Note

This article has been written up on behalf of the English teachers of the Faculty of Medicine Unit, at the MU Language Centre, the Czech Republic.

 

Veronika Dvořáčková teaches medical English at the Faculty of Medicine Unit. In the ESP courses which she co-designs, she likes to implement an interdisciplinary approach drawing from medical humanities (mainly medical ethics and literary approach) as she believes they may provide additional and much needed perspective to the traditional ESP courses concerned with terminology and communication soft-skills. She has co-written the book Anglická terminologie pro učitele – Praktický průvodce (English Terminology for Teachers – Practical Guide, published by Grada Publishing in 2021). Email: veronika.dvorackova@med.muni.cz   

 

Introduction

The process of creating course content, including a methodology guide for teachers, is a constant exercise in replacing that which works well with something that works better. For the purposes of this text, we define the key criterion of the latter by suggesting it is something which—within the constraints of the ESP domain—the students find meaningful. But to capture that which makes students tick is not at all easy. A typical mistake to make is to automatically assume that authentic professional materials and genres alone guarantee ESP lesson success—in other words, to believe students are primarily after face validity and that the teacher knows exactly which activity or lesson goal holds that appeal for them.

The following text examines the issue of genre authenticity as an essential aspect of ESP course design as well as an effective tool in generating and sustaining student motivation and engagement. Based on the experience of teaching authentic professional writing genres and positioning them as key course outcomes, the present paper argues that the relevance and value of authentic genres as perceived by the students is largely determined by the students’ ability to relate them to their concurrent academic or clinical experience.

To support this claim, the text compares and contrasts the use of two authentic professional writing genres (letter of referral and reflective writing) as learning activities in the Medical English and the English for Healthcare courses, respectively. Using the example of two stand-alone lessons, it looks at i) the teacher input as reflected in the lesson sequence leading up to the task performance and ii) student as well as teacher informal feedback as elicited from anonymous student opinion polls as well as from informal conversations after classes.

 

The teaching context

The lessons dealing with the respective genres are taught to different learner groups, both within the context of undergraduate study programmes at a medical faculty. Lesson A concerned with the letter of referral is taught to first-year medical students within their compulsory 100- minute once-per-week course English for General Medicine provided to them over two semesters in their first year. Lesson B dealing with reflective writing is given to students aspiring to become allied health professionals¹ or to enter the nursing profession. Unlike the first-year medics, who have had no exposure to clinical practice, the majority of these students have already had their clinical placements. Their English 100-minute once-per-week classes take place over the two semesters of their second year at university.     

 

3 Lessons compared

Lesson A – Letter of referral

To expose our first-year medics to authentic professional writing genres, we use the letter of referral, which essentially is a formal request for a patient examination or handover of care where Doctor A refers the patient to Doctor B. As an important means of communication between primary (general practitioner) and secondary care (hospitals and specialists), it provides the recipient with a comprehensive overview of the patient’s presenting complaint (the patient’s current condition) and medical history (the patient’s relevant health records) to ensure a fluent handover of care (Geeky Medics, online source). To tackle this complex task, we provide students with generous scaffolding detailed by the following lesson sequence, largely inspired by the treatment of the letter of referral in the Occupational English Test² Preparation Portal (online source).

1. The structure of a formal letter is given. The function of individual paragraphs is described. A detailed guide on writing the opening paragraph is provided. 

2. The procedure to differentiate between what information goes in the second (main medical issues – e.g., blood in stool) and third paragraphs (secondary information – e.g., allergic to pollen) is explained (Occupational English Test, online source). 

3. The transformation of case notes—which students are given in the form of simplified patient medical records—into complex sentences is explained and practised. The art of concise and clear communication is explained in relation to the seemingly restrictive word count for the main body of the letter (180–220 words).  

• Example of a case note: no known allergies, has been referred to allergy clinic – awaiting assessment (Occupational English Test, online source)
• Example of a complex sentence built on the case note: She has no known allergies, however has been referred to the allergy clinic and is awaiting an assessment. (Occupational English Test, online source)

4. The students write a practice letter of referral based on sample case notes in class which they then compare with a model letter based on the same notes.

5. The validity of the genre is communicated by pointing out its relevance to the following:

• the students’ future professional practice in international contexts;
• the art and skill of formal (letter) writing with special emphasis on purpose and content, conciseness and clarity, genre and style, organization and layout, and language (categories taken from Occupational English Test, online source);
• the ability to transform lexicogrammar items (case notes) into a full professional discourse;
• the chance to learn more about the conditions reported by patients, as relevant case notes are well-researched using highly reliable and authoritative online sources (e.g., The National Institute for Health and Care Excellence); and
• the use of peer feedback (to assess the first draft) and the use of metalanguage, i.e., the ability to match general aspects of the genre as detailed in the assessment rubric with their specific representations in a written product. For example, the aspect of conciseness and clarity would be concerned with grouping relevant case notes cohesively (Occupational English Test, online source).

Writing a letter of referral was part of the final assessment, and all students passed, some of them with flying colours. Still, judging by the level of student engagement, some teachers felt it did not make the impact they had been hoping for. This was further confirmed in course feedback, where in response to an intentionally broad question concerned with possible redundant features of the course, the students often mentioned the letter of referral. This should not be surprising as the authenticity we were primarily striving for does not lie in the text but in its interaction with the target context (Belcher, 2006, p. 137, paraphrasing Widdowson, 1979), i.e., in an authentic task which we were convinced we had provided through working with well-researched healthcare data within task creation. However, a situational context with which the students could easily identify was largely missing. It was the second piece of writing—albeit assigned to a different group of healthcare students—in which we were better able to contextualize the authentic task.

 

Lesson B – Reflective writing

In the reflective writing assignment, students produced a contemplative but highly practical piece in which they reflected on their prior academic or professional experience.

While the letter of referral is exclusively related to future professional practice, reflective writing is usually undertaken as part of professional identity formation in medical schools³ and indeed as part of continuous professional development for allied health professions in English-speaking countries (The Health & Care Professions Council, online source). As the task and its outcomes overlap with other courses on the healthcare curriculum and thus transcend the basic ESP domain, additional expertise is naturally needed. In this respect, we were lucky to rely on the dual qualifications of one of our colleagues who is both a former NHS healthcare professional and a teacher of English as a second language and who not only managed to devise the lesson materials and successfully implement them in the course design but also came up with the idea in the first place.  

In the lesson design, we used an adaptation (University of Cumbria, online source) of the reflective model originally proposed by Schon (1983) and adapted by Rolfe, Freshwater and Jasper (2001) for nursing and other helping professions. The model revolves around the sequence of three questions (What? So what? Now what?) which students sequentially respond to using the prompts in the form of additional questions and referring back to the reflective language supplement listing example phrases. For instance, in the Now what? stage a sample phrase could be: Having experienced …, I am now better able to handle …. Using this model, the students are asked to produce a piece of writing between 220 and 320 words long organized into three respective paragraphs.

What follows is a lesson sequence whose aim is to equip students with the relevant lexicogrammar items as well as make them aware of and sensitize them to the significance of some of the issues⁴ they have encountered during their academic or professional life.

1. First, reflection on an experience is presented as an everyday occurrence (e.g., as a result of conscious or even subconscious reflection one may decide never to eat in a particular restaurant again).       

2. Ample examples of encounters which might be reflected upon are given, e.g., students’ experience of working in multidisciplinary teams (placement experience) or something on the curriculum the students found confusing and difficult (academic experience).

3. In the lesson section concerned with organizing ideas, the students are provided with well-researched examples of reflective vocabulary. First, they are given vocabulary lists describing emotions (e.g., irritation, pleased, pride, upset) to enable them to accurately portray the effect the experience in question had on them personally (the What? stage in the first paragraph).

4. Next, the students are exposed to the prompts in the form of questions to further assist them in reflection. For example: What happened? What did you do? (the What? stage); What did you learn about yourself and your colleagues? (the So what? stage); and What do I need to do differently to stop the same problem arising in the future? (the final Now what? stage).       

5. Students analyse an example piece of reflective writing using an adaptation of Rolfe et al.’s (2001) three-stage model.

6. Students practise reflective writing by producing a text on a topic a majority of them can identify with (receiving a test back with a mark lower than you expected). They compare their output with a sample writing on the same assignment. 

7. Students write their second practice piece of reflective writing, this time out of class, choosing a topic from a list provided by the teacher. Group feedback is given by the teacher in one of the subsequent classes. Individual feedback is offered on request.

Similar to the letter of referral, reflective writing was part of the final assessment, with all students passing relatively easily (a great majority on their first attempt, the rest on their second attempt). Although the students were given the option to reflect on their academic experience in case they were not ready to process their placement experience, we were surprised to see the majority of them chose to write about the latter and, more importantly, were able to demonstrate active reflection.⁵

 

Lessons learnt

Although the amount of time and resources spent on teaching either of the genres was comparable, the authentic resources as well as the tasks were adapted to match the current level of students’ English proficiency (CEFR B1–C2 level for the letter of referral and B1–B2 level for reflective writing), and even the test scores when examined in retrospect mirrored the usual distribution of passes (about 90% on first attempt) and fails, still the responsiveness and level of engagement in each target group⁶ differed greatly depending on how easily, or if at all, the students were able to assume the personal and professional identity for the purposes of the exercise. While medical students often commented on the letter of referral as “not important”, “not very useful” or “not fully applicable to [their] future practice” in their anonymous end-of-semester course feedback, the students in the allied health professions typically expressed their appreciation of the genre already when first exposed to it in the classroom. Besides describing it as “very interesting” and “highly relevant not only to [their] practice but also to [their] needs and feelings”, many of them were eager to share their personal experience in spontaneous class debates even before they put it in writing.

When teaching ESP courses, it may be tempting to respond to long-term professional needs instead of trying to meet and readily respond to short-term academic or pre-professional needs, the relevance and effectiveness of which can be verified and evaluated almost immediately. However, if ESP teachers are to meaningfully contribute to the professional development of healthcare students, rather than looking at who their students will one day be they should be concerned with who they are becoming (Sharpless et al., 2015). This shift in focus would be best facilitated by more careful integration of the ESP classes within the broader medical curriculum. The students’ immediate academic and pre-professional needs identified in the process could then be transformed into even more authentic ESP course content relevant to the students’ concurrent medical school experience.

 

Notes

1. The course is attended by students of e.g. physiotherapy, orthoptics, and radiography.

2. The Occupational English Test (OET) is an English as a foreign language test for healthcare professionals. It is recognized by healthcare boards and councils in various English-speaking countries. It assesses the communication skills of healthcare professionals who intend to practise in an English-speaking environment. 

3. For systematic reviews or umbrella reviews, see Chen & Forbes (2014), Frakgos (2016), Franco et al. (2022), Mann et al. (2009), Milota et al. (2019), Uygur et al. (2019), and Winkel et al. (2017), among others.  

4. As many of these encounters are confidential in nature, students are properly instructed on how to ensure the entire content of a reflection is fully anonymized.

5. As suggested above, major aspects of reflective practice in healthcare fall outside the ESP remit, thus the original purpose of the reflective writing which includes specialist feedback (here relevant to healthcare education as opposed to purely linguistic) on the content shared is not achieved. Still, we felt the students appreciated the opportunity to voice the issues they had been grappling with on their own. 

6. We believe that the fact that each learner group was assigned a different writing genre is not of relevance here as both groups usually demonstrate a comparable level of engagement when performing spoken doctor–patient role plays where all of them, regardless of their competence or discipline studied, work from their own patient experience.  

 

References

Belcher, D. (2006). English for Specific Purposes: Teaching to Perceived Needs and Imagined Futures in Worlds of Work, Study, and Everyday Life. TESOL Quarterly, 40, 133–156.

Chen, I., & Forbes, C. (2014). Reflective writing and its impact on empathy in medical education: systematic review. Journal of Educational Evaluation for Health Professions, 11, 20.

Fragkos, K. (2016). Reflective Practice in Healthcare Education: An Umbrella Review. Education Sciences, 6(4), 27.

Franco, R. S., Franco, C., Severo, M., Ferreira, M. A., & Karnieli-Miller, O. (2022). Reflective writing in the teaching of communication skills for medical students-A systematic review. Patient education and counseling, 105(7), pp. 1842–1851.

Mann, K., Gordon, J., & MacLeod, A. (2009). Reflection and reflective practice in health professions education: a systematic review. Advances in health sciences education: theory and practice, 14(4), pp. 595–621.

Milota, M. M., van Thiel, G., & van Delden, J. (2019). Narrative medicine as a medical education tool: A systematic review. Medical teacher, 41(7), pp. 802–810.

Rolfe, G., Freshwater, D., & Jasper M. (2001). Critical reflection for nursing and the helping professions: A user’s guide. London: Palgrave Macmillan.

Schon, D.A. (1983) The Reflective Practitioner: How professionals think in action New York: Basic books.

Sharpless, J., Baldwin, N., Cook, R., Kofman, A., Morley-Fletcher, A., Slotkin, R., & Wald, H. S. (2015). The becoming: students’ reflections on the process of professional identity formation in medical education. Academic medicine: journal of the Association of American Medical Colleges, 90(6), pp. 713–717.

Uygur, J., Stuart, E., De Paor, M., Wallace, E., Duffy, S., O’Shea, M., Smith, S., & Pawlikowska, T. (2019). A Best Evidence in Medical Education systematic review to determine the most effective teaching methods that develop reflection in medical students: BEME Guide No. 51. Medical teacher, 41(1), pp. 3–16.

Winkel, A. F., Yingling, S., Jones, A. A., & Nicholson, J. (2017). Reflection as a Learning Tool in Graduate Medical Education: A Systematic Review. Journal of graduate medical education, 9(4), pp. 430–439.

 

Online sources

The Health & Care Professions Council

benefits-of-becoming-a-reflective-practitioner----joint-statement-2019.pdf (hcpc-uk.org)

Sample profiles | (hcpc-uk.org)

Occupational English Test

The OET Writing Guide: Score high on the Writing sub-test | OET (occupationalenglishtest.org)

The National Institute for Health and Care Excellence

NICE | The National Institute for Health and Care Excellence

Geeky Medics

How to Write a Referral Letter | Geeky Medics

University of Cumbria

ReflectiveModelRolfe.pdf (cumbria.ac.uk). 

 

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