2005 IEEE International Professional Communication Conference Proceedings

0-7803-9028-8/05/$20.00 © 2005 IEEE.

An Oral Communication Curriculum for Health Science Professionals

Christine Parkhurst Massachusetts College of Pharmacy and Health SciencesChristine.Parkhurst@bos.mcp.edu

Abstract

This paper will describe an oral communication curriculum developed at Massachusetts College of Pharmacy and Health Sciences for future health care professionals whose first language is not North American English. The paper will discuss how the MCPHS curriculum helps these students improve their oral communication proficiency, by assessing the oral skills and threshold proficiency level required to succeed, by measuring the students’ oral skills with a specialized rubric, and by using specific exercises adapted from the health sciences curriculum to help these students achieve the level of oral proficiency required of health care professionals.

Keywords: health communication, oral proficiency, threshold proficiency level

Introduction

This paper will describe a communication curriculum developed at Massachusetts College of Pharmacy and Health Sciences for future health care professionals whose first language is not North American English. All the students at Massachusetts College of Pharmacy and Health Sciences [MCPHS] are health science majors. These students need excellent oral communication skills: communication has to be unambiguous to prevent medical errors.

Currently 30%-40% of students at MCPHS are bilingual; the percent varies depending on their major. As U.S. society becomes more diverse, so does the student population, including the population of health science majors. For example, in 2000, 62.2% of first professional pharmacy degree recipients self-identified as white,

compared to 74.6% in 1992 [1]. This growing diversity in race and ethnicity is mirrored by greater linguistic diversity. Therefore, it has become necessary to develop a curriculum to help health science majors whose first language or dialect is not North American English improve their oral communication skills. For convenience, these students will be referred to as NNS (non-native speaker) students.

Background

With 1,392 Pharmacy majors enrolled on the Boston campus in 2004, Massachusetts College of Pharmacy and Health Sciences [MCPHS] has one of the largest Pharmacy programs in the U.S. Although Pharmacy has the highest enrollment, there are eight other health science degree programs, including Nursing and Physician Assistant Studies. Over a third of the students are bilingual, or speak other varieties of World English than North American English. A number of English-speaking students come from the Indian sub-continent, or the English-speaking countries of Africa. The majority of NNS students is of Asian origin, and speaks Vietnamese, Cantonese, Mandarin, or Korean. The next largest groups of students are from Eastern Europe and the Middle East. The communication curricula for students at MCPHS majoring in all health science degree programs are similar to each other. Specific curricular modifications are made for students in each major. For example, students who will become Nurses or Physician Assistants practice general medical interviewing more, while future Pharmacists spend more time on medication counseling, although all students practice both. This paper will use specific examples from the oral communication curriculum developed for Pharmacy majors at MCPHS, and a rubric used to

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assess Pharmacy majors’ oral communication skills.

Assessment of Skills and Threshold Proficiency Level

What oral skills are required for NNS health science majors? What oral communication proficiency level is acceptable for future health care providers? My own background is in ESL/Applied Linguistics/Communication. I teach health communication courses for NNS health science majors at MCPHS, where I collaborated with faculty in Pharmacy and Physician Assistant studies over a period of years to develop a curriculum for NNS health science majors. To answer these two questions, I used several methods.

First, in order to discover what oral communication skills are required, I observed students doing oral communication assignments in health care content classes. I also observed NS and NNS students at clinical rotation sites. I analyzed the content, register (speech style features), and linguistic features (grammar and vocabulary) of the oral communication assignments. I used these observations and analyses as the basis for developing a curriculum in classes specifically designed to help NNS students improve their oral skills. These oral tasks will be described later. In addition, I analyzed the assessment rubrics used in the health care classes for oral assignments to see which required skills were mentioned, and which were not.

Second, I viewed and analyzed videotapes of students performing oral role play assignments (medication counseling) in health care classes. I observed how many phonemic errors per minute students made, in conjunction with suprasegmental features (tempo, pausing, and stress and intonation) as measures of intelligibility. I also counted grammatical errors, problems with technical and non-technical vocabulary, and misuse of register (failure to paraphrase technical vocabulary appropriately or provide background explanations for an audience of “patients”– faculty role-playing patients.) Language skills such as intelligibility and level of grammatical accuracy, and higher-level communication skills such as paraphrasing of technical language for a patient audience, and reflective listening to verify understanding, were compared with the grades assigned by clinical

faculty. This was done in an attempt to understand what level of proficiency health care faculty consider acceptable, and what features they are most attentive to. This information was used to modify the curriculum and requirements of the communication courses for NNS students, and to correlate requirements and expectations with those of content courses.

Third, NNS students who were taking oral communication courses, or who attended one-on-one tutoring sessions, asked for coaching on specific oral assignments in their health science classes. The students described the assignments, and their professors were asked for explanations of the assignments. The students’ descriptions of their assignments, and explanations of what they found difficult, plus observations of the classes in which they did the assignments and discussions with their professors, also provided useful information. Health care professors also asked me to observe specific assignments if one or more NNS students were having problems.

For example, NNS students often had, and have, problems with formal class presentations in their Drug Literature Evaluation or Advanced Therapeutics classes. These assignments require the ability to paraphrase and synthesize very difficult, technical information from journal articles, and present it orally to the seminar class using an appropriate style that is paraphrased rather than memorized. They must then switch to an informal technical oral style to give impromptu answers to questions on the material presented. Nervous students relapse into old fossilized pronunciation habits that make them less intelligible. They also struggle with advanced grammar such as use of past hypothetical conditional and technical vocabulary (“If the patient’s reduced liver function had been recognized earlier, the dose could have been lowered to avoid hepatotoxicity…”) They have trouble switching registers as required. “What is the mechanism of action?” requires a technical answer; “And how would you explain that to a patient?” requires a non-technical paraphrase. For NNS students, doing these exercises successfully requires coaching on the language and sociolinguistic skills required, specific feedback on problem areas, and practice in NNS health communication classes.

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Interaction with real patients and health care professionals on clinical rotations is the last hurdle, and this poses the final obstacle if students have not achieved a high level of intelligibility that requires little or no effort on the part of the listener, as well as other higher-level communication skills. If clinical preceptors feel students’ oral proficiency is not adequate, they are referred for further improvement. Ideally, students are identified and referred for work on oral skills earlier in the curriculum. This requires a means of identifying NNS students whose oral communication skills are not proficient.

Defining a threshold level of acceptable oral communication proficiency for health professionals is an ongoing challenge. There are tests such as the Test of Spoken English, the Clinical Skills Assessment for Foreign Medical Graduates, and oral components on Board exams for licensure in some health care professions, which may vary by individual states; these are used to assess oral proficiency for specific groups of health care providers. However, these exams don’t provide a well-accepted national consensus on what constitutes “good enough” oral proficiency for NNS health care providers. There are no well-accepted national norms for oral communication proficiency as students progress through health care curricula.

Some health care educators oppose the idea of using general standardized tests such as the Test of English as a Foreign Language (TOEFL) or a field-specific test such as the Pharmacy College Admissions Test (PCAT) to assess health science majors’ interpersonal communication ability because these tests do not measure students’ ability to perform personal communication tasks per se [2]. However, standardized tests combined with an admissions interview have been used to assess NNS health science applicants’ communication skills [3]. Wu-Pong and Windridge point out that NNS students’ linguistic status does not predict their academic success even on clinical rotations, which require proficient oral communication skills [4].

One reason a national norm for proficiency has not been established is that oral proficiency is difficult to test. Some experts believe that oral proficiency testing should include sociolinguistic assessment criteria that are specific to a particular discourse domain [5]. In other words, oral proficiency should

be tested within the discourse community of health science, in this case, and students should be tested on domain-specific tasks. Furthermore, the oral communication tasks should be authentic, that is, as similar as possible to the tasks the speaker would actually have to do [6]- for example, in order to assess a speaker's ability to counsel patients proficiently, ask them to counsel patients in a role-play, as the Clinical Skills Assessment for Foreign Medical Graduates exam does. Using a scoring rubric that is as specific as possible about what abilities are required is also necessary for valid assessment [5].

Therefore, over a two-year period I did research to investigate what oral communication skills health science faculty at MCPHS require, and what threshold level of proficiency. Audiotapes of NNS students doing two different role play exercises were used. Audiotapes were used both to assure student anonymity and for better sound quality. The student tapes were chosen because they were tapes of “borderline” students: neither frequently unintelligible nor very proficient. Listening to tapes of students whose performance was often acceptable, but sometimes or in some ways problematic, prompted clinical faculty to reflect on, and explain, their own threshold level of acceptable performance, and the holistic criteria they use.

The role play assignments were a class presentation on a health topic to a hypothetical “patient” audience, a patient counseling role play, and a role play in which the student role playing a pharmacist phones a doctor’s office to do an “intervention”- that is, to clarify a problem with a phoned-in or faxed-in prescription.

Result: Grading Rubrics for Oral Proficiency

Later interviews asked clinical faculty to respond to audiotapes, using the rubric as the basis for their response. The rubric was revised based on their comments. Two forms of the rubric resulted. Since the intention was to use the rubric as a formative tool to help NNS students improve their communication skills in their oral communication classes, no further effort was made to validate the rubric. Making the rubric a reasonably accurate reflection of criteria used by clinical faculty to assess oral communication skills was sufficient.

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The short form of the grading rubric (Appendix A) has five items that cover general areas and includes quotes from clinical faculty explaining the nature of the criteria. The short form is easier for students to use in real time for peer assessment in class. It corresponds to more holistic assessment. The long form of the rubric (Appendix B) is more detailed and includes items corresponding to specific behaviors.

The short form of the grading rubric (Appendix A) has five items that cover general areas and include quotes from clinical faculty explaining the nature of the criteria. The short form is easier for students to use in real time for peer assessment in class. It corresponds to more holistic assessment. The long form of the rubric (Appendix B) is more detailed and includes items corresponding to specific behaviors.

Curriculum Design: Healthcare Content

Health science majors at MCPHS take three different courses to improve their communication proficiency. One course, Interpersonal Communication in Health Care, is required for all students. Two others, Applied Linguistics for Oral Proficiency, and Oral Communication in Health, are elective oral communication courses for NNS students. They can be taken on a voluntary basis, or may be required for students who place into them based on a placement exam given to all incoming students.

The curriculum of these courses has been revised to give students more practice on skills required to achieve proficiency in the areas covered by the clinical faculty. Rather than working on language skills such as accurate pronunciation and grammar out of context, students now work on them within the context of exercises they will have to do in their clinical courses and later as health care professionals. This means that they use adapted forms of the types of oral assignments they do in health care classes, which in turn prepare them for communication activities they may do as health care professionals. Examples of three of these assignments will be provided.

The language skills they need to carry out these exercises are taught as preparation for the exercises. Examples of these exercises are class presentations and role plays in which students do medication counseling, interventions to prevent

potential medication errors, and patient case presentations. Each one will be described, and then discussed.

When students do medication counseling role plays, they use a form developed by the Indian Health Service (a U.S. government agency that provides health care on Indian Reservations). They verify information on the patient profile to make sure they’re talking to the right patient, and that they have important information such as any medication allergies or other medications that the patient is taking. Then they counsel the patient to verify the patient’s understanding of what the drug is for, how to take it, what monitoring parameters to watch for, how to recognize adverse or side effects, and what to do when they occur. They use a non-technical, interactive, fairly informal style to do this. Technical vocabulary must be paraphrased, and background information must be supplied as needed. Any missing information or misunderstandings are clarified. Finally, students must check to see how well the patient understands and remembers in the end. One student plays the pharmacist, and another plays the patient, and then they switch and go on to another medication.

When students do intervention role plays, they start with a prescription that is problematic in some way. There may be incorrect information, such as an adult dose written for a pediatric patient, or a potentially dangerous interaction with another medication, or the wrong dose given the patient’s impaired renal function, and so on. The student practices placing a phone call to the doctor’s office; one student plays the role of the pharmacist, and the other plays the doctor, and then they switch roles for the next practice scenario. The student must quickly and efficiently identify herself, the reason for the call, the nature of the problem, and be ready to offer a suggestion to solve the problem. The doctor’s response must be verified by the pharmacist (“So you’d like me to switch her to 250mg of Zithromax three times a day because she’s not tolerating the Amoxicillin?”) so the action to be taken by the pharmacist is absolutely clear by the end of the phone call. The style here is professional and fairly formal. Information must be given using technical vocabulary quickly and correctly, since doctors’ offices are notoriously impatient and prone to hang up on NNS speakers, according to comments reported to me by students and by colleagues.

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Patient case presentations are done for a professional audience of colleagues. Students do them in upper-level seminar-style classes. They present a patient’s medical and social history, presenting problem, diagnosis and how it was made, and their suggestions for what should be done or should have been done, probable outcome, and prognosis. The style is very formal and technical; students are expected to use conventional language such as “the patient has no known allergies” rather than “the patient wasn’t allergic to any medications.” The student demonstrates his understanding of the case, but also his ability to use the style required. Failure to do so is marked down as not sufficiently “professional.”

Oral exercises are defined by the register, or speech style, required. Students are asked to decide which style they need to use. Does the audience consist of patients or professional colleagues? Therefore, is the style technical or non-technical? Is the context formal or informal? How formal are the vocabulary and style used? Students are often not aware of what vocabulary is formal or technical. Should “vomit” be paraphrased because it sounds like Latin? Is “puke” an acceptable paraphrase? Would a patient know what an antiemetic is?

Class discussions of these considerations make students more aware of the sociolinguistic constraints involved in proficient presentations. Therefore they learn to use a register, or speech style, that is appropriate for the assignment. This requires practice, and over the course of the semester students become more aware of, and better able to use, appropriate vocabulary and other features of specific registers.

Curriculum Design: Language Skills

NNS students need to improve North American English language skills they have not yet mastered. This varies according to the student's background. Students who learned English as a Foreign Language often have mastered basic grammar, but have problems with idioms, listening comprehension, and discourse analysis; they misunderstand subtexts created by intonation and kinesics, for example. Students who were educated in another variety of World English may write eloquent and perfectly grammatical English, but speak with a strong Nigerian English accent, for

example, which is a challenge for elderly patients who are hard of hearing. "Generation 1.5" students (those born abroad who arrived in the U.S. at a young age) may have an ingrained habit of dropping final consonants or final syllables, and ignoring subject-verb agreement, yet have no problem with listening comprehension or advanced grammar such as use of modals and passive voice. Some seem to speak with near-native accents and yet have major problems with basic grammar.

Since students' problems with language skills are so heterogeneous, class exercises in Applied Linguistics in Health Care and Oral Communication in Health cover those particular areas students in the class have problems with. If many Asian students have problems with final consonants, the class does exercises on final consonants. If many students have problems with subtle variations in meaning caused by changes in verb tense and mode, students do exercises on verbs.

However, all exercises on grammar, pronunciation, and vocabulary are immediately linked to exercises adapted from health science classes. For example, pronunciation practice is done by using a pronunciation textbook and by using Pronunciation Power, a computerized pronunciation tutorial. However, students also practice and are quizzed during every class on the pronunciation of the top four hundred brand name and generic prescription medications. Since misunderstanding the names of drugs is the cause of fatal medication errors every year, even students with fossilized pronunciation habits are motivated to say drug names with near-perfect accuracy.

Linking fossilized problems that students have with grammar, pronunciation, or subtleties of discourse intonation to health care exercises they do in their health care classes can motivate students to master material they have been able to ignore up to this point.

Discussion

Developing valid assessment methods, defining a threshold level of oral communication ability, and developing an effective communication curriculum for health science majors all require time and resources. However, communication is an essential part of the health science curriculum, as Burgess points out for Pharmacy majors:

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"Communication skill development is a critical component of pharmacy education and practice" [7].

NNS health science majors are motivated by their desire to join the community of health care professionals. The cumulative grade point average of NNS students at MCPHS is high, on average. They may have a good understanding of health care content, but they need to learn to sound like health care professionals. Many were not born in the U.S. but arrived as children. They often were mainstreamed too early and therefore did not master English grammar. They also have fossilized pronunciation problems which are very difficult to change. For most purposes, their oral proficiency serves them well enough. Their mastery of informal speech and listening comprehension may be quite good. Many sound much like their NS peers when speaking informally. To sound even more similar would pose problems of identity for some, who question the necessity of sounding near-native. For others, the struggle to overcome longstanding habits is ongoing; motivation is not the issue. The issue of where the acceptable threshold of proficiency lies comes up in class discussion.

However, the oral assignments in students’ health care classes, and their NNS health communication classes, make it clear where their oral communication proficiency falls short. Taking on a new identity as a health care professional requires very intelligible, formally correct, and audience-appropriate speech. This motivates some NNS students to change long-standing habits and improve their oral proficiency, not to sound more “native,” but to sound more “professional.”

References

[1] Meyer, S. M. and Patton, J.M. "The Pharmacy Student Population: Applications Received 1999-2000, Degrees Conferred 1999-2000, Fall 2000 Enrollments," Am.J. Pharm. Educ, 65, 68S (2001).

[2] Beardsley, R. "Communication Skills Development in Colleges of Pharmacy," Am. J. Pharm. Educ, 65, 307 (2001).

[3] Jones, J., Krass, I., Holder, G.M. and Robinson, R.A., "Selecting pharmacy students with appropriate communication skills," Am.J. Pharm. Educ. 64, 68-73 (2000).

[4] Wu-Pong, S., Windridge, G. and Osborne, D.," Evaluation of pharmacy school applicants whose first language is not English," Am.J. Pharm. Educ, 61, 61-66 (1997).

[5] Brown, H. Douglas. Teaching by Principles: An Interactive Approach to Language Pedagogy.London: Longman, 2001. p. 395.

[6] O'Malley, J. and Pierce, L.V. AuthenticAssessment for English Language Learners.Addison-Wesley, 1996. p. 69.

[7] Burgess, S. "Packed houses and intimate gatherings: Audience and rhetorical structure" in Academic Discourse ed. J. Flowerdew, Longmans (2002).

About the Author

Christine Parkhurst is an Associate Professor of English and Humanities at Massachusetts College of Pharmacy and Health Sciences. She has presented at TESOL and at AACP, and has published on health communication in American Journal of Pharmacy Education and in English for Specific Purposes. She is currently on the Board of TESOL's English for Specific Purposes Interest Section, and was the Chair of the Liberal Arts Interest Section of the American Association of Colleges of Pharmacy.

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