Medical English as a Lingua Franca

M. Gregory Tweedie, Robert C. Johnson

• Publisher: De Gruyter Mouton
• Year: 2022
• Print ISBN: 9783111355535
• eBook ISBN: 9783110697070
• Edition: 1
• Topic: Languages & Linguistics
• Subtopic: Historical & Comparative Linguistics
• Index: Languages & Linguistics

In this first book-length treatment of MELF, the authors assert that MELF represents an important contribution to our understanding of English as a Lingua Franca (ELF), in that existing ELF research has been limited to relatively low stakes communicative situations, such as interactions in business, academia, internet blogging or casual conversations. Medical contexts, in contrast, often represent situations calling for exceptional communicative precision and urgency. Providing both evidence from their own research and analysis from (the limited number of) existing studies, the authors offer a counterpoint to the optimism regarding communicative success prevalent in ELF. The book proposes a theoretical perspective on how the various features of healthcare communication serve as important variables in shaping interaction among speakers of ELF, further enlarging our understanding of this emerging sub-field.

Chapter 1 Healthcare communication and MELF

Chapter key points:

• The migration of healthcare professionals is a growing phenomenon which affects health systems around the world.
• Research indicates that effective communication in healthcare contexts positively impacts patient outcomes; conversely, ineffective communication has the potential to threaten patient safety.
• The addition of linguistic and cultural factors, associated with the migration of healthcare professionals, likely contributes yet another layer of complexity to effective medical communication.
• Characteristics of medical English as a lingua franca both converge with and diverge from ELF in its primary domains of study thus far. As such, MELF holds the potential to deepen our understanding of ELF.

The single biggest problem with communication is the illusion that it has taken place. – George Bernard Shaw (Dolan 2019)

1.1 Healthcare professional migration

We live in an era of unprecedented labour migration, where workers across the spectrum of employment sectors, from unskilled farm labourers to university research professors, seek better opportunities abroad. Healthcare labour is no exception: the World Health Organization avers a 60% decadal increase of migrant healthcare professionals to Organisation for Economic Co-operation and Development (OECD) countries (World Health Organization 2020b). In fact, healthcare professionals account for the lion’s share of all educated migrants. The number of foreign-born doctors in OECD countries, for example, typically exceeds the number of foreign-born highly educated professionals in general (OECD 2019). In many countries, foreign-trained healthcare professionals account for significant numbers of the total healthcare workforce: in 2017, foreign-trained doctors made up 42% of New Zealand’s doctors, 40% of Norway’s, 32% of Australia’s, and 24% of Canada’s. Israel topped this list with 57.9% (OECD 2019: 1.4). Foreign-trained nurses accounted for 7% of the total nursing workforce in OECD countries, with Australia, Canada, Norway, New Zealand, Switzerland and the UK all exceeding that OECD average. In New Zealand, for instance, foreign-trained professionals made up 26% of all nurses in 2017, reflecting a steady increase through the previous decade (OECD, 2019:1.4).

Another indication of the prevalence of global healthcare worker migration was the development of a Code of Practice by the World Health Organization (2010) to discourage active recruitment of healthcare professionals, in order to prevent critical shortages in migrant-sending countries. Some estimates suggest African countries, for example, may lose as much as 70% of their healthcare system workforce to high-income countries (Aluttis, Bishaw & Frank 2014), a reality which raises unsettling ethical questions for nations engaged in direct recruitment. Yet, the migration of healthcare professionals cannot be understood only in terms of traditional patterns of mobility. Delegates to the 2018 International Platform on Health Worker Mobility at the World Health Organization’s Geneva headquarters were presented with the increasingly blurred patterns of migration source and destination, such as South to South and North to South. For example, doctors from Nigeria represented the top source of doctors entering South Africa between 2011 and 2015 (Cuba and the Democratic Republic of Congo were the third and fourth sources). The second most common source of South African doctors during this time period? The United Kingdom. In another example of the complexity surrounding source and destination for healthcare professionals, one-third of doctors registering in Uganda from 2011–2015 held nationality in North America or Europe. One-half of practicing doctors in the Caribbean country of Trinidad and Tobago in 2014 were trained in India, Nigeria or Jamaica (Health Workforce Department 2018).

In actual fact, the scale of healthcare workforce migration may well be underestimated by the numbers presented above. First, while data are more readily available on the cross-border movement of physicians and nurses, far less can be found on the migration of other types of healthcare professionals, such as radiologists, pharmacists, physiotherapists, and so on. Second, the number of available migratory pathways may further mask the actual extent of migration. A healthcare professional may migrate to a new country for the purposes of study, then join her new country’s healthcare workforce at a later date. Or, recently arrived immigrants may enrol in healthcare education in their new country, and thus be excluded from counts of foreign-trained professionals. The OECD therefore recognizes the distinction between foreign-trained and foreign-born healthcare professionals: the number of foreign-born doctors in 18 OECD countries increased by more than 20% from 2010–2016, with nurses reflecting a similar trend. In Australia, foreign-born physicians account for over half of the total doctor workforce, and in Canada, nearly 40% (OECD 2019: 1.3)

The case for distributive justice and global accountability around international recruitment [of healthcare professionals] was strengthened by Mills et al’s 2011 paper, which estimated the costs to 9 SSA [sub-Saharan African] countries from the loss of locally trained medical doctors who were working in the four main destination countries: United States, United Kingdom, Canada and Australia. Estimates of losses ranged from $2.16 million for Malawi to $1.41 billion for South Africa, resulting in cost savings to destination countries that did not need to train the doctors they recruited internationally: $2.7 billion for the United Kingdom and $846 million for the United States (Brugha & Crowe 2015: 335).

Perhaps not unexpectedly, the global movement of healthcare workers has raised concerns over the impact such migratory flows may have on accurate communication in medical contexts, an observation routinely discussed in popular media (BBC News 2015; BBC News 2016). But what impact do these shifting workforce numbers have upon communication in healthcare? This is the subject of the next section.

1.2 Medical communication and migration of healthcare professionals

Language is medicine’s most essential technology, its principal instrument for conducting its work (Jackson 1998: 65).

The notion that the “most essential technology” of medicine is language is supported by a multitude of studies identifying the benefits of effective medical communication for patients. Besides improved overall health status and psychological well-being (Chou & Cooley 2018), elements of effective medical communication have been found to positively impact patient outcomes in illnesses such as blood pressure (Schoenthaler et al. 2009); diabetes (Greenfield et al. 1988); coronary heart disease (Benner et al. 2008); mortality rates from heart attacks (Meterko et al. 2010); cancer (Mustafa et al. 2013; Arora et al. 2009); and HIV (Flickinger et al. 2016). Effective communication has been shown to reduce negative post-surgery outcomes (Trummer et al. 2006; Lee et al. 2013), and positively impact pain control (Oliveira et al. 2015). As a potential remedy to today’s soaring healthcare costs, effective communication also saves money (Chou & Cooley 2018; Epstein et al. 2005; Zhang et al. 2009).

Given the weight of the empirical evidence about its benefits to health, one would assume effective medical communication is widely prioritized and practiced. However, despite over 200,000 patient interactions during a typical physician’s career (Chou & Cooley 2018), in the words of three MDs summarizing the literature, “We [physicians] do not seem to be very good communicators” (Tongue, Epps & Forese 2005: 652). Research suggests physicians typically select a patient problem to explore before fully hearing her or his concerns, with one study indicating doctors listen to patients for only 18–23 seconds before redirecting the conversation (Marvel et al. 1999). There may also be a wide gap between physicians’ perception of themselves as communicators and the perceptions of patients. 75% of 700 orthopaedic surgeons surveyed perceived themselves as having satisfactorily communicated with their patients, while only 21% of patients perceived the communication as satisfactory (Tongue, Epps & Forese 2005). Research has uncovered multiple other factors hindering doctor-patient communication, including: excessive medical jargon (Deuster et al. 2008); a disproportionate emphasis on biomedical talk (Kain et al. 2009); ineffective questioning techniques (Roter et al. 1999); unequal power relations between physicians and patients (Todd 1984); doctors’ avoidance of emotional issues due to time pressures (Maguire & Pitceathly 2002); and physicians’ burden of work and fear of litigation, among others (Ha & Longnecker 2010).

ELF healthcare interaction: End-of-shift patient handover simulation

Nurse B (first language: Arabic): Why you … take the blood sugar? The blood sugar, it’s high?

Nurse A (first language: Tamil): Blood sugar, not take.

Nurse B: You not take blood sugar?

Nurse A: No. Not diabetic, not diabetes.

(M. Gregory Tweedie & Robert C. Johnson 2018a)

The above barriers to healthcare communication describe only physician-patient interactions, and in settings in which language differences are not predominant. In many contexts, healthcare is delivered by a complex array of interactions between many medical specialties: one estimate suggests an involvement of more than 50 specialties and subspecialties (Leape & Berwick 2005). This complexity doubtless impacts effective interprofessional communication, as does hierarchical structure, a culture of individual autonomy, and dispersed accountability (Leape & Berwick 2005). In describing physician-nurse communication in the context of maternity care, Lyndon et al (2011) detail hindrances to communication such as face-saving; relational preservation; fear of negative repercussions; deference to hierarchy; and conflict avoidance. The effectiveness of pharmacist-physician communication is said to be impacted upon by several factors, including the tendency to work in silos; conflicting understandings on the role of pharmacists; a lack of time on both sides; and an overreliance on oral rather than the precision of written communication (Kelly et al. 2013; Coomber et al. 2018).

Given these complexities, it is not unwarranted to assume medical migration and attendant language differences will add yet another layer of convolution to healthcare communication (see Figure 1.1).

Figure 1.1: Layers of complexity in healthcare communication: a delicate balancing act.

If medical migration and differing linguacultures impact healthcare communication, it may be a case of making an already bad situation worse. Miscommunication is understood to be the main reason for medical mishaps (Khairat & Yang 2010). In an integrative review, Foronda and colleagues paint a bleak picture: “Ineffective communication in healthcare results in delayed treatment, misdiagnosis, medication errors, patient injury, or death” (2016: 36). Considerable data exists to quantify this blunt assessment. CRICO Strategies, a division of Harvard Medical Institutions, maintains a large database of malpractice cases in the United States. Their analysis of more than 23,000 cases in which patients suffered harm indicated three in ten involved a breakdown of communication (CRICO Strategies 2015: 1). CRICO’s 2015 Annual Benchmarking Report highlights 7,149 cases wh...

Table of contents

• Title Page
• Copyright
• Contents
• Acknowledgements
• Introduction: MELF and ELF
• Chapter 1 Healthcare communication and MELF
• Chapter 2 Tools for analysis: Framing MELF
• Chapter 3 The researchers, the research, and the research setting
• Chapter 4 Strategies for MELF communication
• Chapter 5 Finding common ground in MELF
• Chapter 6 Implications and conclusion: Healthcare education in MELF contexts
• Appendix: Transcription Glossary
• References
• Index