRAPHS AND CHARTS

APPENDIX

OWN PUBLICATIONS

ACKNOWLEDGEMENT

–  –  –

DIN = Deutsches Institut für Normung EGP = English for General Purposes ESP = English for Specific Purposes GP = General practitioner ICD = International Statistical Classification of Diseases and Related Health Problems ISO = International Standards Organisation KWIC = Key Word in Context LGP = Language for General Purposes LSP = Language for Specific Purposes MDRI = Medical Diagnostic Report on Injuries SFL = Systemtic Functional Linguistics SPSS = Statistical Package for the Social Sciences

–  –  –

The communication of medical and health care professionals has been regarded for thousands of years as a very closed system which has never allowed laypeople to become part of it. On the one hand, laypeople do not possess the knowledge of the medical background and the specific code system which is called medical terminology. On the other hand, patients are not required to understand everything said by physicians about their conditions. However, over the years medicine has overlapped with an increasing array of scientific fields which has contributed greatly to its technical and methodological development. Nowadays, disciplines focusing on and interacting with various aspects of medical research operate on the border areas of health sciences.

In accordance with the core message of the quote above, this study is meant to be one of the drops which started to fall on the stone of medical professional communication from the direction of linguistics in the 20th century. These drops are not there to form the stone’s inner structure or alter its essence. They merely observe its development and come into contact with its surface again and again by exchanging ideas and ways of thinking.

Applied linguistics has realised that the empirical exactness of natural sciences is needed for the objectification of linguistic research. Just as linguistics has been enriched with these aspects of the sciences including medical sciences, the latter might also adopt some suggestions from the field of humanities in order to establish valuable and effective cooperation resulting in a new, long-lasting ‘dripstone’ formation.

1 1. INTRODUCTION

1.1. Writing medical reports Writing reports on diagnostic findings is an obligatory part of every physician’s work all over the world. It is required by hospital administration, the patient, the patient’s GP or another medical doctor having referred the patient, and sometimes by the physician him/herself as research material. A diagnostic report must contain the patient’s medical history, the present symptoms, examinations along with their results and records of the treatment applied. In cases of using invasive diagnostic or therapeutic methods the steps of interventions are also to be recorded.



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