Medical literature reflects an increasing awareness of the importance of communication and the doctor-patient relationship, which have been shown to have an impact on patient satisfaction, compliance, medical outcome, and malpractice suits against physicians (Simpson et al., 1991). Considering the large number of internationally-trained physicians currently practicing in the United States, the ESL/ESP professional has a unique opportunity to contribute to the improvement of doctor-patient communication through instruction in language and culture in a U.S. medical setting. As a contribution to curriculum development in this area, this paper describes the daily tasks of international internal medicine residents in training in a U.S. hospital, highlighting in detail one of the most important: the medical interview.
Physicians who have received their medical training outside the U.S. and Canada are known as international medical graduates (IMGs). Although this group includes U.S. or Canadian-born physicians who have gone elsewhere for medical training, the majority came to live in the United States for the first time after medical training. According to a recent report, 25.5% (24,982) of all residents in U.S. training programs in 1996 were IMGs; most of these are concentrated in the fields of internal medicine, pediatrics, psychiatry, and family medicine (Dunn & Miller, 1996). The majority of these physicians eventually make their home in the United States, making up approximately 23% of the physicians practicing in the U.S.A. (Inglehart, 1996).
Currently, IMGs interested in practicing in the United States must be initially certified by the Educational Commission on Foreign Medical Graduates. The certification process includes an objective English language proficiency exam similar to that required by most universities (Friedman, Sutnick, Stillman, Regan, & Norcini, 1993). Despite receiving a passing score on this test of general English skills, many IMGs are not well-prepared for the communication tasks that await them as physicians in US hospitals and clinics. These tasks can be divided into three categories: interactions with professionals, with patients and families, and academic interaction.
Interactions with other professionals include collaborating with other members of the hospital medical team in diagnosing and treating patients; presenting and discussing cases to supervisors; teaching and supervising junior members of the team; answering pages and phone calls; requesting tests, results, and consultations; interacting with other health care providers such as sub-specialist physicians, nurses, physical therapists, social workers, and occupational therapists; and reading and writing notes in charts.
Interactions with patients and families requires great sensitivity and a high level of skill in interpersonal communication. Some of the tasks are taking a history, performing a physical exam, explaining diagnostic procedures and medical conditions, and negotiating treatment plans.
Academic interaction requires physicians to read and write journal articles, collaborate on research projects, present at conferences, attend lectures and participate in discussions. While many of these tasks are limited to the training period, all physicians are required to be lifelong learners, and some choose to pursue careers in academic medicine.
While instruction in any of the categories described above may easily form the basis of an English for Medical Purposes curriculum, for the purposes of this paper, I will describe one task, the medical interview, in detail, followed by suggestions for the teaching of that task to IMGs.
The Medical Interview
The medical interview has received a great deal of attention in the medical literature and in the curricula of medical schools for the past two decades. In countless books and articles, it is identified as a core clinical skill; the average physician will conduct approximately 120,000-160,000 interviews in the course of a 40-year career (Lipkin, Frankel, Beckman, Charon, & Fein, 1995). In his introduction to a recently-published text on the medical interview, Mack Lipkin, one of the foremost researchers in doctor-patient communication, writes:
Why is the interview so important and why is it so necessary to teach students about it from the outset of their professional work? The interview is the core clinical skill. It determines the quality and quantity of data the health care professional has to work with in identifying and solving the patient's problem. It determines the quality of the relationship between practitioner ... and patient, a relationship that is key to patient cooperation and satisfaction, to practitioner satisfaction, and to helping the patient grow and develop. It determines as well the patient's understanding of what is going on and being done, his or her willingness to take the risk of a true partnership with the practitioner, and the likelihood that the patient will participate effectively in such matters as going for tests, taking medications, and changing lifestyle. (Coulehan & Block, 1997, pp. vii-viii)
For international medical graduates, the medical interview is surely no less important; it may be, however, more difficult to perform successfully because of the additional barriers of language and culture differences between doctor and patient. Therefore the ESL/ESP professional must pay particular attention to understanding the communication components of this skill.
The medical interview generally consists of the following structural elements:
(a) The opening: The physician greets the patient, establishes initial rapport, and elicits the primary problems for which the patient is seeking medical care.
(b) The history of the present illness: The physician asks a variety of questions to encourage the patient to describe the current problems in detail.
(c) The past medical history, the family history and the social history: The physician departs from the discussion of current medical problems and gathers information from the patient about past medical problems, medical problems in the family, and lifestyle issues such as occupation, support systems, smoking, alcohol and drug use, and sexual issues.
(d) The review of systems: The physician seeks information about current or past problems involving the various body systems.
(e) The physical exam and other diagnostic procedures as necessary.
(f) The closing: The physician and patient discuss further diagnostic procedures, medical conditions, and options for treatment.
Medical residency curricula often include training in the medical interview. The Wayne State General Internal Medicine Program however, provides instruction in the communication aspects of the medical interview, highlighting issues which may present a particular problem for IMGs. This interviewing skills course is taught to small groups, with frequent, short sessions throughout the first year of the residency, totaling approximately 12 to 15 hours of instruction. Methods include readings, lectures, discussion, videos, role-play, and the opportunity to be videotaped performing a simulated interview with an actor, with a subsequent one-on-one review with the instructor. The course curriculum is adapted from the three-function model of the medical interview, which defines the main functions of the interview as (1) gathering data, (2) establishing rapport and responding to emotions, and (3) educating and motivating patients to adhere to treatment (Cohen-Cole, 1991). Following is a description of each of the three main components of the course.
Part I: The Doctor-Patient Relationship
The doctor-patient relationship, as all social relationships, is heavily laden with cultural norms and values. In a society that places a great value on hierarchy, for example, the physician may be treated with great respect; his/her knowledge or advice is not questioned, especially in public. On the other hand, in the United States, the social and professional hierarchy is not as closely adhered to as it is in many other societies. Patients in most cases view the doctor-patient relationship as a partnership, sometimes even a business transaction, and believe that they have equal rights to information and decision-making. Therefore, in the interviewing skills class, topics such as culture and values that influence the doctor-patient relationship, cross-cultural images of both doctor and patient, and the current medico-legal environment are discussed.
Part II: Gathering Data
The nature of biomedical diagnosis requires that the physician gather a great deal of very specific information from a variety of sources, but primarily from the patient. Furthermore, in internal medicine, the history usually includes not only medical information, but social information and health maintenance information. In many medical settings around the world, because physicians see a much larger number of patients and have fewer resources for diagnosis and treatment, the medical interview itself is very brief, focusing on the current problem. This section of a medical interviewing course includes topics such as greeting the patient, using attentive nonverbal behavior, organizing and setting priorities for the interview, balancing open- and closed-ended questions, and listening actively.
Part III: Building Rapport and Responding to Emotions
Although frequently omitted from the medical school curriculum, rapport between the doctor and the patient is the foundation on which the interview is based. Most physicians admit that proper diagnosis and treatment is quite difficult when there is a lack of trust. The key to building trust and rapport is not only to feel empathy, but to show it. Therefore residents need to understand and respond, at least superficially, to the emotions that their patients express during the medical encounter. During this segment of the interviewing skills course, residents have the opportunity to discuss the way they express emotions as contrasted with the ways in which their patients may express emotions. Some residents may be very uncomfortable, for example, with raised voices, or swearing as an expression of anger, or withdrawal as an expression of sadness. They learn and practice skills of showing empathy, such as reflecting emotions ("You seem very upset by your illness") or expressing personal support ("I'm here to help you in any way I can").
Part IV: Discussing Diagnosis and Negotiating Treatment
Physicians frequently have difficulty explaining medical conditions in lay terms, especially if patients in their home countries are unaccustomed to requesting detailed explanations. This difficulty can be exacerbated by lack of familiarity with lay medical terms as well as with social and cultural issues that may interfere with the patients' ability to adhere to a treatment plan. For example, patients who lack medical insurance or transportation may be resistant to a physician's suggestion that they undergo a variety of diagnostic tests requiring frequent visits to the hospital, especially if they don't have a clear understanding of the reason for the tests. In the interviewing skills class, residents practice giving clear explanations in lay terms and checking to see if their patients understand. In addition, the doctors explore further the concept of the doctor-patient partnership in order to learn to negotiate rather than dictate treatment, increasing the potential for adherence to the treatment plan. Role plays give them the opportunity to practice explaining a variety of diagnoses and negotiating treatment plans.
Physicians naturally feel uncomfortable providing news of a diagnosis such as a terminal or stigmatized disease. In many countries and ethnic groups, this information is communicated to the patient's family; in fact, it may be considered unethical to give bad news to a patient because it is perceived to hasten the illness process. In the interviewing skills class, therefore, residents discuss the cultural and ethical implications of bad news delivery as well as the appropriate language skills for use in such a highly emotional interaction. Some of these skills include choosing an appropriate time and place to talk with the patient, providing a basic diagnosis using nontechnical language, eliciting and responding to patients' emotions regarding their diagnosis, listening actively, offering hope, and providing only necessary details rather than overloading the patient with extraneous technical information (Eggly et al., 1997).
Part V: The Social History
The purpose of the social history in the medical interview is to determine social influences on patients' medical conditions, such as occupation, smoking, use of alcohol or other substances, marital status, support systems, and sexual activity. IMGs, as well as other physicians who do not share the social background of their patients, can easily offend patients or miss important information because of their personal biases against or lack of awareness of their patients' lifestyles. For example, many residents have reported that in their countries, a married person is assumed to be sexually monogamous, have children within the marriage, and to participate in a mutually supportive relationship. Deviations from this social rule are considered shameful and not publicly acknowledged. Physicians, therefore, consider probing into sexual activity or number of children once their patient has stated his or her marital status to be extremely rude. In the United States, however, it is appropriate for physicians to explore issues such as sexuality, children, or abuse, regardless of marital status.
Follow-Up
Following the interviewing skills course, residents are videotaped conducting an interview with a professional actress who portrays the role of a patient. This tape is reviewed with the instructor in order to provide individual feedback on interviewing style. Residents are then videotaped in the outpatient clinic with real patients at least twice a year throughout their three years of residency training. This allows residents to continue to work on doctor-patient communication skills and to ask questions about their interactions on a one-to-one basis.
Other Teaching Opportunities
While the interviewing skills course addresses the communication tasks of a core medical skill, there are other opportunities to teach IMGs during their residency training. Private tutorials address individual needs including pronunciation, presentation skills, and writing professional letters. Lectures to large groups include topics such as avoiding medical jargon, understanding medical terms used by patients, and U.S. culture and values in a medical setting. Medical teams on in-patient wards appreciate the perspective of an impartial observer who is trained in communication.
ESL/ESP professionals have a unique opportunity to make a contribution to medicine by improving the communication between IMGs and their patients. While initially we may feel intimidated by the highly specialized nature of our clients' work, as we begin to understand the communication tasks that occur on a daily basis, we can quickly see that we have a great advantage because we are neither doctors nor patients; we are experts in the art of communication.
References
- Cohen-Cole, S. A. (1991). The medical interview. St. Louis: Mosby Year Book. Coulehan, J. L., & Block, M. R. (1997). The medical interview: Mastering skills for clinical practice. Philadelphia: F.A. Davis Company.
- Dunn, M. R., & Miller, R. S. (1996).The shifting sands of graduate medical education. Journal of American Medical Association, 276(9), 710-713.
- Eggly, S., Afonso, N., Rojas, G., Baker, M., Cardozo, L., & Robertson, R. S. (1997). An assessment of residents' competence in the delivery of bad news to patients. Academic Medicine, 72(5), 397-399.
- Friedman, M., Sutnick, A. I., Stillman, P. L., Regan, M. B., & Norcini, J. J. (1993). The relationship of spoken-English proficiencies of foreign medical school graduates to their clinical competence. Academic Medicine, 68, S1-S3.
- Inglehart, J. K. (1996) Health policy report: The quandary over graduates of the foreign medical schools in the United States. New England Journal of Medicine, 334, 1679-1683.
- Lipkin, Jr., M. L., Frankel, R. M., Beckman, H.B., Charon, R., & Fein, O. (1995). Performing the interview. In M. Lipkin Jr., SM. Putnam, & A . Lazare (Eds.), The medical interview: Clinical care, education, and research. New York: Springer-Verlag.
- Simpson, M. A., Buchman, R., Stewart, M., Maguire, P., Lipkin, M, & Novack, D. (1991). Doctor-patient communication: The Toronto consensus statement. Brit J Med., 303, 1385-1387.