The medical English course discussed here has evolved over nearly 20 years: large chunks or bits and pieces of the course materials and concept were changed every academic year. In some years this resulted in a complete makeover following new insights after course materials trial-and-error phases, students’ comments in yearly anonymous course evaluation surveys, teacher excitement about new material (for example, in the early 1990s, implementation of authentic patient language available in a real-life TV documentary, and later on the discovery of possibilities on the Internet), trends in ESP and English for Academic Purposes (EAP) (Hyland 2006), team work with colleagues working in EMP and in other ESP areas, etc. For a number of years now, the (ever-changing) course notes specifically developed for this course have been used in conjunction with an excellent commercially available vocabulary resource book (Glendinning and Howard 2007) and an online database developed in-house (Buyse et al. 2011). The medical English course is part of several medical language courses (medical English, French, Spanish, German) organized by our language institute on behalf of the Faculty of Medicine at the University of Leuven, Belgium, to prepare fifth-year medical students for the clerkship rotation in their sixth year. The Faculty is well aware of the risks attaching to limited language proficiency and has invested considerable efforts and resources to ensure that its students obtain the necessary language proficiency. In their sixth year, students are given the opportunity to complete some of their clerkships abroad. Clinical placements abroad are in Obstetrics & Gynaecology, Paediatrics, Surgery, and Internal Medicine. In order to be able to apply for a place abroad, students need to have passed an initial test assessing their general school-leaver knowledge of English (CEFR level B2) and to have attended and successfully completed a two-semester course in medical English.

The learners discussed in this case study are a group of about seventy fifth-year medical students from the Faculty of Medicine, KU Leuven, Belgium. They constitute a homogeneous group of students in their early twenties from broadly similar secondary education backgrounds in Flanders, the Dutch-speaking part of Belgium. A small minority is from the Netherlands, and each year there are one or two students from native or near-native English backgrounds. Overall, the level of English of these students ranges from good to very good. This is partly thanks to their English language training in secondary school and to the use of extensive study materials in English throughout their academic programme. Moreover, English and Dutch belong to the same Germanic language family, which means students feel comfortable (and sometimes overconfident) relying on their intuition for both vocabulary and grammar. Also, because so much of the Internet, TV and music scene is in English, students very often consider and describe their English as very good. Certainly, compared to their knowledge of French, German and Spanish, these students are right in estimating their mastery of English as more than adequate. The diagnostic test organized in the beginning of the academic year generally confirms their expectations, although results are disappointing for a minority. Results usually range from approximately 15 % to 95 %. In order to be able to apply for a place abroad, a result of 50 % on the in-house test or on a recently taken IELTS or TOEFL test is required. If students subsequently obtain a place abroad, they need to attend the medical English course. With this background information on the learners in this course, it may come as no surprise that in their first medical English class some students express disbelief about the possible use of a course of medical English in their already overloaded programme.

The course book Medical English Communication Practice (Vekemans 2015) covers the diagnostic path from consultation and admission through examination and investigation to diagnosis and treatment and has an extra chapter on pregnancy and childbirth. The last chapter contains grammatical issues that are still problematic for most Dutch-speaking learners of English, with a limited amount of theory and exercises from authentic medical language contexts. These course notes are used in class as a basis for mostly productive communication practice, i. e. some writing, but most of all speaking skills.

The vocabulary, quite a lot of which is at least part of most students’ receptive proficiency, is revised in a guided self-study route using the vocabulary resource book from CUP’s Professional English in use series (Glendinning and Howard 2007). A selection of units in this book is revised as homework in conjunction with class work based on Medical English Communication Practice. For most of the vocabulary in this book, translations, collocations and context sentences have been provided in the in-house UrgentiAS database (Buyse et al. 2011). Students are thus well equipped to revise the vocabulary on their own and test results for vocabulary generally range from very good to excellent.

The first semester of the course focuses on English language and communication skills related to consultation, hospital admission and subsequent examination and investigation. Students practise their speaking skills to take a patient’s history: presenting complaint, past medical and family history, more detailed history taking, and a mini-review of systems, obviously constrained by the current level of their medical knowledge and clinical skills. Role-plays typically involve doctor-doctor communication on the one hand and doctor-patient communication on the other. They are based on simulations from the United States Medical Licensing Examination (USMLE) and Objective Structured Clinical Examination (OSCE).

Since these fifth-year medical students already have a profound knowledge of medical terminology and enjoy using it, they tend to lose sight of most patients’ limited knowledge of medical terminology and need some steering in this respect. Here, in spite of their mastery of the English language, they often acquire new vocabulary and learn, for instance, that it may be wiser to use “gullet” to a native English-speaking patient rather than “oesophagus”. Should they have difficulty remembering the words used by the patients they encounter when they are abroad, they can still fall back on their medical terminology as a second-best strategy (Dahm 2011). Pronunciation too still holds surprises. Medical terminology, with its Greek and Latin origins, is transparent in most European languages, but the pronunciation of the Dutch “oesophagus” or “psoriasis” and their English variants is quite different. Moreover, surprises about the pronunciation of medical terminology are often all the greater because Dutch-speaking students are exposed to many types of spoken English on TV and the Internet on a daily basis and no longer expect surprises.

In the first semester, students are also required to write a case history. The language of case histories is first explored and practiced. Students are then asked to write out a case history based on patient-provided information from an audiovisual source (e. g. from YouTube) accompanied by written medical information. They have no problems transferring patient narrative into medical terminology, but some still have difficulties with grammatical issues and with the dry, matter-of-fact register used in these reports. For example, verbosity in the form of superfluous introductory sentences about blood that is going to be taken needs to be replaced by straightforward, easily accessible information about blood test results. Informal, spoken-register phrases about, for example, a family history that “showed nothing special” need to be replaced by more neutral and professional ones (“was unremarkable”) and the passive mode needs to take its rightful place in sentences about medical procedures instead of unnecessary references to anonymous doctors with the clumsy “they”.

In the second semester, the focus shifts to diagnosis and treatment and to pregnancy and childbirth. This is programmed as a last chapter because students only have a course on these issues starting at the beginning of the second semester. As knowledge and words for it usually go hand in hand, even their medical terminology in this field is still somewhat shaky. Hence, the language teacher proceeds with even more care than usual, and topics treated in this chapter contain more basic (usually patient-oriented) and manageable information.

In the diagnosis and treatment section, language functions are practiced in the contexts of students’ future placements abroad. For example, a part of this unit focuses on discussing the diagnosis of a paediatric patient with Crohn’s disease, which involves drawing the digestive system and naming its parts so that the patient and her family understand the diagnosis. Over the years, some cases have triggered more response than others. The successful ones have been retained and supplemented with other materials: for example, abstracts about different modes of treatment, which students enjoy exploring. These cases mostly involve diseases covered in other courses. Students may then offer comments: “Ah, that’s a nice coincidence, we’ve had Crohn’s disease in class this week!” However, whenever their curriculum changes, these fortunate “coincidences” are lost and new ones need to be discovered.

In this section too a number of tricky communication issues are dealt with. One involves watching a clip from a commercially developed DVD (McCullagh and Wright 2008) about a patient with a facial injury who needs to stay in hospital longer than she had expected. The consultant in the clip breaks this less than good news in such a (typically English?) gentle way that it invariably gets on the nerves of the Belgian students, who are probably much more accustomed to brisk and direct communication. This usually triggers a discussion about cultural differences, in which the students first blame the English consultant for wasting time by asking about all sorts of unnecessary patient-oriented matters (“Should anyone be informed?”, “Are you alright with this?”, “What can be done about work?”). In their view, the consultation takes up too much time. They are usually surprised to learn that it took only seven minutes, which in fact is not much time to devote to a patient who was expecting to go home straightaway and who was told she would need an operation later the same day. If all of the material in this commercially developed course were used, students would probably dislike being confronted with these stylistic differences, but in small doses this is manageable, and it may help to prepare them for the cultural differences that inevitably also exist within the medical profession.

A second communication matter that needs to be handled with care is giving a patient bad news. This has recently been added to the course notes. Previously, it was assumed that students would rely on their common sense and on the practice in communication that other courses of their curriculum provided. Only after a few serious mishaps in doctor-patient role-play, both in class and during the oral exam, did it become apparent that students can never have enough practice in these matters. Fiction can be useful in this respect, because neither students’ own performances nor that of their role model, i. e. the fully qualified doctor, are criticized. A fictional doctor and an artistically distorted view of medicine can be blamed instead. The first few minutes of Wit, a film directed by Mike Nichols, in which a doctor informs his patient of a terminal illness in old-school style, bombarding the patient with medical terminology and without so much as a trace of gentleness and consideration for the patient’s fate, can do wonders in this respect.

Spread over the two semesters, some grammatical issues are dealt with, typically problems that are persistent in Dutch-speaking learners of English. Rules are kept to a minimum and the exercises contain sentences from authentic medical contexts, thus providing useful exposure to medical collocations at the same time. Some pronunciation practice is also scheduled in nearly every class in both semesters.

In the second semester, students in pairs present a case using PowerPoint and ensuring interaction with their audience in true doctor-doctor communication about possible diagnosis, investigations, treatment modalities, ethical concerns, etc. They can choose the material they present themselves as long as it is relevant to one of the four placement disciplines available to them abroad. During these presentations, which clearly contain medical information that is largely if not entirely unintelligible to the language teacher, the teacher is completely in the background, taking notes on language use and presentation skills for later feedback. For each presentation, the presenters prepare a glossary with words, translations, collocations and example sentences from authentic contexts, and an outline of the case. The outlines are used immediately after the presentation as a starting point for a role play with one of the students as the patient in the case study. They thus have to “translate” the medical information into a patient-centered consultation on an ad-hoc basis. At the end of the second semester, each group has ten or more of these outlines, available on paper and on the online course platform. They are re-used in the oral part of the exam.

Assessment consists of two end-of-term written tests, the case presentation in class, and an oral test at the end of the second term. The written tests are designed to test the vocabulary of the self-study routes and the course notes, and the grammar section. Students are supplied with extensive information about what exactly is tested and in what form. Sample questions are provided. The first written test also includes writing a case study based on one of three outlines supplied in the test. There is no oral test at the end of the first semester. Oral skills tests in the second semester include the case presentation and an oral test following the second written end-of-term test. This oral test is taken in pairs or in groups of three. The language teacher is not involved in the interaction. First, students need to read a number of medical terms aloud to check their pronunciation skills. The test is then divided into two parts: doctor-doctor communication and doctor-patient communication. For the first part, students use material from two possible sources of CME websites (this will be described in Section 3.4). For the second part, students blindly select one of the outlines of the case studies presented in their group and prepare to be the doctor for the outline they have drawn themselves. Their test partner takes the patient role. After this role play, the “patient” then assumes the role of doctor for a role-play based on the outline this student has drawn. Students can prepare these role-plays at home to some extent by reading the information on each outline from the point of view of the doctor or the patient and deciding what is relevant in both cases. The fact that students can prepare quite a bit at home is not considered a drawback. The point of these oral tests is not to stress the students, nor to press them for reproducible language mastery, but to elicit genuinely useful and professional medical communication.

On its website, the US Department of Health & Human Services defines CME as follows: “CME is the abbreviation for Continuing Medical Education and consists of educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession” (http://www.nih.gov/news/calendar/cme.htm).

In most American states, medical graduates need to acquire CME credits on a regular basis during their entire career. CME is obviously not an exclusively American concept. American organizations that develop or accredit CME are organized on a worldwide basis. Europe also has its own CME forum (http://europeancmeforum.eu/) and organizations such as the Association for Medical Education in Europe (AMEE) (www.amee.org/home) (Davis et al. 2008).

In one of AMEE’s education guides, a table shows characteristics of CME as distinct from permanent education. Important in the context of this article is the difference in educational strategies: CME is about transmission of information and knowledge, whereas education strategies in permanent education are about problematization and reflection about quality of services (Ribeiro et al. 2010). Obviously, in this respect CME is more appropriate for use in an undergraduate context.

Organizations such as the British General Medical Council have a similar role in ensuring that doctors remain up-to-date as they set the standards both for undergraduate and postgraduate medical education and training. For a number of years now, both undergraduates and graduates have been able to benefit from their interactive Good Medical Practice in Action learning materials. These online interactive simulations are all about ethical matters, both in a GP and in a hospital context and are useful and interesting for doctors and medical students worldwide (http://www.gmc-uk.org/gmpinaction/).

Medscape Education is part of the American website Medscape from WebMD, which in turn is part of WebMD Health Professional Network, which includes theHeart.org and eMedicine.com. It organizes CME credits for doctors and its mission statement reads as follows: “To provide clinicians and other healthcare professionals with the most timely comprehensive and relevant clinical information to improve patient care; To make the clinician’s task of information gathering simpler, more fruitful, and less time-consuming; and To provide physicians with the educational tools needed to stay current in their practice” (http://www.medscape.com/public/about).

Medscape was founded in 1995, listing four specialties at that time: HIV/AIDS, infectious diseases, surgery, and urology. There have been several important milestones for the organization over the last 20 years, but of particular interest for language teachers were 2007, with the launch of TV-style visual material, 2008 with the start of leading experts video blogs, 2008 with the launch of a French version, and 2012 of a German version.

The Medscape website consists of three parts: News and Perspective, Drugs and Diseases, CME and Education. The CME and Education section lists 34 medical specialties in alphabetical order. Each specialty features the same subsections: clinical briefs, patient cases, knowledge and practice, journal articles.

In order to have access to Medscape Education, a log-in needs to be created. It is accessible for medical students as well as for (medical language) teachers. A number of Medscape patient cases are marked with an icon (a little camera) indicating that they contain audiovisual material. For language and communication teaching purposes, these materials offer many possibilities.

Language teachers may consider a CME website a bridge too far for medical students who have not yet completed their degree. However, an exploratory tour of these materials and their audiovisual material in, for example, Medscape’s patient case sections, will certainly convince many of their usefulness in a language teaching context. Patient cases include doctor-patient encounters that provide fine examples of professional interaction. The cases do not suffer from any of the flaws so typical of language teaching materials in which actors speak more emphatically or more slowly. Even if the patients in these materials are actors, the material is authentic in that it is designed for doctors’ use in a healthcare context. Lack of exactly these types of materials is often mentioned as one of the flaws of commercially available textbooks in ESP in general (Baghban and Ambigapathy 2011) and EMP in particular (Ling Shi et al. 2001). Another handy teaching feature of both the Medscape interactive material and Good Medical Practice in Action is that all the cases have full transcripts.

In order for the implementation of this type of material to succeed, the EMP practitioner needs to select appropriate cases. This may involve some experimentation. However, if one is aware of the type of courses students have already had, selecting a case that is not too specialized for them is not so difficult. Moreover, medical students like a challenge and they are happy to help out when there are doubts about a selection’s suitability. An audiovisual Medscape patient case usually contains a mixture of doctor-patient communication and doctor-doctor information. Even if students are not yet fully aware of all the medical information available to graduates, the doctor-patient encounters are always easily accessible for medical students in the clinical phase of their curriculum. Furthermore, the doctor-doctor information components may be left out until their contents are checked against students’ knowledge of the matter.

A first case in the course described here concerns a 42-year-old Hispanic immigrant with chronic back pain. This Medscape case is about pain assessment in chronic back pain and the case is included in an early part of the course notes dealing with how pain is handled in history taking. In an earlier class, students revised typical vocabulary to describe different types of pain and ask about different aspects of pain using the SOCRATES acronym (site, onset, character, radiation, associations, timing, exacerbating and alleviating factors, severity) (Longmore et al. 2010).

In the Medscape case students meet 42-year-old Hector, who speaks English with a Spanish accent, and a native speaker American doctor. Students recognize a number of elements that can be expected at home as well as abroad: a multicultural context with both native and non-native speakers of English. Hector’s language is typically that of a non-native speaker and the doctor is all a doctor should be: medically and verbally competent, kind and patient-oriented. There is some humour near the end, when the patient becomes impatient with some of the lifestyle advice given by the doctor. The clip starts with a voice-over fragment providing information about the presenting complaint and the medical history in the typical case study format. This fragment has been included in the course notes, as well as the rest of the transcript of the consultation, with eight sentences or questions relating to pain left out. Students are divided into two groups and are asked to supply four sentences each. The doctor-doctor information in this case is available in the course notes, with useful vocabulary highlighted. Since this material comes early in the course and is the students’ first encounter with the Medscape website, it is limited to a receptive language activity.

Further on in the course, a second example is implemented in a more interactive and productive way. It concerns the case of an Afro-American man with Type 2 diabetes complaining of leg fatigue. The timing of the case in the course is important here since students are studying diabetes in one of their courses at that time of the year. Hence, they have no problems following the case of peripheral artery disease (PAD) in this patient. Although the information about diabetes is familiar to them, the actual information focus in the material is new as it concentrates on diagnosing and treating PAD in the Afro-American population, in which it apparently occurs more frequently. The voice-over fragment with the presenting complaint and the past medical history is no longer reprinted in the course notes, but students need to reconstruct it after they have heard it. The video fragment is paused three times to allow interaction with viewers via a multiple-choice question. Students can discuss these questions with their peers and then vote for an answer. In this case, students managed flawlessly with all three questions about PAD and greatly enjoyed engaging in a clearly professional activity. The doctor-to-doctor information about diagnosis and treatment of PAD is used in this case as well. Students are asked to answer a number of comprehension questions. Before the patient in the clip is given the diagnosis in the second doctor-patient encounter, students are asked to reconstruct this dialogue in the course notes: the doctor’s lines are provided but in a jumbled order. The activity ends with a gap-fill vocabulary exercise based on the voice-over fragment from the beginning, relying on students’ memory of the words. If there is any time left, students can engage in an information-summarizing role-play.

After these two Medscape cases, students have become familiar with the website, and when in the second semester they need to search for case-study material to present in class, a number of them use cases from Medscape themselves.

The Good Medical Practice in Action website is explored as a homework task with students reporting on an interesting case to the rest of the class. Since students have little time for homework tasks in what they describe as the year with the heaviest workload of their curriculum, and since most of them seem to have a smartphone, the plan for the coming academic year is to try and use this website ad hoc in class without homework preparation.

The oral assessment part of this course consists of three components: a pronunciation check, doctor-patient communication in pairs, doctor-to-doctor communication in pairs. For the first two parts, see Section 2.5 above. For the last part, students are asked to choose material either from the Good Medical Practice in Action website or from an audiovisual Medscape patient case.

In the academic year 2013–2014, most students chose a case from Good Medical Practice in Action. Students that year who were interested in selecting a Medscape case to prepare for their oral assessment complained that they had a hard time finding a suitable audiovisual case. In spite of advice to start early on in the semester with their oral assessment preparation, they usually leave matters very late. As the semester proceeds and nears the exams at the end, they become inundated with study, work and tests. In their hurry to find material for the oral test, they do not seem to have the patience to sieve through the website. Therefore, in the following academic year, 2014–2015, students were provided with a teacher-assembled PowerpPoint collection of click-through screen shots of audiovisual cases called “Medscape patients, the start of a collection”. In the 2014–2015 oral test, most students chose to start from a Medscape patient case to talk to their test partner in a doctor-to-doctor simulation. The idea of this part of the test is that they should show that they are capable of talking about a case (and respectfully about the patient behind the case) in a number of different roles: as a peer to a fellow medical student or doctor colleague, as a supervisor to a junior medical student or a colleague, or as a supervisor to a medical student. The student who takes the first role should inform the other student about the chosen format (i. e. about the role the other student should play). The students who take the second role in this simulation are not evaluated and do not need to prepare the interaction by familiarizing themselves with the material chosen by the students who are tested. This gives the best guarantee of authentic interaction: in most cases, students have enough work preparing their own information, and since they are not evaluated in the listening role, they feel comfortable asking questions or responding with “I don’t know” if they have the role of junior student in the junior student/supervisor format. To date, no second-role student has sabotaged the narrative of their first-role partner, and very often the two students are so involved in the medical information that they engage in a small discussion about one or another technical matter. Needless to say, the language teacher is never involved in these role plays, apart from giving encouraging nods and asking the odd question as a genuinely interested lay person. Instead, notes are taken on the language, the task at hand and the professional style of the encounter. Students are aware of what exactly is being assessed as they have been supplied with this information in a document on paper and online long in advance.

The anonymous online course evaluation survey in May 2015 was filled in by 39 out of 67 students. The survey asked questions about several aspects of the course and students evaluated these on a scale from 1 (“I completely disagree”) to 5 (“I completely agree”). Course evaluation results overall were very good: 70.7 % (score 5) and 26.8 % (score 4) agreed that they had made progress in their English language and medical English proficiency; 66.7 % (score 5) and 33.3 % (score 4) agreed that overall they were satisfied with this course; 68.3 % (score 5) and 29.3 % (score 4) agreed that there had been a good mix of activities in class. In the comments on these questions, one student explicitly mentioned being glad to have been introduced to Medscape.

Students evaluated the oral assessment part of the exam in a separate question as excellent (24.3 %), very good (35.1 %), good (37.8 %), rather weak (2.7 %) and very weak (0 %). Considering the fact that their oral assessment consists of three subparts and is probably the most stressful part of the exam at the end of a very hectic semester, this is a gratifying result.

In a separate question, students were asked to comment on their choice of either Good Medical Practice in Action or Medscape patient cases as a starting point for the doctor-to-doctor communication component of the oral assessment. This section was commented on by 30 students, 25 of whom had selected a Medscape case and five a Good Practice in Action simulation. Most of the latter were chosen by students who were interested in ethical matters. One student reported that this is something they still have less experience with and that this was the reason for the choice. Reasons for choosing a Medscape patient case included: interesting audiovisual material; it was easy to picture the overall situation and to talk about this to another doctor; realistic cases from the perspective of placement abroad; student-friendly selection mode thanks to teacher selection of the cases; and a case subject that tied in with other course subjects from the second semester.