English in Medical Education

An Intercultural Approach to Teaching Language and Values

Peih-ying Lu, John Corbett

• Publisher: Multilingual Matters
• Year: 2012
• ISBN:
  9781847697783
• Topic: Languages & Linguistics
• Subtopic: English Language
• Index: Languages & Linguistics

This book addresses recent developments in medical and language education. In both fields, there have been methodological shifts towards 'task-based' and 'problem-based learning'. In addition, both fields have broadened their focus on clinical expertise and linguistic skills to address issues of cultural competence. English in Medical Education responds to these changes by re-imagining the language classroom in medical settings as an arena for the exploration of values and professional identity. The chapters cover topics such as the nature of cultural competence; how to understand spoken discourse in a range of medical settings; the use of tasks and problems in language education for medics; the development of critical skills and the use of literature and visual media in language education for doctors. It will interest everyone teaching English for Medical Purposes.

1 Introduction – English in Medical Education

This book explores the many interactions between recent and current developments in medical and language education. It will be of most relevance to those who are involved in teaching English to medical students, but it should also interest those who are teaching English to practising healthcare professionals and those involved in developing cross-cultural competence in medical education. Some parts of the book may also be of use in designing courses in medical communication for native speaking medical students; it will be clear that we have drawn inspiration from descriptions of a number of such courses ourselves. There are, of course, many textbooks that are written to be used either in the teaching English for medical purposes (EMP) or in training proficient or native speaker students to communicate effectively in medical settings. However, these textbooks differ from each other in many respects and the present volume also offers a change of focus and direction from most of the books currently available. This introductory chapter surveys the current scope of EMP, explains why we believe a change of direction may be merited, at least in some educational contexts, and previews the contents of the book as a whole.

English, of course, has long been recognised as a basic requirement for medical training internationally (e.g. Maher, 1986), and medical schools in countries ranging from Poland to Singapore now advertise programmes in medical education that are fully or partly taught in English. Institutions in other countries include English language training as a component of a medical degree; in some Taiwanese medical schools, for example, language classes may form part of a General Education component that is taught for two years before a further five years of pre-clinical and clinical training begins. In other schools, EMP might be taught in parallel with the medical curriculum. Of course, in Anglophone countries, the intake of medical students now generally includes a substantial cohort of non-native speakers (e.g. Hayes & Farnill, 1993). Beyond the bounds of medical schools, too, large-scale migration of both health-care providers and their potential patients means that practising clinicians and their colleagues regularly face situations where English is being used as a lingua franca in consultations.

The teaching of English for medical purposes has arisen in response to these educational and professional pressures. The textbooks and learning materials currently available to teach EMP focus on different aspects of the discipline. Some target the language and skills that medical students require in order to read medical texts in English or to cope with the demands of a course taught partly or entirely in English. Others address the occupational demands of working in an Anglophone environment on practising physicians whose first language is not English.

The learning materials used in EMP courses are naturally shaped by the pedagogical assumptions that underlie them. To take a few typical examples, The Language of Medicine in English (Bloom, 1982) and English for the Medical Professions (Beitler & Macdonald, 1982) focus largely on reading skills as a means of acquiring medical vocabulary. There are nods towards other means of reinforcing the vocabulary thus encountered, by memorisation through structural drills and further practice via conversational interaction, but reading remains the core activity. Bloom (1982) is designed around 10 relatively broad topics, from ‘Medicine, its History and Folklore’ to ‘Medical Emergencies’ and ‘Prevention and High Technology Health Care’. The structure of each unit is similar (Bloom, 1982: i):

Each lesson begins with a glossary of special terms in which specific vocational words and expressions are defined. There follows a vocabulary practice section in which questions and answers guide the reader to proper use of these terms. Then the terms are used again within a contextual frame of reference. Each section is followed by topics for discussion which give the student an opportunity to use special terms, structural patterns, and general vocabulary. The lesson ends with comprehensive vocabulary review and conversational practice.

Beitler and Macdonald (1982: i) also have reading as their primary concern, although their topics are more technical, including ‘Genetics,’ ‘Anatomy and Physiology’ and ‘Chemistry,’ and their stated aim is:

to bring students rapidly to a point where they can read medical texts of increasing difficulty and density with relative ease and a high degree of comprehension. Each reading is preceded by a rigorous vocabulary presentation and drill, and followed by extensive reading and comprehension exercises.

Both textbooks are designed for learners who have already acquired a relatively high level of general English proficiency and who are now embarking on medical studies.

By contrast, Professional English in Use: Medicine (Glendinning & Howard, 2007), English in Medicine: A Course in Communication Skills (Glendinning & Holmström, 2005) and Cambridge English for Nursing (Allum & McGarr, 2010) are all principally directed at learners who are already practising professionals, though they may also be of use to students in the pre-clinical and clinical phases of their training, especially when the students are interacting with patients. Glendinning and Howard (2007) shares with the other textbooks described above a primary concern with teaching medical vocabulary. Designed mainly for self-study, it introduces practitioners to the terminology associated with topics such as ‘X-Ray and Computed Tomography (CT)’, ‘Epidemiology’, and ‘Screening and immunization’. However, part of this textbook, like Glendinning and Holmström (2005) and Allum and McGarr (2010), also deals with typical encounters in which listening and speaking skills are more prominent. In medical settings, oral communication skills include the ability to ‘take a history’, ‘examine a patient’, ‘discuss a diagnosis’, ‘welcome a patient on admission’, ‘describe wounds’ and ‘show empathy’. The reading and writing illustrated by these textbooks also relate to the overall goal of being relevant to working professionals: they include case notes and forms, as well as medical journal articles. In many respects these textbooks are similar to guides to medical communication that are aimed at native speaker medical students, such as the popular textbook Communication Skills for Medicine. The preface to this volume states its purpose thus (Lloyd & Bor, 2009: i):

Many doctors increasingly recognise that communication skills in medical practice are not simply about positive engagement with patients. Effective communication also helps us to understand better a patient’s problem, the impact it has on a patient’s life and relationships and how best to manage the problem in the patient’s life. Nowadays, effective communication skills are also vital for reducing the risk of error in clinical practice as well as avoiding complaints about one’s practice. Both of these could have serious consequences for the doctor.

Lloyd and Bor also organise their teaching units around communicative events such as medical interviews and exchanging information; however, compared to Glendinning and Holmström’s textbook, Lloyd and Bor’s volume brings to the fore those communicative situations that native speakers would find as difficult to handle as non-native speakers. These situations include breaking bad news, taking a sexual history, dealing with complaints, calming challenging patients, coping with personal issues and communicating with children and young people. Particularly relevant to the present volume’s concerns is one chapter on ‘Communicating with patients from different cultural backrounds’, an issue also dealt with by two training DVDs designed for doctors working in a multicultural city (Moss & Roberts, 2003; Roberts et al., 2008). The training DVDs attempt to raise practitioners’ cultural competence by training them in conversational analysis and reflection. The use of language theory, in this case pragmatics and speech act theory, as a framework for reflection is also key to Skelton’s (2008) discussion of language and clinical communication. Skelton’s provocative contribution casts a sceptical eye over a ‘checklist’ approach to teaching communication skills, arguing that a wholeperson approach to education is no less necessary than a whole-person approach to medicine.

Clearly, all of the types of EMP learning materials described have their uses. Medical students need to grasp the technical language of the discipline quickly; they need to be able to function effectively in the kinds of communicative situation that recur frequently in medical interaction; and they particularly need advanced communication skills to deal with difficult and stressful situations, where the emotional stakes are high. Their instructors need to embed the teaching of communication skills in the rich context of the students’ own lives. We certainly do not wish to understate the continuing value of existing materials and courses; however, we feel that – except occasionally in passing – most of the EMP materials and courses of the kind illustrated by these examples manifest a curious absence. The passing references to ‘empathy’ and ‘different cultural backgrounds’ point to a potential direction for EMP that, particularly in medical education in a second language, has been relatively neglected (see, however, Candlin & Candlin, 2003).

In medical education, the direction to which we refer is usually called ‘cultural’ or ‘cross-cultural competence’ (e.g. Betancourt, 2003, 2004). In language education, its correlate is ‘intercultural communicative competence’ (e.g. Byram, 1997; Corbett, 2003; Risager, 2007). In these approaches to medical and language education, attitudes, values and beliefs are moved from the margins of pedagogy to occupy a much more central position. This position is sometimes expressed as ‘professionalism’ in medicine. Hafferty (2006: 2151) argues that the ‘next wave’ of professionalism demands qualities beyond clinical knowledge and ‘outward behavior’:

Being a physician – taking on the identity of a true medical professional – also involves a number of value orientations, including a general commitment not only to learning and excellence of skills but also to medical behavior and practices that are authentically caring.

It is our argument in the present volume that issues of ‘cross-cultural competence’ and ‘professionalism’ coincide with questions of attitude, value and identity in intercultural language education. As noted above, many medical students in today’s world combine their clinical education with either pre-clinical general education or supplementary language classes, usually in English. Therefore, the purpose of the present volume is to explore the rationale for addressing intercultural communicative competence in medical education, and to suggest some ways in which the concerns of medical education might be practically addressed in the intercultural language classroom.

The correspondence between cross-cultural medical education and intercultural language education forms the substance of the second chapter in this volume. In this chapter, we take up the challenge set out at the outset of Candlin and Candlin (2003: 134):

Applied linguists, and in particular those concerned with the analysis of discourse in professional contexts, would do well in our view to look outside their own professional literature for studies that direct themselves at health care communication, especially where this involves issues of intercultural communication.

As they go on to demonstrate, the professional literature in healthcare is rich in studies of intercultural communication, and they note the ‘discursive turn’ taken by sociologists of medicine (ibid: 142). What interests us most in Chapter 2, however, are the resonances between cross-cultural competences and intercultural communicative competence as curricular goals in medical and language education respectively.

A brief survey of literature on discourse and intercultural communication can be found in Corbett (2011). This overview notes the distinction sometimes made between studies of communication that are ‘cross-cultural’ and those that are ‘intercultural’. The former compares communication in one culture with that in another; for example, patterns of communication in a television programme that exists in different international formats might form the basis for a cross-cultural comparison of versions across cultures (cf. the discussion of Western and Asian patterns of discourse in the quiz show, The Weakest Link, in Cheng and Warren, 2006). Intercultural communication, on the other hand, is arguably concerned with what happens when people from a given culture interact with people from other cultures. While this terminological distinction may be useful, it is not generally observed in the medical literature, where ‘cross-cultural communication’ generally refers to interactions between people from different cultural backgrounds, as is evident from the following excerpt from a medical article on cross-cultural competence (Betancourt, 2003: 546):

Sociocultural differences between patient and physician influence communications and clinical decision making. Evidence suggests that provider-patient communication is directly linked to patient satisfaction and adherence and subsequently to health outcomes. Thus, when sociocultural differences between patient and provider aren’t appreciated, explored, understood, or communicated in the medical encounter, patient dissatisfaction, poor adherence, and poorer health outcomes result. It is not only the patient’s culture that matters; the provider’s “culture” is equally important.

In the present volume, then, ‘cross-cultural’ and ‘intercultural’ communication are regarded as largely synonymous, as they are in much of the medical literature. When ‘cross-cultural’ is used in the present volume, it simply suggests that the source of the issue being discussed is in the medical rather than the applied linguistics literature.

Studies of intercultural communication are themselves diverse; they range from research into communicative styles and values associated with broad cultural groups (e.g. Trompenaars & Hampden-Turner, 1998; Hofstede, 2005) to smaller scale empirical studies of particular episodes involving intercultural exchanges (e.g. Bailey, 2000). While we draw on many examples of intercultural interactions from the professional literature, our overall approach to intercultural language education is influenced by the work of pedagogical theorists and practitioners such as Michael Byram (1997, 2008) and Karen Risager (2007). This pedagogical orientation moves language education beyond a narrow focus on linguistic competence, and even beyond a concern with communicative skills and strategies, towards a wider conception of language ability that draws upon a knowledge and appreciation of different value systems (cf. Corbett, 2011: 314–315). Intercultural speakers can draw upon extensive understanding of different styles of interaction and cultural behaviour, they are politically aware, and they exhibit attitudes of openness and curiosity.

Byram and his colleagues have been influential in shaping that part of the Common European Framework of Reference for Languages: Learning, Teaching, Assessment (CEFR) which deals with intercultural communicative competence. While the components of intercultural communicative competence are set out in some detail in Chapter 2, it is worth quoting here the CEFR’s general statement about intercultural language education (Council of Europe, 2001: 1):

In an intercultural approach, it is a central objective of language learning to promote the favourable development of the learner’s whole personality and sense of identity in response to the enriching experience of otherness in language and culture.

At first glance, this statement may seem to have little relationship to the instrumental demands of cross-cultural training in medical education, as outlined by the quotation from Betancourt, above. However, it seems to us reasonable to suggest, at least, that there is a demand for healthcare professionals who are disposed to regarding encounters with ‘otherness’ as ‘enriching’, and whose sense of personal and professional identity has been shaped by positive engagement with people from other cultures. In other words, we believe that the attitudes, values and beliefs that form the core of intercultural communicative competence are cognate with those that are articulated in the medical literature as ‘cross-cultural’ competence – and it is this relationship that we explore more expansively in Chapter 2. Effectively, we argue that the literature on cross-cultural competence in medicine enhances and deepens our understanding of intercultural communicative competence in healthcare settings. Together, they provide a curricular basis for our intercultural approach to teaching English in medical education.

If Chapter 2, then, defines the ‘what’ of our approach, Chapter 3 addresses the ‘how’. After the so-called ‘methodology wars’ of the last century, English language teaching has moved into what has sometimes been characterised as a ‘post-methods’ phase (e.g. Kumaravadivelu, 1993, 2006). The label is, perhaps, unfortunate, since even ‘post-method’ forms of language education assume that there are more and less effective ways of teaching and learning a language. However, current language pedagogy seeks to resolve potentially unhelpful conflicts between teaching for communicative fluency and teaching for structural accuracy by focusing instead on classroom tasks that learners are required to perform (Kumaravadivelu, 2006: 65; original emphasis):

It is precisely because a task can be treated through multip...