Improving written and verbal communication skills for international medical graduates: A linguistic and medical approach

Abstract

Background: Adapting to UK communication styles can be difficult for International Medical Graduates (IMGs). Reache Northwest provides education, training and support for internationally trained refugee and asylum seeking health professionals who are looking to return to work in the UK.

Aims: A Safe and Effective Communication Skills course was designed by a team of language teachers and clinicians to provide IMGs with an understanding of the written, verbal and summarisation skills required in the UK work environment.

Methods: A series of language exercises adapted to clinical situations was developed. These increased in complexity to the practical application of language skills in clinical settings using simulated patients. The combination of language and clinical tutors meant that feedback could be given from a language teacher's perspective, the clinical perspective and the cultural context.

Results: The combination of language and clinical tutors meant that analysis of communication difficulties could be made from different perspectives and detailed, specific feedback could be given to each student in these areas.

Conclusion: Using a combined linguistic and clinical approach can provide solutions to clinical communication problems that may otherwise be missed. This strategy could be extended to cover communication areas in other contexts.

Background and context

Reache Northwest is a hospital based unit which provides education, training and support for internationally trained refugee and asylum seeking health professionals (RHPs) who are looking to return to work in the UK. Since the centre was established in 2003, over 120 doctors have entered work.

Table

Practice points

Communication difficulty can take many forms – language (e.g. grammar, use of idioms, tenses and pronunciation), clinical, e.g. the content and structure of information required by a clinician and cultural, e.g. how to address a consultant when you wake them in the middle of the night. Using a combined linguistic and clinical approach can provide solutions to clinical communication problems that individual approaches may miss. Teaching should be practical with multiple opportunities to practice skills in a variety of settings. Feedback and opportunity to practice again is very important.

Over a third of the current National Health Service (NHS) medical workforce qualified overseas. NHS Employers conducted a workforce survey in May 2010 which showed that 40% of respondents had already undertaken, or were planning to carry out, some form of international recruitment (NHS Employers Website 2010).

The ‘Warwick report’ for the General Medical Council (GMC) summarised the difficulties that International Medical Graduates (IMGs) may have in adapting to the NHS – those who qualified outside the UK may be from countries with very different medical practices in terms of the ethical framework, governance arrangements, cultural expectations of patients and teams, technology and drugs. They may be used to different working arrangements on wards with no formal ward round structure, large differences in the leadership roles of nurses and more private practice with different responses to patient expectations. The report discusses several studies which identified effective communication as a challenge facing IMGs. These include straightforward language barriers but also more complex issues relating to picking up non-verbal cues, concerns about different cultural protocols and the lack of communication skills teaching in their country of qualification. They also documented the patchy provision of induction and language and cultural induction and training provided in the UK (Slowther et al. 2009).

GMC fitness to practise statistics showed that, in 2009, 44% of initial complaints involving IMGs were classed as serious and led to a full investigation compared to only 33% of referrals for UK graduates (GMC Annual Statistics 2009).

Over a number of years, Professor Allen examined the GMC fitness to practise procedures. She found that a higher proportion of referrals to the GMC from public bodies were about IMGs, and that there were differences in the nature of the allegations made. It is acknowledged that the issues are complex but part of the problem was colleagues’ inability to understand the cultural background of international doctors. It was felt that although they speak good English, maybe the way it is spoken or maybe the interpretation by the people they work with could be a problem (Allen 2003).

Reache students range from newly qualified doctors who have never practiced to those who have been senior professionals – consultants, professors – some running major public health or other programmes with international organisations for many years.

During our 8 years of experience in teaching RHPs, we have found differences from IMGs in learning needs and learning styles that may create barriers to learning. In general, RHPs have not chosen to come to the UK to establish their profession or enhance their career, they are here from necessity and usually have an expectation of returning to their home country ‘once things have died down’. RHPs’ may perceive necessities to proving competent in the UK system, e.g. International English Language Testing System and probation periods of employment as barriers and discrimination, whereas IMGs usually have an understanding of the requirements needed to practise in the UK, as they will have considered this before choosing to study or work in the UK, though this does not make the transition any easier.

Reache members tend to be used to formal didactic teaching styles in large lectures and questioning of teachers or discussion is not encouraged. Alongside this, individual learning through books is the norm and often our students are not used to either giving or receiving feedback. In addition, RHPs often have had long career gaps – ranging from 1 year to sometimes over 10 years. This can cause lack of confidence as they may be out of date and they may also have mental health problems including Post Traumatic Stress Disorder. There may also be legal problems and many suffer from poverty, housing problems, family problems and social isolation.

Provision of specific Communication teaching for IMGs is patchy in the UK. Leeds University currently runs a project for international medical students in their undergraduate programme, giving them the opportunity to develop their communication skills at an earlier date. The London Deanery established the Language and Communications Resource Unit in 2010 to help trainees of all levels with communication and language difficulties. Experience suggests that trainees with communication difficulties are not being identified and supported in the early stages of their careers. Anecdotal evidence suggests that supervisors are aware of weaknesses but some are unwilling to document them or challenge trainees due to lack of ability to clearly describe the problem or for fear of being seen as racist or bigoted. Sometimes, there is an expectation that experience in the role will fix the communication and cultural issues.

Identification of learning needs

Between 2005 and 2007, Reache ran a clinical apprenticeship programme for 17 doctors across four hospitals in Greater Manchester. This scheme allowed Refugee doctors with GMC registration to work as honorary house officers in supervised placements. Formal feedback was obtained from supervising consultants who identified specific weaknesses in some communication skills particularly written and verbal handover skills, history taking and summarisation skills and also explaining their findings and treatment plan to patients. As one of the consultants explained, ‘I think one of the problems is they don’t fully understand what the language suggests to them, as well as being able to translate it. It is one thing to speak the language and the other one is to actually understand what people say to you’. This was reinforced by informal feedback received from consultants providing clinical supervision on attachments and also from colleagues working with Reache members at later stages of their careers.

Our experience of running communication skills courses led to the use of interactive, experiential learning methods with individualised feedback, multiple attempts at skills rehearsal and the use of simulated patients trained in medical education for this course.

Methods

A Safe and Effective Communication Skills course was designed by a multi-disciplinary team of language teachers and clinicians, taking into account a variety of linguistic, cultural and clinical issues to give IMGs an introduction to the communication skills required in the UK work environment. The aim of the course was to improve written and verbal communication skills in a clinical context to a level appropriate for a foundation year 1 doctor.

The course included history taking, summarising, discharge summaries, presentation skills and a communication model (SBAR – Situation, Background, Assessment, Recommendation – Haig et al. 2006). The teaching was delivered through presentations, workshops and practice using linguists and healthcare professionals. All training was placed in a medical context using simulated patients and ‘mock’ records. A total of 20 participants took part on each course.

Session 1 – half day

This focussed on legible, accurate recording of what is said and accurate summarisation of written material. It consisted of a series of three exercises in speaking, listening and summarising using clinical scenarios done in pairs, to allow everyone to do each task and to experience different accents and pronunciation.

For each stage, a different 200-word clinical exposition was presented on screen, one student facing the screen (reader) the other facing away (scribe).

• Exercise 1: the reader had to dictate the expositions completely and the scribe had to write a word for word dictation.

• Exercise 2: the reader had to summarise the material and give a verbal summary of the key points which had to be written down by the scribe.

• Exercise 3: the reader had to make a verbal summary which had to be written as bullet points by the scribe.

The work was peer marked and feedback given from a linguistic and clinical perspective. This focussed on legible, accurate recording of what is said; accurate summarisation of written material and developing the ability to tune out other people in room and concentrate on what is said.

Session 2 – half day

The aim of this session was to integrate the language skills into a clinical context and comprised

• A short presentation about what is expected from note taking in the UK covering content, structure, style and legibility.

• The students were shown two videos of medical encounters on a ward. For each encounter, the students wrote clinical notes as if they were the FY1 doctor. These were then peer marked against pre-prepared ‘correct’ summaries with feedback by tutors.

• A presentation on handover skills using the SBAR method (Haig et al. 2006)

• A practical exercise in pairs – verbal handover of the patients they had written notes on, using the SBAR method, with tutor feedback.

Session 3 – full day

This session extended skills into a clinical context using Simulated Patients. Scenarios reflected situations where a patient had been on a ward with one condition but a new problem had arisen (e.g. admitted for appendectomy and developed symptoms of a chest infection). The student role was that they had been called to the ward to make an assessment of a new situation in a patient they had not met. The scenarios were kept medically very simple to allow the focus to be on communication.

The student was briefed verbally as if called by a nurse to a ward, read some pre-prepared notes about the patient, took the history, wrote notes, then handed over the patient verbally to a colleague.

The scenarios were kept short to allow multiple attempts with feedback.

Results

Immediate learner feedback on the course was positive with an overall rating of excellent. Anecdotal tutor feedback after the session was that skills improved during the course. The combination of language and clinical tutors meant that analysis of communication difficulties could be made from different perspectives and detailed, specific feedback could be given to each student in these areas.

In particular, the students initially did not ask for clarification of terms they did not understand or ask for information to be repeated if they did not hear clearly. Part of the teaching and feedback focused on how to avoid lack of clarity when dictating, adjustments to accents and tone of voice, rehearsal of appropriate ways in which one can ask for clarification and techniques for summarising more accurately (scanning, keyword, abbreviations).

The language teacher analysed their performance linguistically – sometimes small adjustments to syntax, pronunciation and context improved the effectiveness of communication. For example, raised tones at the end of statements caused confusion as they sounded like questions and communicated a sense of hesitancy. The clinician analysed the clinical content and structure required both in the written notes and on verbal handover.

Both tutors addressed the cultural context – how to address a consultant when you wake him/her in the middle of the night to ask for advice, how to address a nurse who requests your attendance to see a patient.

Some activities were initially too complex for the learners; we found that multitasking in communication skills, i.e. listening to the history and preparing feedback to their colleague at the same time was very difficult – these will be pared down to simpler tasks before being re-combined in a future course.

We plan to survey students and their host consultants when they return to work to gain further feedback. This will inform the design of future courses.

Conclusion

The impact of culture (locally, nationally and internationally) on communication skills may be underestimated in training. Many of the learning needs are hidden. The course we developed using a combined linguistic and clinical approach can provide solutions to clinical communication problems that may otherwise be missed. This strategy could be extended to cover communication areas in other contexts.

Acknowledgments

This work was carried out by all the members of Reache as a team. Special thanks are due to Dr Kossay El Abd, Mr Mick Sykes and Dr Maeve Keaney for their input and also to Anne Ashworth, Margaret Cartledge and Marylin Morrison for ideas and support. Reache North West is funded by NHS North West and supported by Salford Royal Foundation Trust.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.