communication skills Enhancing international medical graduates’ communication: the contribution of applied linguistics Maria R Dahm,1 Lynda Yates,1 Kathryn Ogden,2 Kim Rooney2 & Brooke Sheldon2

CONTEXT International medical graduates (IMGs) make up one-third of the Australian medical workforce. Those from non-Englishlanguage backgrounds can face cultural and communication barriers, yet linguistic support is variable and medical educators are often required to provide feedback on both medical and communication issues. However, some communication difficulties may be very specific to the experiences of IMGs as second language users. OBJECTIVES This interdisciplinary study combines perspectives from applied linguistics experts and clinical educators to address IMGs’ difficulties from multiple dimensions and to enhance feedback quality. METHODS Five video-recorded patient encounters with five IMGs were collected at Launceston General Hospital. Three clinical educators gave quantitative and qualitative feedback using the Rating Instrument for Clinical Consulting Skills, and two applied linguistics experts analysed the data for

language, pragmatic and communication difficulties. The comparison of the educators’ language-related feedback with linguistic analyses of the same interactions facilitated the exploration of differences in the difficulties identified by the two expert groups. RESULTS Although the clinical educators were able to use their tacit intuitive understanding of communication issues to identify IMG difficulties, they less frequently addressed the underlying issues or suggested specific remedies in their feedback. CONCLUSIONS This pilot study illustrates the effectiveness of interdisciplinary collaboration in highlighting the specific discourse features contributing to IMG communication difficulties and thus assists educators in deconstructing their intuitive knowledge. The authors suggest that linguistic insights can therefore improve communications training by assisting educators to provide more targeted feedback.

Medical Education 2015: 49: 828–837 doi: 10.1111/medu.12776 Discuss ideas arising from the article at www.mededuc.com discuss.

1

Macquarie University, Sydney, New South Wales, Australia Launceston Clinical School, University of Tasmania, Launceston, Tasmania, Australia 2

828

Correspondence: Kathryn Ogden, Launceston Clinical School, University of Tasmania, Locked Bag 1377, Launceston, Tasmania 7250, Australia. Tel: 00 61 409 181437; E-mail: [email protected]

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 828–837

Linguistic analysis of IMGs’ communication skills

INTRODUCTION

Current figures suggest that one-third of the Australian medical workforce are international medical graduates (IMGs) who trained overseas, often in countries in which English is not the dominant language1,2 and where approaches to care may be very different from the patient-centred model of care practised in Australia, which emphasises patient autonomy and shared decision making.3–5 Patientcentred care is reflected in local medical education,6,7 but IMGs may be unfamiliar with not only the Australian medical system and approaches to care within it, but also with the communicative demands of working with such approaches in English.5,8,9 Moreover, in addition to more readily identifiable difficulties with English grammar, vocabulary, pronunciation or comprehension, IMGs may also have difficulty in identifying and correctly using what have been termed the more ‘subtle features’9 of communication, or those pragmatic features associated with interpersonal communication. As these vary considerably across languages and cultures,10 they pose particular challenges to doctors who have trained in another language and can impact negatively on their ability to meet the expectations of colleagues and patients, particularly in situations that demand a nuanced approach to verbal and non-verbal interpersonal communication, such as in the establishment of rapport, and the projection of willingness to listen or the display of empathy through words and actions.9,11,12 However, cultural and communication training and support for IMGs is not only expensive and difficult to access, but can also vary considerably in quality.8,13 A recent move away from the conceptualising of English language training for IMGs as purely remedial5,14 and an increased focus on the pragmatic aspects of communication9 have meant that it often falls to medical and clinical educators to tackle the specific communication issues that arise in the course of learning how to practise in a second language. However, although native-speaking clinicians may be tacitly aware of many of these more subtle linguistic features, they can find it difficult to explicitly identify and explain them, let alone to teach them. This is particularly crucial given that best practice guidelines for the provision of feedback in clinical education stress the importance of being specific in describing observed actions and linking them to associated skills,15–17 and in providing specific, concrete examples for constructive feedback.16 Specificity is as important in addressing

difficulties in interpersonal communication strategies as it is in improving clinical skills.17 In this, concepts and tools from applied linguistics can be very helpful. Applied linguistics and clinical communication skills Applied linguistics is a diverse field of study ‘concerned with solving or at least ameliorating social problems involving language’.18 Of particular relevance to the present study are the areas of intercultural communication and professional medical discourse, or the kind of talk that is appropriate in medical contexts. In order to illuminate issues that arise when speakers from one cultural background interact with speakers from another, we will draw on the concepts of socio-pragmatic and pragmalinguistic knowledge.19 To explore aspects of medical discourse, we will draw on concepts of interpersonal approachability features12 and framing.20,21 Socio-pragmatic knowledge refers to the socio cultural values to which speakers orient during an interaction, that is, their understanding of behaviours and attitudes that are considered appropriate in that context in a particular culture. These values may be either general in nature or specific to a situation or relationship. General communicative values relate to, for example, how formal or deferent people are generally expected to be in a community, whereas values specific to the doctor–patient relationship may relate to, for instance, how autonomous a patient is expected to be in making management decisions. Pragmalinguistic resources refer to the actual linguistic words, phrases and structures (i.e. what is actually said and how it is phrased) that speakers use to express what they mean to say. A doctor may, for example, use a direct approach to instruct a patient to undress, as in ‘Take your shirt off’, or a more mitigated way in order to avoid the impression of brusqueness, as in ‘Would you mind just taking your shirt off for a moment?’ Approachability features12 are those subtle interpersonal strategies that speakers use to establish rapport and trust and help them appear approachable. These include small talk,22 colloquial language,23 backchannel cues (i.e. the minimal verbal and nonverbal interjections that speakers make to show they are paying attention when someone is talking24) and genuine empathic statements.25,26 The use of these features may be challenging on a socio pragmatic level for IMGs who have grown up and trained in a different culture. They may have a

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 828–837

829

M R Dahm et al different understanding of the doctor–patient relationship and thus may not view small talk or the elicitation of extended patient narratives as appropriate for consultations. Even if they do recognise the importance of encouraging a patient’s narrative, they may not be aware of specific ways to demonstrate this approachability in English because the pragmalinguistic devices that English speakers regularly use to show this openness may be different in their first language. Thus they may not fully appreciate the importance of close listening and eliciting extended narratives from patients in the often unfamilair model of patient-centred care (i.e. they may lack the socio-pragmatic knowledge) or they may be unsure of exactly how or how often to encourage patient narratives through short interjections and minimal responses such as ‘mmh’ and ‘okay’. In other words, they may lack the necessary pragmalinguistic knowledge.27

The study addresses the following research questions: 1

2

How do applied linguistics experts (ALEs) and clinical educators identify and address languagerelated challenges in IMG–patient interactions? How can insights from applied linguistics enhance medical educator feedback to IMGs on their communicative practices in English?

The ALEs in this study have expertise in researching intercultural communication and professional discourse, and in the application of findings to professional practice. The clinical educators are medically trained and clinically active doctors involved in supervising and providing feedback to both undergraduate and postgraduate medical trainees.

METHODS

The concept of ‘framing’ draws on the socio-pragmatic and pragmalinguistic knowledge speakers have about a situation. It refers to the idea that individuals adopt different (interactive) frames of reference in order to identify and understand the different kinds of interaction in which they are involved.20 Whenever speakers engage in an interaction, they need to accurately identify what kind of activity they are in and what kind of frame should guide their behaviour. Thus, for example, a police interrogation is generally very different from a dinner party conversation and hence the frame guiding the type of questioning behaviour appropriate in each situation will also differ. As we grow up in a culture, using a particular language, we learn, often subconsciously, what are deemed to be appropriate or expected behaviours in a particular situation (i.e. socio-pragmatic knowledge) and also how these behaviours should be realised through language (i.e. pragmalinguistic knowledge). Despite the potential of these concepts to make feedback on communication issues more specific, and thus salient and constructive for IMGs, little collaborative interdisciplinary research has incorporated insights from both a medical and an applied linguistics perspective.28,29 Moreover, research to date on the language and communication difficulties of IMGs has largely drawn on interview or focus group data rather than on data from interactions involving patients.5,30 This paper reports on a pilot study designed to address this gap by providing an analysis of the communication challenges faced by IMGs in interactions with real patients using insights from both medical and linguistics experts.

830

Participants For this pilot study, we drew on five video-recorded consultations between non-native English-speaking IMGs and Australian patients who were either hospitalised or living with chronic illness. All IMGs had already met the standard language benchmarks for registration with the Australian Medical Board.31 Interactions lasted 22–30 minutes and were conducted as formative assessment activities within the IMGs’ ongoing workplace-based registration assessments.32 Although the patients were genuine patients reporting real problems, the consultations themselves were conducted specifically as part of the IMGs’ workplace-based assessments in order to provide feedback and were therefore not part of the actual management of the patients’ conditions. The five consultations analysed here were randomly selected from a bank of 20 such consultations recorded on the assessment programme. The principal problems of each patient and basic demographics for each IMG are given in Table 1. As the latter are currently practising, only basic demographic details are provided in order to protect their anonymity. All consultations were conducted in out-patient consulting rooms at a hospital. The patient and doctor were seated on chairs facing one another. The doctor did not use a desk, but did have a clipboard. The patient seen by IMG C was accompanied by a partner, but all others were alone. No extraneous factors impeding the consultation were identified by the researchers on examination of the recordings.

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 828–837

Linguistic analysis of IMGs’ communication skills

Table 1

Demographic data for international medical graduates (IMGs) and data on patient presentations

Years of Age group, IMG

gender

Region of origin

A

30–34, male

Southern central Asia

Years in

local practice

Patient’s presenting complaint or

Australia

experience

reason for hospitalisation

5

1.75

Adult out-patient Multiple problems: early dementia, hypertension, osteoarthritis, social isolation

B

25–29, female

Southern central Asia

2

2

Adult out-patient Main problem: chronic kidney disease Comorbidities: hypertension and type 2 diabetes mellitus

C

35–39, male

Southeast Asia

3

1.5

Adult out-patient Presenting problem: chronic abdominal pain Comorbidities: chronic obstructive airway disease and depression

D

30–34, male

Southern central Asia

2

1.5

Adult in-patient Postoperative following bowel resection for colorectal carcinoma Currently with stoma

E

30–34, female

Southern central Asia

2

1

Adult in-patient Recent cerebellar infarct Comorbidity: ischaemic heart disease

Doctors were instructed to take a full history and to conduct a relevant examination sufficient to produce a written management plan for the patient. Authors KO, BS and KR (clinical educators) were involved in the design, implementation and interpretation of the study and made the clinical assessments on the workplace-based assessment programme. There was no perceived conflict in these roles. For this study, they assessed each video in the usual way using a locally developed instrument, the Rating Instrument for Clinical Consulting Skills (RICS).33 This is designed to allow ratings and qualitative feedback on clinical consultations in four key domains: task exploration and context; diagnostic examination; problem solving and management, and patient-centred approach. Following face and content validation, the 20 core RICS items identified as the most reliable were rated on a 6-point Likert scale and were also used as prompts for qualitative feedback. The remaining 16 items were used as prompts for qualitative feedback if relevant, but were not rated. As communication-related skills are integral to all domains, these are addressed in items throughout the assessment instrument. Examples of RICS items are provided in Fig. 1 and Appendix S1 (online). Each IMG performance was given a final

global competency rating of satisfactory, borderline or unsatisfactory. The recordings were de-identified and transcribed in close verbatim style to include backchannels, hesitations and false starts. Non-verbal behaviours such as writing on charts, adjusting seating positions and gaze were also noted. Both videos and transcripts were analysed qualitatively from a linguistics perspective by authors MRD and LY. The ratings and feedback by clinical educators were recorded and made available electronically for analysis. Analysis The ALEs first viewed the videos to gain an overall impression of each consultation. This was followed by a close linguistic analysis which was reiterative and drew on techniques from discourse analysis34,35 and interlanguage pragmatics36 in three steps. In Step 1, MRD and LY immersed themselves in the data through repeated readings supplemented by video viewings to check conclusions and impressions. They focused on the IMGs’ performance using free coding37,38 to flag and categorise problems related to linguistic difficulty or intercultural transfer. Categories were refined and duplication eliminated through

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 828–837

831

M R Dahm et al

The candidate uses questions which allow a targeted exploration of the patient. (Task exploration and content) The examination is used to assess the current clinical situation and hence to inform the future management plan. (Diagnostic examination) An approach that facilitates collaboration with the patient to prioritise and plan management is demonstrated. (Problem solving and management) The candidate builds the relationship and demonstrates an empathic approach. (Patient-centred approach)

Figure 1 Examples of items on the Rating Instrument for Clinical Consulting Skills

discussion. In Step 2, communication-related comments in the clinical educators’ qualitative feedback were identified and categorised, and in Step 3 the IMGs’ performances were revisited with a specific focus on the language problems identified in Step 2. This three-step method allowed the linguists to explore the IMG data with open minds before pursuing issues identified by the educators. The project was approved by the relevant human research ethics committees. Both patients and doctors provided informed consent to the use of the video-recordings in this project.

RESULTS AND DISCUSSION

Topics for feedback on communicative difficulty Analyses of interaction and feedback data revealed that the clinical educators and ALEs in most cases identified similar areas of communicative difficulty for the IMGs. These were similar to those identified in the literature and are summarised with illustrative examples in Table 2. Although the clinical educators were specific about the nature of the problem about half the time (44.2%, 57 of 129 language-related comments), just over half of their language-related comments were not accompanied by specific explanations or concrete suggestions for how the difficulty could be remedied (55.8%, 72 of 129 comments), as in this example:

“You just exercise and everything will be alright” = inappropriate statement.(Educator 3 about IMG D) In her feedback, clinical educator 3 identifies a problem with the phrase IMG D has used to provide advice, but does not specify exactly what is inappropriate about the phrase; she does not say that the advice is too direct and is not softened by mitigation such as by the use of a hedge, modal or conditional construction.39 As the ALEs focused solely on communication difficulties, their comments used linguistic categories and concepts to provide targeted insight into the specific nature of the difficulty, its underlying causes and how they might be remedied. Contribution from applied linguistics Both groups recognised and pinpointed the communicative difficulty that arose when IMG B started to use a series of rapid closed questions before eliciting a more general account of the patient’s condition: Went to closed questioning too soon.(Educator 3 about IMG B)

Language barriers prevented more targeted exploration.(Educator 3 about IMG C) Although such general comments identify a problem on a relational level, they lack detail and there is no specific mention of exactly what the IMG said or did not say that interfered with good communication. Further, although more specific clinical educator comments explicitly identified a problematic language item, often including an approximate

832

quote from the IMG and an assessment, they rarely gave detail of exactly why the use of this particular item or structure was unsuccessful or how the issue might be remedied. In the next example, the clinical educator comments on the way in which IMG D offered advice to be a little more active as a way of alleviating symptoms:

The ALEs, however, also noted the specific nature of the effect this had on the course of the consultation by drawing on the linguistic notion of ‘framing’:20,21 After initial “How are you” starts using rapid series of closed questions about symptoms (nauseous, headache, eating, weight, swelling), creating an “aggressive” interview frame and effectively keeping

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 828–837

Linguistic analysis of IMGs’ communication skills

Table 2

Areas of communicative difficulty in international medical graduates (IMGs) noted by clinical educators

Areas of communicative difficulty

Examples of feedback

Need to show they are listening more attentively10,54

‘Be careful to listen fully to the patient’s responses’ (Educator 3 of IMG D)

Over-use of medical terms and jargon9,55,56

‘Used jargon that confused the patient [hypertension], used the word[s] “suicidal ideation”’ (Educator 2 of IMG C)

Use of expressions of empathy that seem tokenistic rather than genuine3,42

‘Very few empathic statements – couldn’t finish her PhD. Concern about dementia –some attempt at empathy, but doesn’t come off, doesn’t appear genuinely concerned’ (Educator 1 of IMG A)

Missed opportunities for exploration of patients’ understanding, feelings, concerns3,4,15,30 Missed opportunities/cues for small talk, empathy, reassurance9,57,58

‘Failed to explore “trying to get the dialysis fixed up” and what this means [to] the patient and his wife’ (Educator 3 of IMG B) ‘Doesn’t explore evidence of depression – a common problem post-stroke. Fails to engage in rapport-building conversation, patient tries hard (particularly at the end) to engage doctor – she is somewhat dismissive’ (Educator 1 of IMG E)

Use and timing within consultation of open and closed questions9,58

‘Doesn’t use enough open-ended questions to explore concerns. When does use open-ended questions, doesn’t effectively follow them up to further explore concerns’ (Educator 1 of IMG A)

‘Inappropriate’ language use

‘It is inappropriate to tell the patient [to] “keep your chin up, you will be fine”’ (Educator 3 of IMG C)

the patient from giving his perspective.(ALE 1 about IMG B) By starting too soon with rapid questions, IMG B created a frame – an expectation for the kind of activity they are engaging in – that invoked a climate of interrogation. This medically driven framing of the consultation discourages the patient from offering a lengthier narrative and encourages a responsive rather than a proactive role. An IMG may pass prematurely to closed questions of this kind because he or she lacks the socio-pragmatic understanding that a patient-centred approach is expected. Alternative approaches to questioning and elicitation may therefore be needed,3 perhaps because IMGs have developed socio-pragmatic understandings and therefore interpretive and guiding frames overseas that are different from those expected in Australia. Because they are using a second language, IMGs may also be unsure of exactly how to elicit information from patients in ways that allow greater exploration of the patient’s perspectives and feelings; they may not yet control the full repertoire of pragmalinguistic resources that allow native and expert users of English to communicate the more pragmatic, subtle aspects of interpersonal stance. Thus, whereas native speakers can draw upon – usually implicitly – a whole repertoire of linguistic devices

to make polite requests, soften directives or show they are listening attentively, IMGs are not necessarily able to do so. Furthermore, as this is an area of language that is notoriously under-represented in the language curriculum40 and difficult to identify without instruction, IMGs may be aware of the linguistic items themselves, but unfamiliar with their impact and function in interpersonal communication. Thus, IMG B may have moved directly to an inappropriate questioning frame because she had transferred her socio-cultural understandings of a consultation from the language and culture in which she had trained, or because she had difficulty in recognising and controlling the precise language forms needed to adopt a more appropriate frame, or both. Either way, a separation of the cultural bases of language behaviour (socio-pragmatics) from the language used to behave appropriately (pragmalinguistics) can be very helpful in both identifying and remedying problems that are often identified as simply relating to language. We illustrate this with an extended example below. Unpacking ‘inappropriate’ language Clinical educators often noted language they felt was ‘inappropriate’. Drawing on their intuitions as

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 828–837

833

M R Dahm et al native English-speakers, they used relational terms such as ‘threatening’, ‘disrespectful’, ‘uninterested’, ‘too directive’, ‘overly polite’ and ‘suggestive of condescension’. As we will illustrate, the specific nature of the difficulty can be usefully illuminated in terms of socio-pragmatic transfer, pragmalinguistic difficulty and the use of approachability features that serve to pinpoint more exactly what went wrong, why and therefore what can be done about it. Excerpt: IMG E IMG

‘Okay, so before this stroke, how had been your exercise? Were you getting, uh, shortness of breath or chest tightness, chest pains on exercise?’

Patient ‘No, nothing, I, I felt very fit.’ IMG

‘Alright.’

Patient ‘In fact I’ve been doing some heavy landscape gardening around my place.’ IMG

‘Oh.’

Patient ‘I’ve got nine acres there and I (. . .) I’ve been moving huge blocks around, digging ponds. . .’ IMG

‘Okay.’

Patient ‘. . .and putting in waterfalls and all sorts of things.’ IMG

‘Okay. And, uh, have you got any diabetes?’

As their feedback to the interaction given in this example shows, two of the three clinical educators identified the IMG’s behaviour to be in some way inappropriate: Fails to engage in rapport-building conversation, patient tries hard (particularly at the end) to engage doctor – she is somewhat dismissive. (Educator 1 about IMG E) Really listen to the patient so that you can respond APPROPRIATELY, not just say “Okay” to everything. Were you really not impressed by his landscaping endeavours??(Educator 3 about IMG E) Thus, clinical educator 1 felt that IMG E sounded ‘dismissive’, and clinical educator 3 identified a difficulty in her use of the backchannel cue ‘Okay’ and felt that this made her sound uninterested in what the patient had to say. From an applied linguistics perspective, IMG E can be seen as failing

834

to fully realise the role of minimal backchannel cues in signalling that the listener is open and genuinely interested in listening or the importance of using cues of this kind as important indicators of approachability.12 Listeners interject cues such as ‘okay’ into the speaker’s narrative to show they are paying close attention and to signal an interpersonal engagement with the narrative.41,42 Although IMG E’s initial use of such cues signalled that she was listening, her subsequent question (‘Okay. And, uh, have you got any diabetes?’) failed to display genuine interest in the patient’s narrative. She did not pick up on opportunities for small talk and appeared to tolerate rather than encourage such conversation. Once again, a strong adherence to a medical frame seems to have been an issue for IMG E as she pursued her medical agenda and set the consultation up as a medical interview rather than as a conversation between equals. This may be a socio-pragmatic issue. This particular IMG may have transferred her expectations of the consultation from her experience in southern central Asia, where many other patients and staff may be present43,44 so that small talk in a doctor’s office may be perceived negatively as jeopardising patient privacy or may not occur at all. She may therefore not have fully understood the importance of small talk in a patient-centred approach.12,22,45 Communication skills handbooks often encourage doctors to show that they are actively listening through the use of minimal responses or backchannels such as ‘mmh’ ‘yeah’ or ‘okay’,46 but are rarely explicit on the need to avoid the overuse of such tokens or the value of more extended responses in showing engagement. Although IMG E routinely used backchannels to overtly signal active listening, she did not engage more actively with the patient’s story. A slightly extended comment cue such as ‘Oh really? That’s quite a commitment!’ would have allowed her to show more interest. This IMG may not have done this because she did not understand the importance of this type of listening behaviour to signal both listening and engagement42 (i.e. this is a socio-pragmatic difficulty). The issue here may also be pragmalinguistic because although backchannels may be a universal phenomenon, their form, frequency and the ways in which they are used vary across languages and cultures.47,48 This IMG may have transferred backchannelling behaviour learned in her first language and culture into her use of English.

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 828–837

Linguistic analysis of IMGs’ communication skills Whatever the cause, failure to engage with the patient may have consequences on a number of levels. It can indirectly affect the accuracy of diagnosis, patient compliance and trust, and thus seriously impact health outcomes,49,50 potentially resulting in medico-legal as well as interpersonal consequences. This makes it important for IMGs, particularly those from societies in which doctor–patient relationships are more hierarchical,51,52 to understand the sociopragmatic expectations within a patient-centred approach that require doctors to both listen to patients carefully and to show they are listening. Pragmalinguistically, IMGs need to know how to supply a suitable extended backchannel cue where it is appropriate.

CONCLUSIONS

Our small-scale pilot study shows that although clinical educators and ALEs identified similar areas of communicative difficulty for IMGs, they often did not provide specific explanations of their assessments or suggest alternative structures. We illustrate how insights from applied linguistics can illuminate error-focused feedback from clinical educators and complement their medical expertise and tacit understanding of the communication demands of medical practice with explicit analyses of the causes and therefore potential methods of remediation of communication issues. Such technical and structural insights into how communication works in English can assist clinical educators (and by extension IMGs) to tackle more explicitly areas of socio-pragmatic understanding and pragmalinguistic expertise in which deficiencies can interfere with successful communication with patients. On a socio-pragmatic level, clinical educators and IMGs can be encouraged to explore the values underlying communication strategies, and to examine how much informality and what level of social distance might be appropriate, and the role of small talk and relationship building. On a pragmalinguistic level, they can explicitly address ways of encouraging small talk, making conversational gambits and showing active listening. In this study, we have explored the benefits of collaboration between clinical educators and ALEs as a means of informing and improving feedback given to trainees and students of non-English-speaking backgrounds. We have identified a number of specific areas in which ALEs were able to add value to the feedback provided by clinical educators. How-

ever, the study is limited by its small scale. Thus, for example, although tone, stress and other features of pronunciation are crucial in how speakers can be perceived in professional contexts,53 it was beyond the scope of this study to address these issues. Future research could usefully focus on these and other aspects of the delivery of both verbal language and non-verbal aspects of communication. Although this project was small in scale, it was nevertheless able to pilot the notion of collaboration between ALEs and clinical educators, and to offer some insight into the behaviours of IMGs and the clinical educators charged with assisting them to practise in Australia. Further larger, multi-site, interdisciplinary research collaborations may prove very valuable in expanding awareness among educators, IMGs and other medical students of the socio-pragmatic expectations and pragmalinguistic realisations in health communication, and thus help to make feedback on communication skills more effective.

Contributors: MRD contributed to the conception and design of the study, and the analysis and interpretation of data, and drafted the manuscript. LY contributed to the conception and design of the study, and the analysis and interpretation of data. KO contributed to the conception and design of the study, and the collection and analysis of data. KR contributed to the conception and design of the study, and the analysis of data. BS contributed to the analysis of data. All authors contributed to the critical revision of the paper and approved the final manuscript for publication. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Acknowledgements: the authors would like to acknowledge the participating international medical graduates and patients. Funding: this study was funded by a Macquarie University New Staff Grant. Conflicts of interest: none. Ethical approval: this study was approved by the Tasmania Health and Medical Human Research Ethics Committee (H0013027) and Macquarie University Human Research Ethics Committee (5201200960).

REFERENCES 1 Australian Institute of Health and Welfare. Medical workforce 2012. National Health Workforce Series no. 8. Cat. no. HWL 54. 2014. http://www.aihw.gov.au/ WorkArea/DownloadAsset.aspx?id=60129546076. [Accessed 7 April 2015.] 2 Australian Medical Council. Australian Medical Council Annual Report. 2013. http://

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 828–837

835

M R Dahm et al

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

836

www.amc.org.au/images/publications/2013-annualreport-web.pdf. [Accessed 7 April 2015.] Dahm MR. Patient-centred care – are international medical graduates ‘expert novices’? Aust Fam Physician 2011;40 (11):895–900. Australian Medical Council. Good medical practice: a code of conduct for doctors in Australia. 2009. http://www.amc.org.au/images/Final_Code.pdf. [Accessed 4 December 2014.] McGrath P, Henderson D, Tamargo J, Holewa HA. Doctor–patient communication issues for international medical graduates: research findings from Australia. Educ Health (Abingdon) 2012;25 (1):48–54. Barr J, Ogden K, Rooney K. Committing to patient-centred medical education. Clin Teach 2014;11:503–6. Barr J, Ogden K, Rooney K. Viewpoint: let’s teach medical students what patient partnership in clinical practice can be, with the involvement of educationally engaged patients. Int J Consum Stud 2010;34 (5):610–2. McGrath P, Henderson D, Holewa H. Language issues: an important professional practice dimension for Australian international medical graduates. Commun Med 2013;10 (3):191–200. Pilotto LS, Duncan GF, Anderson-Wurf J. Issues for clinicians training international medical graduates: a systematic review. Med J Aust 2007;187 (4):225–8. Dorgan KA, Lang F, Floyd M, Kemp E. International medical graduate–patient communication: a qualitative analysis of perceived barriers. Acad Med 2009;84 (11):1567–75. Cordella M, Musgrave S. Oral communication skills of international medical graduates: assessing empathy in discourse. Commun Med 2009;6 (2):129–42. Dahm MR, Yates L. English for the workplace: doing patient-centred care in medical communication. TESL Canada J 2014;30 (7):21. House of Representatives Standing Committee on Health and Ageing. Lost in the labyrinth: report on the inquiry into registration processes and support for overseas trained doctors. 2012. http:// www.aph.gov.au/parliamentary_business/committees/ house_of_representatives_committees?url=haa/ overseasdoctors/report.htm. [Accessed 7 April 2015.] Wette R, Basturkmen H. Two perspectives on the language difficulties of overseas trained doctors: evidence from role plays. N Z Stud Appl Linguist 2006;12 (2):64–77. Gigante J, Dell M, Sharkey A. Getting beyond ‘good job’: how to give effective feedback. Pediatrics 2011;127 (2):205–7. Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. Oxford: Radcliffe Publishing 2005. Quilligan S. Communication skills teaching: the challenge of giving effective feedback. Clin Teach 2007;4:100–5.

18 Davies A, Elder C. Applied Linguistics: Subject to Discipline? The Handbook of Applied Linguistics. Oxford: Blackwell Publishing 2008. 19 Thomas J. Cross-cultural pragmatic failure. Appl Linguist 1983;4 (2):91–112. 20 Tannen D, Wallat C. Interactive frames and knowledge schemas in interaction: examples from a medical examination/interview. Soc Psychol Q 1987;50 (2):205–16. 21 Goffman E. Frame Analysis: An Essay on the Organization of Experience. Boston, MA: Northeastern University Press 1974. 22 Ragan S. Sociable talk in women’s health care contexts: two forms of non-medical talk. In: Coupland J, ed. Small Talk. Harlow: Pearson Education 2000;269–87. 23 Yates L. Negotiating an institutional identity: individual differences in NS and NNS teacher directives. In: Bardovi-Harlig K, Hartford B, eds. Interlanguage Pragmatics: Exploring Institutional Talk. Mahwah, NJ: Lawrence Erlbaum 2005;67– 98. 24 Cutrone P. A case study examining backchannels in conversations between Japanese–British dyads. Multilingua 2005;23:237–74. 25 Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract 2013;63 (606):e76–84. 26 Epstein RM. The science of patient-centred care. J Fam Pract 2000;49 (9):805–10. 27 Coulehan JL, Platt FW, Egener B, Frankel R, Lin CT, Lown B, Salazar WH. ‘Let me see if I have this right. . .’: words that help build empathy. Ann Intern Med 2001;135 (3):221–7. 28 Cross D, Smalldridge A. Improving written and verbal communication skills for international medical graduates: a linguistic and medical approach. Med Teach 2011;33 (7):e364–7. 29 Woodward-Kron R, Stevens M, Flynn E. The medical educator, the discourse analyst, and the phonetician: a collaborative feedback methodology for clinical communication. Acad Med 2011;86 (5):565–70. 30 McDonnell L, Usherwood T. International medical graduates – challenges faced in the Australian training program. Aust Fam Physician 2008;37 (6):481–4. 31 Medical Board of Australia. English language skills registration standard. 2010. http:// www.medicalboard.gov.au/RegistrationStandards.aspx. [Accessed 7 April 2015.] 32 Medical Board of Australia. Standard pathway. 2014. http://www.medicalboard.gov.au/Registration/ International-Medical-Graduates/StandardPathway.aspx. [Accessed 7 April 2015.] 33 Ogden K, Barr J, Hill A, Summers M, Mulligan B, Rooney K. Validating a tool designed to assess medical student’s patient-centred capabilities and integration of consultation skills. 15th Ottawa

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 828–837

Linguistic analysis of IMGs’ communication skills

34

35

36

37

38

39

40

41 42

43

44

45

46

Conference on Assessment of Competence in Medicine and the Healthcare Professions, 9–11th March 2012, Kuala Lumpur. http://media.wix.com/ ugd/bd1cfc_c54c42a6e92b626fbcb65c15e4ad90f4.pdf. [Accessed 21 April 2015.] Harvey K, Adolphs S. Discourse and healthcare. In: Gee JP, Handford M, eds. The Routledge Handbook of Discourse Analysis. London: Routledge 2012; 470–81. Roberts C, Sarangi S. Theme-oriented discourse analysis of medical encounters. Med Educ 2005;39:632–40. Bardovi-Harlig K, Hartford B. Interlanguage Pragmatics: Exploring Institutional Talk. Mahwah, NJ: Lawrence Erlbaum 2005. Corbin J, Strauss A. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory, 3rd edn. Los Angeles, CA: Sage Publications 2008. Guest G, MacQueen KM, Namey EE. Applied Thematic Analysis. Thousand Oaks, CA: Sage Publications 2012. Culpeper J, Crawshaw R, Harrison J. ‘Activity types’ and ‘discourse types’: mediating ‘advice’ in interactions between foreign language assistants and their supervisors in schools in France and England. Multilingua 2008;27 (4):297–324. Yates L. Speech act performance in workplace settings. In: Martınez-Flor A, Us o-Juan E, eds. Speech Act Performance: Theoretical, Empirical and Methodological Issues. Amsterdam; Philadelphia, PA: John Benjamins Publishing 2010;109–26. Bensing J. Doctor–patient communication and the quality of care. Soc Sci Med 1991;32 (11):1301–10. O’Grady C. Teaching the communication of empathy in patient-centred medicine. In: Hoekje BS, Tipton S, eds. English Language and the Medical Profession: Instructing and Assessing the Communication Skills of International Physicians. Bingley: Emerald Group 2011;43–72. Humayun A, Fatima N, Naqqash S, Hussain S, Rasheed A, Imtiaz H, Imam SZ. Patients’ perception and actual practice of informed consent, privacy and confidentiality in general medical outpatient departments of two tertiary care hospitals of Lahore. BMC Med Ethics 2008;9:14. Moore M, Chaudhary R. Patients’ attitudes towards privacy in a Nepalese public hospital: a cross-sectional survey. BMC Res Notes 2013;6:31. Hudak PL, Maynard DW. An interactional approach to conceptualising small talk in medical interactions. Sociol Health Illn 2011;33 (4):634–53. Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients, 3rd edn. Oxford: Radcliffe Publishing 2013.

47 Heinz B. Backchannel responses as strategic responses in bilingual speakers’ conversations. J Pragmat 2003;35 (7):1113–42. 48 Cutrone P. A cross-cultural examination of the backchannel behaviour of Japanese and Americans: considerations for Japanese EFL learners. Intercult Pragmat 2014;11 (1):83–120. 49 Ong LM, De Haes JC, Hoos AM, Lammes FB. Doctor–patient communication: a review of the literature. Soc Sci Med 1995;40 (7):903–18. 50 Street RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician– patient communication to health outcomes Patient Educ Couns 2009;74 (3):295–301. 51 Claramita M, Nugraheni MD, van Dalen J, van der Vleuten C. Doctor–patient communication in Southeast Asia: a different culture? Adv Health Sci Educ Theory Pract 2013;18 (1):15–31. 52 Moore M. What do Nepalese medical students and doctors think about patient-centred communication? Patient Educ Couns 2009;76 (1):38–43. 53 Yates L. Learning how to speak: pronunciation, pragmatics and practicalities in the classroom and beyond. Lang Teach 2014;FirstView:1–20. 54 Hall P, Keely E, Dojeiji S, Byszewski A, Marks M. Communication skills, cultural challenges and individual support: challenges of international medical graduates in a Canadian healthcare environment. Med Teach 2004;26:120–5. 55 Bates J, Andrew R. Untangling the roots of some IMGs’ poor academic performance. Acad Med 2001;76 (1):43–6. 56 Dahm MR. Exploring perception and use of everyday language and medical terminology among international medical graduates in a medical ESP course in Australia. English Specific Purposes 2011;30 (3):186–97. 57 Fiscella K, Frankel R. Overcoming cultural barriers: international medical graduates in the United States. JAMA 2000;283 (13):1751. 58 Khalil T, Bhopal J. The patient-centred interview and international medical graduates: a preliminary view. B C Med J 2009;51 (6):246–9. SUPPORTING INFORMATION

Additional Supporting Information may be found in the online version of this article: Appendix S1. Items on the Rating Instrument for Clinical Consulting Skills. Received 15 December 2014; editorial comments to author 12 March 2015, accepted for publication 22 April 2015

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 828–837

837