Technical Writing: The ESL Connection in Pharmacy

T. R. Girill
Society for Technical Communication/Lawrence Livermore National Lab.
trgirill@acm.org

Technical Writing: The ESL Connection in Pharmacy

The Risk

In May, 2010, pediatricians Iman Sharif and Julia Tse
published a revealing evaluation of the adequacy of computer-
generated medicine labels for non-English-speaking pharmacy
patrons (I. Sarif and J. Tse, "Accuracy of Computer-Generated
Spanish-Language Medicine Labels," Pediatrics, 2010, 125(5),
960-965). They studied 286 pharmacies in the Bronx (New York
City), where 72% translated prescription medicine labels at least
daily into Spanish (and other languages) to help their ESL patrons
(and as required by law). The vast majority (86%) used commercial
computer programs rather than bilingual staff members to
generate the Spanish label text. Iman and Tse carefully compared
the (English) input and (Spanish) output in these cases. They
were disturbed to find that 43% of the translated labels contained
incomplete or flawed text, often in a Spanish-English jumble
(Spanglish).

In this situation biochemistry and software design meet
social responsibility with high stakes: such medicine labels are
supposed to offer reliable, explicit instructions for administering
life-saving drugs or potentially dangerous chemicals to sick
patients, often children. Iman and Tse found the high rate of
textual errors and omissions "frightening to any physician,
[with] obvious opportunities for harm" (p. 964).

The Cases

A closer look at the flawed-label cases reveals a classic
failure of text usability. Many Spanish-speaking pharmacy
customers have enough "social English" to manage routine
transactions (shopping, for example). But they often lack
"academic English"; hence the importance of reliable medicine-
label translations for them.

To be effective, dosing instructions need to contain enough
relevant details to correctly (self-)administer the prescribed
medication. A translation that omits or confuses those key details
renders the instructions unusable and perhaps dangerous. The
software employed by the Bronx pharmacies combined basic translation
algorithms with a database of English-Spanish medical terms to
convert English labels into Spanish with no help from the clerk
who ran the program at pill-delivery time. Iman and Tse, however,
found crucial gaps or flaws in those databases that removed vital
details from the "translated" output (pp. 962, 964):

* Amount:
"Dropperfull" is a common pediatric dosing unit,
for example, yet the three most widely used
translation programs omitted it from their term
database. Hence this word ended up uselessly
untranslated in the Spanglish output ("tome dos
dropperfulls...").
* Manner:
"Apply topically" or "take orally" are critical
way-to-administer details, yet simple database
spelling errors often rendered such strings meaningless
in Spanglish ("by mouth" [boca] became the
unintelligible "a little" [poca], for example).
* Rate:
Some medically-relevant words occur in both English
and Spanish but with very different meanings. Thus
"once a day" is ambiguous in Spanglish, since it
could mean "1 time" (English) or "11 times" (Spanish).
This particular confusion has resulted in several
documented patient deaths in New York.

Teaching Techniques

How can technical writing practice in science class prepare
your students to avoid or mitigate such serious usability
problems? Refining kitchen recipes turns out to present students
with just the same text-design, detail-management issues as
Iman and Tse found in medicine labels, but with no specific
medical (or Spanish) knowledge presupposed. For example,
effective instructions for making something as simple as cranberry
sauce demand details analogous to the troublesome ones above
(see http://www.ebsct.org/TechLit/analysis4.html):
* Amount:
Omitting "2 cups of sugar" from an early step causes
the recipe to fail.
* Manner:
"Uncovered, without stirring" fills the same key role
in this recipe that "take orally" does on a medical
label.
* Rate:
Like most fruit, cranberries are sold by weight but
cooked by volume. Hence, the conversion "1 pound of
cranberries equals 4 cups" is a vital enabling detail.

Students who scrutinize kitchen recipes from the usability
perspective not only become sensitive to precisely the
instruction flaws that Iman and Tse detected in translated
medical labels, but they also hone the text-design skills to
correct those flaws.

Relevance to Life

Today's science students could easily find themselves
tomorrow in any of three roles in the real-life medicine-label
scenario:
* the influential software designer who develops a
usable label-translation tool on which some major
pharmacy chain blindly depends,
* the pharmacy technician who (perhaps alone on the
night shift) has to verify or clarify a translated
label by personally explaining how to reliably use
a prescribed medication, or
* the distraught parent, regardless of their native
language, who needs to be savvy enough about text
usability to not leave the pharmacy without getting
adequate usage instructions that they fully
understand.
Preparation for all three roles can start with the technical
writing principles that you introduce. After all, fixing
recipe flaws prevents cooking frustration, but fixing
medical-label flaws can literally save lives.