Abstract
Writing is a complex process reflecting the writers' communicative skills. To help EFL students write in English appropriately, the teachers must take their major problems in writing into account if they are expecting a favorable outcome. This research is concerned with EFL writing problems at the university level, trying to point out the major difficulties with which Iranian students face when writing their reports. This study aims at determining the defects in writing skill of medical students. The specific objective of this study is to determine whether language skills or writing skills are the major problem areas to which our fifth year medical students and interns are confronted. In order to compare these students, 101 admission and progress notes written in the internal medicine and pediatrics wards by these students were surveyed based on systemic sampling approach. The notes were scored for language skills comprising spelling, vocabulary, grammar and syntax, and writing skills including punctuation, cohesive devices, coherence and organization. Implications of the findings for EFL writing instruction are discussed. Data analysis indicates that Iranian EFL medical students have problem both in language and writing skills, but with a higher percentage of problem in writing skills. Although grammar, vocabulary and syntax are essential for a well written report, other more important areas are significant as well. Language accuracy, although very significant cannot alone result in effective writing; what our students need is also writing skills.
Introduction
Writing is a complex activity, a social act which reflects the writer’s communicative skills which is difficult to develop and learn, especially in an EFL context. Research in this field has examined the nature and types of writing task and by providing better understanding of ESL/EFL students' writing needs, there has been an effort to help the development of this major skill theoretically and pedagogically (Zhu, 2004; Carson, 2001; Hale et al, 1996). Examining the features of EFL writing tasks and the students' problems in performing the task would certainly be pedagogically beneficial. As stated by Atkinson (2003), EFL students' writing in a language classroom context shows their ability to solve a rhetoric problem and their awareness of their own communicative goals, of the reader, and of the writing context. In spite of numerous approaches to the teaching of writing (communicative language teaching (CLT), process-based approach, product-based approach, genre-based approach, etc….) having evolved from different teaching methods, tackling EFL writing is still one of the challenging areas for teachers and students. The students of medicine in Shiraz University have to pass more English courses than those studying in other national medical universities and there is a 3 unit writing course specifically offered for graduate students. Nevertheless, these students still have many problems in their reports, notes and case histories. On the surface, when looking at the notes and reports written by students and interns involved in the clinical period and studying at Shiraz University, many EFL teachers think that grammar and vocabulary are the main problem area and that their writing would improve with remedial grammar/voc lessons. If looked more deeply, we see that the students and interns do not set out to write a good report in the first place, but a specific number of words which are organized loosely in sentences. As Widdowson (1995) points out, we need to consider the larger discourse context or the meaning that lies beyond grammatical structure. To go beyond grammar, language should be looked at as a form of social practice (Fairclough, 1992).
Despite the need to write notes and also the increase in the number of medical students who write their theses in English, in Iran, there are very few researches into the difficulties encountered, or on writing courses designed to help such students write the thesis and notes to an acceptable standard. Many studies have been done in the area of EFL writing problems but only a few of them have pinpointed and found actual problems in both areas of language skills and writing skills.
Therefore this research is concerned with EFL writing issues at the university level, trying to point out the major difficulties with which our students at Shiraz University of Medical Sciences face when writing their reports. It is hypothesized that medical students have problem in writing notes in the medical charts in the hospitals. The academic language has specific features and follows specific purposes and it requires the students to be trained to write in this particular social context. Such ESP courses require specific instructional and curricular approaches applied to our university writing classes. Also, language accuracy, although very significant, cannot alone result in effective writing; what our students need is also writing skills. Based on the hypotheses made, the following research questions are pursued:
- Are grammar, vocabulary and syntax the main problem areas in EFL writing? In other words, would the EFL students’ writing improve with remedial grammar/ vocabulary lessons?
- Is lack of writing skill the main problem to which our students and interns are confronted?
- Is there any difference between the fifth year medical students and interns in their skill in writing?
The findings of this research will hopefully have implications for teaching and will reduce the difficulties of our students in writing in English.
Material and method
Study setting
The study reported in this article was conducted at the medical school of Shiraz University in the south of Iran, which enrolls approximately 120 medical students each year. Writing requirements for these students include a three unit course, consisting of three hours weekly during the term. This course is offered by English language experts in the English department of the university. During this course, the students are required to learn basic English structures as well as paragraph writing with different purposes and are encouraged to write both in class and through homework. After finishing their basic sciences period, these students enter the hospitals to start their clinical period as student first and then extern and intern. During this period they have to visit patients and write reports and notes in their files. This study examined 101 notes written by the fifth year medical students and interns in pediatric and internal wards of a teaching hospital of Shiraz University of Medical Sciences. Upon entering the university, these students have to take part in a placement test based on which they are put in pre-university, general English I or II. The other English courses required are ESP and academic writing. Except academic writing, the other courses aim at improving the students' reading comprehension. Based on the students' scores in our English courses, their level of English ranges from lower to upper intermediate.
These notes were written in the academic year of 2004 in the hospitalized patients’ charts as well as those filed in the medical record of the hospital. The notes were selected by systematic sampling from the admission and progress notes which are usually more complete than other types of notes and those written in other wards. Moreover, on-service, off-service and discharge notes were excluded due to their shortness. Therefore, the instruments of this study were the existing data while guest students, externs and foreigners were excluded from the studies. The subjects' name remained confidential by codes given to each note. Finally some of the students were interviewed to see what they view as their problems.
Analysis
The notes were analyzed to identify the major problems in EFL writing. They were examined from the point of view of language skills, i.e. spelling, grammar, syntax and vocabulary as well as for the writing skills, i.e. punctuation, cohesive devices, coherence and organization. As to spelling, any type of mistake was considered, for example writing "admession" instead of "admission" or "daybetic" instead of "diabetic". As to grammar, such sentences as "She developing a knee pain since one month ago" were considered as wrong. In syntax, the students sometimes did not follow the rules of grammar used for ordering and connecting words to form phrases and sentences. An example of the wrong use of vocabulary was using "breast" instead of "chest", and sometimes forgetting the word for "knee" and leaving it blank. Sometimes, there were no close relationship, based on grammar or meaning, between different parts of a sentence or between one sentence and another (cohesion). In some cases, there was no consistency or natural and reasonable connection between the parts of their notes (coherence). All such cases were considered as a mistake.
The data were then analyzed to see whether any one of the factors mentioned is the cause of the main problem in writing then a comparison was made between students and interns’ skill in writing. The statistical tests used for analysis of the data were descriptive statistics and chi-squares test.
Results
To achieve the first and second research questions of this study, the data were first analyzed descriptively and the frequency tables, the percentage of errors for the 8 components described in the previous section were obtained (Table 1)
As reflected in Table 1, descriptive statistics reveal that the highest errorless scores are given to organization, use of vocabulary and spelling while grammar, syntax, punctuation, cohesive devices and coherence comprise the most problematic areas, with cohesive devices being the maximum problem. The percentages of no error cases are very low. The use of vocabulary is better than that of correct cases in other components. The same picture is true with organization which had a higher percentage of errorless cases.
On the other hand, the results displayed in the table reveal that the means of the errors in each component are very close to each other, indicating that there is problem in all components. The mean errors of spelling, punctuation, cohesive devices and coherence are higher than others.
To further investigate whether most of the errors were generally found in the language skills (spelling, vocabulary, grammar and syntax) or writing skills (punctuation, cohesive devices, coherence and organization), descriptive statistics were performed. It was revealed that for language skills, the maximum of errors was 26 overall (mean=11) and for writing skill, it was 30 (Mean=11.31). Obviously, the difference between the means of the first four factors and the second ones is not statistically significant.
To answer the third research question of this study and determine whether there is a difference between the students and interns’ skill in EFL writing, crosstabulation and chi-square tests were carried out. As shown in Table 2, a higher percentage of interns had less than 22 errors than the students and a lower percentage of them had more than 22 errors. The results of the chi-square test for their total writing revealed a significant difference between students and interns (P=.01), with the interns showing a higher skill in their writing.
To further investigate the difference between these two components of writing, chi-square test was carried out for both groups in the two components. The outcome of the crosstabulation and chi-square test revealed that the difference between the two groups of students and interns for language skills (the first four factors) was not significant (2 sided= .07) and also it was non-significant for the writing skill (2 sided=.163) (Tables 3, 4)
Although in their total writing (Table 2) and in the first four factors of language skill (Table 3) they have performed differently and the differences were statistically significant, the difference between the mean score of errors (Table 1) and also the difference between the first and second four factors (Table 4) were non-significant .
Finally to compare both groups’ performance in each component individually, the results of the chi-square tests revealed a significant difference between them only in the first component of language skill, i.e. spelling (P=0.022) but not in all other 7 components (P=0.209, 0.216, 0.632, 0.129, 0.453 and 0.608, respectively). Tables 5 and 6 summarize different parts of this section. First the differences in 8 components individually and then the differences in the components of language skill and writing skill separately and finally the difference in their total mean scores of the errors were obtained.
As explained previously, the mean errors of the students in each individual component of language skill and writing skill are very similar to those of interns. As to the comparison of language skill and writing skill and in general, the students performed less favorably than the interns. The mean errors in the students’ writing were higher than those of the interns (language skills: 1.3 V.S. 9.61, writing skill: 11.94 V.S. 10.96 and total writing: 24.2 V.S. 20.30). This indicates that although statistically non-significant, the interns have performed better in their writing.
Discussion
In order to help medical students perform EFL writing task in their academic career, understanding of the nature of writing task and students’ writing needs and problems seems to be essential. The study reported here presents an effort to understand these. Although before the writing course, we offer 3-4 more other courses in reading skills, the development of which is indispensable for the development of writing skills, the students still have problems. This study identified the percentages of errors in each component of EFL writing. According to Table 1, some components of both language and writing skills cause problem for students and interns while trying to write in English. The percentages of no error cases are very low, indicating that, overall, there is a major problem not only in language skills but also in writing skills. The use of vocabulary is better than the use of correct cases in other components. That’s probably because the medical students have a good knowledge of technical terms. However, their writing reveals that in the use of general vocabulary, they have more problems. The same picture is true with organization which had a higher percentage of errorless cases. The reason is that there is a stereotype organization for writing reports starting with the patient’s personal information, the complaints, symptoms, diagnosis and the drugs prescribed. But in practice we see that in writing a well organized paragraph, they still have some problems.
On the other hand, the results reveal that the means of the errors in each component are very close to each other, indicating that there is problem in all components. The mean errors of spelling, punctuation, cohesive devices and coherence are higher than others. This may suggest that discoursal aspects of writing should be more emphasized in our writing classes.
The descriptive statistics performed revealed that the difference between the means of language and writing skills was not significant, indicating that there is a major problem not only in language skills but also in writing skills. This finding was confirmed when the mean score of errors by the students and interns were compared statistically in all 8 components of writing. There was no significant difference. However, when descriptively examined, there was a difference between the scores, with the interns performing better. Therefore, they all have problem in the 8 components under the study and their writing will improve not only with remedial grammar/vocabulary lessons but also by focusing on writing skills. Of course, it can not be claimed that grammar, vocabulary and syntax are not essential for a well-written report or patient’s note. Other more equally important areas such as cohesive devices, coherence, organization and even punctuation are important as well which might be ignored while overconcentrating on grammar and vocabulary. Based on the interactive approach to writing, the writer is “involved in a dialogue with his/her audience” (Johns, 1990) and he has to write effectively to have communication. A piece of writing might be good in terms of language; yet, it might not succeed the goal it has been written for and is unable to produce an effective text. In this regard, the study of Gabrielatos (2002) confirms our results, denoting that language accuracy, although important, cannot alone lead to efficient writing which needs writing skills to be developed as well. According to him, in most cases, learners have problems both in language and writing skills.
As to the comparison of both groups in the total writing, the results of the chi-square test indicated a significant difference between them in general. The interns showed a better skill in writing. What is consistent with this finding is the fact that the difference between the two groups in the 4 components of language skill was significant; however, it was non-significant for writing skill components. Although interns write better in terms of language skills, both groups performed similarly regarding the writing skills. The difference between both groups was only significant for spelling but in all 7 other components, there was no statistically significant difference. These results were in the same line with the other results obtained in the study. Therefore, both groups had problems although interns performed better in language part. Of interest is their mean errors in each individual component of writing (8 components under the study) which were mostly similar. When these 8 components were divided into language and writing skills, the mean scores revealed that the students had more errors than the interns although these differences were statistically non-significant. Moreover, although for writing skill they were not significantly different, they showed a difference in language skills as well as the total writing which proved to be significant. In all, they had problem in all areas of writing and both aspects of writing must be focused in our classes. Better performance of interns may suggest that their more exposure to English texts during the clinical period for 2-3 years more than the students has enabled them to perform better. Therefore, in our classes we need to emphasize extensive reading.
As to the results of the interview with the subjects, it was indicated that, as expressed by themselves, the students do not have enough time to devote to writing courses and in general to their English courses due to the simultaneous offering of their specialized courses. To them, it would be more beneficial not to spend more time on English language and EFL writing classes. Secondly, their courses are not presented in English and they don’t have to write their tests in English. Moreover, they suffer from insufficient knowledge of general vocabulary so that they can write appropriately.
The results of this part, the interview as well as the author's experience with these students lead us to the conclusion that some problems go back to our classes and method of teaching and some to our students' low knowledge of vocabulary and finally their low motivation for learning writing. In order to be able to help EFL students write in English appropriately, there is a need for teachers to take the processes involved in good writing and the favorable outcomes of a writing program into account. In our classes, the teachers mostly focus on sentence level problems and try to correct the compositions sentence by sentence. As stated by Nelson and Carson (2002, p.18), this causes the students not to be able to transform their thoughts into writing and tends to privilege product over process. In a study done by Hayland (2000, p. 46), it is recommended that correcting errors does not necessarily produce learning. Based on the results of this study, if ESL writing is one of the skills of language learning, first of all vocabulary and grammar is important. The need for EFL composition instructors, therefore, is not to cast-aside sentence level learning but to find new and better ways to do it.
In addition to grammar and vocabulary work, our students’ practical needs must be emphasized more; theoretical teaching does not suffice. The students must have more opportunity to write. We teachers need to facilitate the planning and production stages of writing for adult students of English as a foreign language. The problems in our classes is exactly what Holmes (2004) mentions,” Teachers have trapped the students within the sentence and respond to the piece of writing as item checkers not as real readers. As he suggests, we need to develop a more top-down and student-centered approach to the teaching of writing. What is lacking in our classes is enough attention to the relevant issues of discourse and genre in our traditional, largely syntax-focused classrooms.
Secondly, through examining the notes, it emerged that although in using technical words, they have no problem, they do not have access to a normal range of vocabularies to be able to write a well-organized and appropriate note, for example using the term "febrile" instead of "temperature" as used inappropriately in a specific context. In many cases, when they need a general word like "consistency", the students apparently do not remember the word and leave it blank. Lack of vocabulary probably causes more syntactic difficulties than any other single problem. As revealed in their interview, when they don’t know the word for something, they use one of two strategies: they either use a bilingual dictionary and choose a word they have not acquired and therefore have no feeling for, or they “write around” the gap, describing the concept they are groping toward. The first strategy usually ends up with a word with inappropriate connotations, and the second often produces a complex and tangled sentence structure. What seems to be lacking is knowledge of general words since they know the technical terms in their field well, which seems to be necessary to be expanded to provide the learners with the means to access various types and levels of writing. So lexical remediation with respect to general language is recommended. As Muncie (2002) indicates, limited vocabulary is a major obstacle to students’ learning to write in a foreign language. He concludes that vocabulary learning is very important to the development of ESL writing and that ESL writing instructors need to recognize and encourage vocabulary learning. Kosuth in University of Minnesota Dutch (2004) explains learning to write as reciprocally and simultaneously integrated with learning to read. Therefore, their range of vocabulary can be extended in reading comprehension classes.
Moreover, our students do not have enough motivation to learn writing during the first years of university when they have to pass their writing course. We have to justify their future need to writing to be able to overcome this lack of strong motivation. Actually when syllabus and time constraints come to the fore, there is not enough provision for practice of the writing skill in our classes, the problem that must be solved anyway.
To solve these problems in the way of effective teaching of writing some recommendations are presented hereafter. First of all, as the language teaching approaches have moved toward discoursal aspects of the language, we, as teachers of writing, need to develop a more top-down approach in our writing classes. We need to change our one-dimensional focus, i.e. reinforcement of grammatical and lexical patterns to the content and self expression. As stated by Holmes (2004), we need to change our focus from “writing to learn” to “learning to write” (p.118, developing teachers.com). To do this, Gabrielatos (2002) suggests awareness raising in which learners are guided to discover/identify specific elements of good writing and features of different text types. Awareness raising procedures can include the following: analyzing a poorly formulated text in order to identify problems, propose remedies, analyzing learner texts for merits/shortcomings, for style/register, ordering jumbled sentences to create a paragraph/text, etc. Of interest is what stated by the proponents of social interactionist view of language literacy that holds that a learner's early attempts at writing are grounded in speech and that the development of written language is best enhanced within a supportive conversational environment (Weissberg, 1994). Therefore, it is concluded that more class hours are needed to offer the students the chance to use and experiment with the features of good writing discussed in classroom. It is recommended that the authorities and curriculum planners arrange the medical courses in a way that in the first year of the university the students be exposed to English language and other general courses before they start their specialized courses. Furthermore, more courses and, as a result, more hoursare needed to be allocated to EFL and specifically to writing courses.
As to the students' low motivation, we have to react thoughtfully to their writing. This could be of great significance because careless reaction could discourage the students from actively developing their writing “power”. Excessive stress on grammar and focus on content accuracy may make them feel burdened (Graves, 1983).
What our students in writing classes need is recycling and enough practice on activities such as analyzing the text for elements of good writing, identifying problems, ordering jumbled sentences to make a paragraph or jumbled paragraphs to make a text, finding topic and supporting ideas. To achieve this goal, more individualized work is essential if our classes are to be effective. The problem is that our classes are too crowded to do it. Moreover, a 3 unit course does not seem to be sufficient for developing such skills. As Gabrielatos (2002) points out, learners need to be involved in the process of learning since what is taught is not necessarily what is learned. In this process, recycling is essential for learning. Writing, according to Fairclough (1992) is power. To gain such power, our learners learn to write and write to learn. Fortunately, researchers have suggested solutions to writing problems of ESL/EFL writing. For more details, refer to Muncie 2002, Kasper & Petrello, 1996, Hans 2002 and Riazi & Mir, 2002.
As an example, recycling method of Gabrielatos (2002) can be used to give students enough practice in good writing in the actual classroom. He proposes a writing skill program in a developmental cycle based on learning procedures proposed by some researchers in writing (Altrichter et al 1993, Kolb 1984). According to him, special writing lessons are necessary during which the teacher guides the learners to be aware of all elements of good writing, give examples, create chances for practice and give them feedback. The cycle involves awareness, feedback, support, practice and feed back.
Limitations of this study must be taken into account when interpreting the findings. Firstly, this study examined the notes written at two wards and one university only. Different medical schools offer different courses and even most of them offer no writing course. Secondly, the data were examined by two researchers only. Further research could involve more researchers to examine the notes. In spite of the limitations noted here, this study provides useful information concerning the major problems these students encounter when writing in English.
Conclusion
Therefore, to help EFL learners write effectively, a distinction must be made between language accuracy and writing skills. It is not only language problems to which EFL learners are confronted when trying to write; the writing problems which lie beneath the surface must be looked at as well. It is also concluded that our students need more hours of EFL and writing classes. It is concluded that different approaches to teaching writing cannot be applied in our EFL context successfully unless we take our students' social and academic context, needs and purpose of writing into account. Considering our students' problems based on the results of this study, it seems that the model proposed by Badger and White (2000), entitled as "process genre approach" would be appropriate to be used in our university writing classes. In this model, writing is viewed as involving knowledge about language (as in genre and product approaches) and knowledge of the context in which writing happens and specially the purpose of writing (as in genre approach). Therefore, writing development happens by drawing out the learners' potential and providing input to which the learners respond. Our students need to get familiar with the academic discourse and workplace, so our teachers must emphasize the link between discourse, community and knowledge in an attempt to offer a new insight on EFL writing.
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