What social contexts and what genres should English linguistics be examining in medical contexts? What aspects of these contexts should teachers of English in medical communication be envisaging in a university course? What is our theoretical framework based on? What aspects of texts should we be teaching?

Answers to these questions – to be taken as a stimulus for further reflection rather than as prescriptions – need to focus on the conceptual and cultural before tackling the procedural. Teachers of English linguistics in medical degree courses in Italy are confronted with new circumstances each academic year and are left with the feeling that they need to “raise their game” vis-à-vis their students, whose level of English is on average higher than that of students enrolled in previous years, but whose outlook often seems to be that further language learning has little point. Moreover, when confronted with an approach to English which does not conform to their expectations about the “learning” of English, there is the risk that the relevance of this new perspective and the amount of reflection on medical texts and genres involved will be missed (see the comments by one of the authors [Kantz] in Section 9 in Baldry et al. 2014: 206–209). Negotiation is needed.

In this respect, one of the very first lessons in the course described here required students ⁴ to compare medical cartoons, some of which are reproduced in this article. This was designed to question and overcome cultural assumptions, notably to change the students’ cultural framework as regards their perceptions of the human body in such a way as to encourage more abstract and medically-oriented thinking. University education is about creating frameworks within which abstract thinking can take place. One reason for choosing cartoons rather than, for example, photographs of doctor-patient interactions, is that the former are more easily relatable to the first steps in university education, while the latter are more concerned with vocational and clinical training that occurs in later stages. Cartoons are also a better basis for negotiating new ways of looking at medical discourse in the primo biennio as they are more abstract than photographs. For medical students, the passage from high school to university is very much about achieving greater abstraction and involves a presentation of many different specialised genres, both oral (medical lectures) and written (medical textbooks). Clearly, first-year students, fresh from high school, need a framework through which to encourage expression of abstract thinking. This applies to all their thinking as well as their representation of meaning-making, whether linguistic or visual, in project work. In particular, they need to become attuned to the way abstraction is represented in their first language, in this case Italian, as well as English. The cartoons discussed in class are representative of greater abstraction yet form part of students’ previous knowledge, and thus represent a good “negotiational hub” on which the transition to abstract thinking can be pinned.

A first step was thus to make it clear that, too often, both as doctors and patients, we take the body’s meaning-making processes for granted in ways that can impair and adversely affect mutual understanding. Here too, the capacity to stand back from specific examples of doctor-patient interaction and understand, for example, ongoing power relationships in an abstract way is a basic premise. An enabling strategy for this purpose consisted in comparing and noting the differences between a 1937 Punch cartoon, ⁵ a black-and-white ink drawing of a male doctor auscultating a female patient’s head with his stethoscope, apparently attempting to hear the humming noise (tinnitus) the woman was complaining of, and the 2009 Dan Reynolds cartoon “Diabetes is affecting my eyesight” (Figure 2). Students were asked to reflect on the following question: What interactional differences are there? Clearly, in line with the 70-odd years that separate the publication of these cartoons, the second cartoon is patient-oriented (Roberts 2006: 189; Gotti and Salager-Meyer 2006) in a way that the first is not. This is in keeping with a general cultural shift in the same period. This shift may be explained in terms of who has the power to control (Fairclough 2001). Indeed, the first cartoon was used to explain that there is a difference between institutional power and discourse power. For the purposes of this article and the course in question, this distinction relates to the authority invested by society in, for example, a physician (institutional). This makes the relationship between patient and doctor asymmetrical, with the physician traditionally holding all power as illustrated, though with an obvious, and rather humorous, recourse to hyperbole, in the Punch cartoon.

Figure 2:

Medical cartoon by Glasbergen (reproduced with permission).

The Dan Reynolds cartoon was used to explain to students that a patient may, however, temporarily have power in the discourse when, for example, she explains her circumstances to the doctor. This is a much simplified model which does not contemplate gender roles but potentially could do so. It is a good starting point for students’ project work that goes into a more complete understanding of institutional, societal discourse, gender roles and power together with the complex interplay between them as described, for example, in van Dijk (1989), Cortese (2001) and Sarangi (2010).

The body-as-text relationships presented in the cartoons reproduce the stereotype of the institutional power of the doctor over the patient during medical interaction, in the first case a physical examination and in the second case the doctor recording the patient’s history. The humour simplifies the teacher’s need to explain that institutional power is expressed visually, whereas discourse power is expressed verbally in these (but obviously not all) cartoons.

The institutional power of the doctors is expressed by the fact that they are standing, while the patients are sitting, in keeping with the bigger and smaller “roles” formulated by Kress and van Leeuwen (1996 [2006]: 114–154). In both cases, institutional power is the same. This meaning is communicated by the positions of two human bodies: that of the doctor and that of the patient. The discourse power, on the other hand, is different. In the first cartoon, the patient is the silent victim of the doctor’s paternalistic quote “To be perfectly frank, my dear lady, no, I can’t hear a ‘funny humming noise’.” In the second case, it is the patient who bamboozles the poor doctor, who remains silent. Silence is as powerful a form of communication as speech and contributes to attitudinal, evaluative meaning (Baldry and Thibault 2006: 37). Later on in their careers, these same students will discover that silent mutual gaze is even more powerful, as terminal patients and doctors engaging in end-of-life talk or palliative care talk know only too well. However, the bases for such subsequent interactions lie in the systematic analysis of the human body’s capacity to make meaning, the basic goal of this course in medical English.

2.1 Multiliteracy skills and GMER principles

The three cartoons presented above highlight pathological thinking about the human body. Imperfect thinking and imperfect bodies often go together: the nutty squirrel, the woman who thinks the doctor can hear her tinnitus, the woman who cannot make healthy food choices because of her presumed diabetes-linked short-sightedness. While a little grotesque, the humour makes it easier for students to pick up on the idea of the human body as a meaning-making text that tells a story. This is because the focus is on the pathological rather than the physiological. It is often easier to understand abnormal messages produced by the body than it is to understand normal ones, which we take for granted, though obviously both need to be explored.

The human-body-as-text approach facilitates explicit characterization of multiliteracies (Fairclough 2000) and the GMER principles (Global Minimum Essential Requirements; Loiacono 2012a, Loiacono 2012b, and Loiacono 2013), both of which deal with good quality medical communication in relation to a dual stance involving physiological and pathological states at the same time.

In 1996, a team of ten academics, the New London Group, met to discuss how literacy pedagogy could meet the challenges of globalisation, new technologies and increasing cultural and social diversity and summed up the outcome of their discussions with the word “multiliteracies”: (Figure 3).

[…] a word we chose because it describes two important arguments we might have with the emerging cultural, institutional, and global order. The first argument engages with the multiplicity of communications channels and media; the second with the increasing salience of cultural and linguistic diversity. […] A pedagogy of Multi-literacies, by contrast, focuses on modes of representation much broader than language alone. These differ according to culture and context, and have specific cognitive, cultural, and social effects.

(Cope and Kalantzis 2000: 5; emphasis added)

In 1999, the Institute for International Medical Education (IIME) was given the task of defining a global standard in medical training, which came to be known as the GMER principles. The Global Minimum Essential Requirements “define the knowledge, skills, professional behavior and ethics that all physicians must have regardless of where they have received their general medical training” (IIME 2002).

This global standard in medical training takes the form of 60 GMER principles, reproduced in Loiacono (2013: 205–255), which take the form of recommendations. They are grouped into seven domains which contain the core competences: (1) Professional Values, Attitudes, Behaviour and Ethics; (2) Scientific Foundation of Medicine; (3) Clinical Skills; (4) Communication Skills; (5) Population Health and Health Systems; (6) Management of Information; (7) Critical Thinking and Research (Figure 4).

(http://taltoolbox.blogspot.it/2012/07/new-literacy-in-web-20-world.html).

Figure 3:

An example of new literacy skills.

The GMER principles can be considered as a specialist form of multiliteracy skills applied to the medical sector. GMER skills relate to core medical skills and, in a way, synthesise all the multiliteracies that we call on our medical students to master. As Fairclough puts it:

The concept of Multiliteracies focuses [on] two key developments in contemporary societies: first, cultural hybridity increasing interaction across cultural and linguistic boundaries within and beyond societies, and, second, multimodality: the increasing salience of multiple modes of meaning – linguistic, visual, auditory, and so on, and the increasing tendency for texts to be multimodal.

(Fairclough 2000: 171).

Doctors have to speak and interact globally and English is only the starting point in this process. Becoming aware that the essence of their profession actually amounts to “reading” and interpreting the human body as text is a further step towards this goal.

The correlation between GMER principles and multiliteracies is exemplified in Table 1. The course experimentally illustrated the correlations through films which represented the human body, focusing especially on how the mind influences perceptions of the body: for example, in motivating students to apply GMER Principle 22, “Listen attentively to elicit and synthesize relevant information about all problems and understanding of their content”, to the film Fish on a Hook (Kantz 2012: 379–390). This film, investigated in the course, is an animation that visually compares a mentally sick person to a fish on a hook. Apart from the question of visual literacy and understanding of a visual metaphor (the human body as a fish), students had to engage with a person stuttering in English. The pathologically deformed voice in English is actually quite hard to understand, an awakening for students as regards their need for experience of medical discourse in English as opposed to grammar rules learned at school (Kantz 2015). The relationship between Internet, globalization and the communities of practice (Gee 2000) presupposed by the GMER interpretation of multiliteracies is explored in the next section from a procedural standpoint and from the standpoint of highlighting the benefits of teamwork among students.

Tab.

Table 1:

Correlations between multiliteracies and GMER principles.

2.2 Teamwork, project work and LearnWeb

Within the specific research reported here, students, partly in the classroom, partly working online, were encouraged to concentrate on group project work, which involved Internet searches for and investigations of different types of medical texts across different cultures and discussions within their group and with the teachers. This provided a good training ground for pulling apart the seven types of multiliteracies mentioned in Figure 3 and putting them together again. This type of integration requires hands-on practice (Marenzi and Kantz, 2013; Marenzi, 2014).

Figure 4:

GMER seven domains: essential core competences.

Our recommendation to the students was to collect good-quality resources that formed a corpus of multimodal texts, e. g. videos relating to a specific genre such as public service announcements and/or on a specific theme such as mental illness (Baldry and Kantz 2009; Kantz 2012 and Kantz 2015). This constituted a basis for acquiring the specialised medical communication knowledge and GMER skills targeted in the course: many online resources exist that show how body events and body processes and related ideas, theories and opinions are expressed not just through linguistic resources but through the multimodal integration of linguistic, visual, spatial and temporal resources in medical texts – most of all through the human body’s most natural integration of these resources.

The system chosen to encourage group project work was LearnWeb (http://learnweb.l3s.uni-hannover.de) that was initially developed in 2010–2011 to support multiliteracies at European universities (Marenzi and Zerr 2012). It provides group access to a range of web services, each with a different stance on web genres and resources, in keeping with the principles explained above of training students to think about and experiment with multimodal medical communication, as well as mastering specific biomedical terminology.

Teamwork is an essential part of this investigative experimentation, one that is implicit in the GMER approach to multiliteracies. By assigning students to a small group of online investigators, it encourages the creation of a community of practice engaging with medical English texts. In LearnWeb 2.0, teamwork is encouraged as different types of texts are identified and critiqued (through forums, annotations, ratings) by students working together in a virtual community. The interface design aims at improving collaboration and online searching. The resources collected by student groups are contextually visualised: for example, videos can be watched directly, with students’ comments and descriptions attached and transferred from one group to another, or removed from a group’s corpus.

By providing a seamless view of various types of resources stored in several Web 2.0 tools, students working as a group are able to carry out search queries defined within a distributed virtual working space in the same way as they would with their own desktop search engine. They can jointly browse through the results list and select texts that suit their learning task best. When a student identifies an interesting text in the results list, he or she can select it and, by clicking the “Copy to…” button, upload the text to the group archive, thus making it immediately available to the other ten or so group members and effectively contributing to corpus construction. The next step is to enrich the text with metatextual information (comments, ratings, tags).

A forum module is integrated into each group’s workspace to support structured communication among students in the group, allowing them to communicate and interact directly. The course teachers can see statistics relating to the groups’ activities and can also send messages of encouragement to students on the basis of the logs and graphs generated. These are also useful for research into changing attitudes to the learning of English at university.

As mentioned in the Introduction, this section deals with project work and questionnaires. The latter asked the students for their opinions as regards the GMER principles after they had completed their project work. As regards project work, limitations of space allow us to give only a brief indication of the students’ careful reflections on ways of presenting the human body in medical communication. Figure 5, part of a corpus created by one of the student teams, shows two consecutive “frames” in a sequence of images presented in class by one student. They suggest the student’s grasp of society’s evolving capacity to represent the human body’s inner workings without losing sight of its outward shape. This data suggests that students have achieved only a small step on this road. For example, the written presentation does not explain that transparency has been incorporated as a meaning-making resource into digital representations of the brain. In actual fact, during his oral presentation, the student in question did make a reference to the idea of a semi-opaque translucent image as a method of representing inner and outer body forms. The penny, as it were, was beginning to drop.

Figure 5:

Example of group project work.

This is obviously a basis for reflecting, for example, on traditional and innovative ways of looking at and representing the human body: X-rays, scans, skeletons, rubber or plastic “reproductions” of human organs, digital images and so on. Specifically, in a digital world, it invites reflection on how trajectories of veins, arteries and nerves and their intersections with bones are represented. All this is an indication of the importance of visual genres in medical training and their integration with linguistic resources, as Figure 5 clearly shows. The reference to the significance of colour intensity as a meaning-making resource further indicates the student’s growing awareness that medical communication is multi-semiotic.

As regards responses to questionnaires, an online questionnaire was created based on the fourth domain of the GMER principles, Communication Skills: “The physician should create an environment in which mutual learning occurs with and among patients, their relatives, members of the healthcare team and colleagues, and the public through effective communication. To increase the likelihood of more appropriate medical decision making and patient satisfaction, the graduates must be able to: […]” (IIME 2002).

The questionnaire, shown in the Appendix, asked students to rate themselves as regards their level of achievement vis-à-vis the GMER principles relating to this domain. It was presented to the students as an online form at the end of their course and before they took their English exams. At the end of their first year, 85 students responded to the questionnaire and 93 in a follow-up study of the same cohort of students towards the end of their second year.

As stated above, the questionnaire asked students to self-evaluate their communication skills in relation to GMER principles. For example, the first question reproduces Principle 22, relating to the capacity to listen attentively and synthesise information. The students were asked to judge their ability in terms of applying this principle to frontal lessons in the course. In addition to classic questions about basic skills of listening, speaking, reading and writing, often associated with CEFR-based programmes, the questionnaire was concerned with communication in professional contexts.

Of course, as first-year students, the linkage between communication skills and vocational training implicit in the GMER principles comes up against the problem that the students have no experience of the interaction with patients and their families that these principles presuppose, e. g. Principle 23. In order to get round this problem, the students were asked how good their interaction was with fellow students in project work. This question assumed that this was their first approach to English skills in the workplace.

Similarly, in relation to Principle 29, relating to the ability to maintain good medical records, the students were asked about their ability to collect and organise resources as described in the previous sections of this article. A third type of question, not shown in the Appendix and included only in the follow-up questionnaire, asked students to comment on whether they noticed any improvement, changes or progress in their learning strategies both in English and in other subjects, thanks to the teamwork approach and related concepts of multiliteracies and multimodal medical communication.

The follow-up questionnaire also asked students (now in their second-year) whether they had filled in the questionnaire before, in order to verify the validity of the comparison. There were 57 “yes” answers and 36 “no” answers.

It would be possible to match about half the respondents in the second cohort with those in the first – about half remained anonymous and about half gave their names. However, the purpose of the follow-up was not to provide a precise indication of changes in attitude on a longitudinal basis, but rather to see whether an approach based on this type of quantification could be deemed reliable. In other words, in order to have data that could be supplied rapidly by students and collated rapidly by researchers within the heavily-constraining time limits of learning and teaching in medical degree courses, the goal was to establish whether the data in the first year roughly corresponded to those in the second year. Specifically, it was assumed that students would have forgotten the percentage replies that they gave in the first year by the time they came to fill in the form a year later; it was further assumed that if the percentages roughly matched, then some overall validity could be attributed to the responses.

As a way of backing up these assumptions, students in the follow-up were given the chance optionally, as mentioned above, to comment on their progress. Of the 93 respondents only 11 gave replies to this optional question, lending support to the idea that a questionnaire has to be simple in its format and allow the possibility for replies to be given very quickly. Even so, the replies contained clues to students’ thinking, such as: “I remember filling in the questionnaire but don’t remember the questions with much detail”. Another way of testing/ensuring the validity of responses is to change the format. Hence, as well as asking students to make single selections in terms of percentages, we also asked them to make multiple selections in relation to specific questions, for example Principle 27, “demonstrate sensitivity to cultural and personal factors that improve interactions with patients and the community”. Here, students could choose any of the five options listed, provided that at least one was selected. The preferred choice was mental health issues, the second deformities, the third, fourth and fifth, smell, scars and tattoos. The percentages, however, varied roughly from year to year between 20 % and 40 % as the table shows (Table 2).

As mentioned above, the questionnaire reflected the students’ projects. This is more than apparent in relation to the same principle. The questionnaire had to carefully balance the need for quantity and quality of replies. This question is interesting because it could have been framed in such a way as to explore the students’ understanding of what sensitivity, cultural issues and interaction mean for a doctor. However, such a question would probably have reduced the number of respondents to the questionnaires. By incorporating into the questionnaire issues that the students themselves had proposed in their project work (there were projects on scars, tattoos, mental health, etc.), we hoped to encourage a higher response rate. What we have said so far relates to the validity and reliability of the data. This is not perfect but, given the difficulties of implementing questionnaires, it appears to have produced a set of sound data on which to work.

Another aspect of the questionnaire relates to judgements about communication skills and in particular the value of peer interaction. One of the hoped-for benefits from the course was that students would perceive an improvement in discussion skills. This is hard to achieve in a university context where there are large numbers of students, but in theory we felt that basing the course partly on project work and peer interaction ought to stimulate the perception that speaking skills within groups working on a project were improving. Contrary to expectations, based on previous experience, confidence with writing skills was not judged to be higher than with speaking skills. In fact, as Tables 3 and 4 show, they are roughly the same.

These two tables also suggest growing confidence over time in relation to skills in medical English. To what extent the trends perceived in this study are confirmed in subsequent years of study is a matter for further research in a more detailed longitudinal study.

The GMER principles state that medical graduates must be able to “interact with other professionals involved in patient care through effective teamwork”. What is teamwork? Certainly, interaction can be seen as a form of teamwork, and teamwork can be seen as a form of interaction. From one perspective both are a form of learned behaviour; learned, that is, on the basis of experience. If you ask an adult student attending a university course in English, “Do you know how to interact with others?” they will of course say “yes”, but the truth is that they do not. In particular, the first-year students described in this article did not know how to interact with teachers about medical issues either in Italian or English, nor could they be expected to do so at the beginning of a medical degree. However, one problem is that students do not necessarily understand what interaction is, with many students thinking that interaction is just an exchange, a form of conversation. Interaction instead relates to a more profound understanding of other people and oneself. Medical students above all need to be able to “read” other people as well as themselves and understand that genres encapsulate interactional experiences associated with specific social and professional contexts. Part of the doctors’ occupational identity as shown in the cartoons discussed above cartoons, is created by extensions to their body: stethoscopes, pens, clipboards and white coats. What happens when these things are removed? was one of the provocative questions asked of the students, whose replies indicated that the penny was dropping. Such a procedure usefully challenges basic assumptions and is the basis for subsequent courses. Thus one future step might be assignments relating to videos of wards where doctors do not wear white coats (e. g. some psychiatric wards), or wear the same outfits as nurses. It will be interesting to observe the patients’ reactions to the (unexpected) circumstance of not being able to tell who the doctor is, or the reactions of new medical trainees who do not know their patients (in the psychiatry ward).

We all have anecdotes about the problems of medical interaction that can be usefully incorporated in our teaching as the use of cartoons has demonstrated. However, we need, as researchers into English linguistics, to find an interpretative framework that measures student reception of the notion of interactional competence (Hymes 1972) and their readiness to take it on board and put it into practice.

Questionnaires are a traditional way of measuring student responses to teaching, but linking them to student project work is a rather more innovative approach and therefore merits careful analysis. All this presupposes that students must make the journey, which scholars have undertaken in the last fifty or so years, from linguistic to interactional competence (Hymes 1972). This leap, as we said at the outset, comes up against the objection: “I already know English, so what can you teach me apart from specialised vocabulary?” Crucially, the question needs to be raised as to whether there are signs in the students’ response to the course that awareness of the vast field of interactional competence that lies beyond linguistic competence is beginning to emerge – not just at a cognitive level, but also in terms of actual learning behaviour, such as that manifested in project work carried out in English. This entails an operational distinction between theory and practice as regards interactional competence. In this experimentation, the questionnaire measures the theoretical side, the project work measures the implementational side.

This article has considered the question of constantly redefining the role of English in the medical degree syllabus in Italy (Baldry et al. 2014; Gotti 1984 [1991]; Loiacono et al. 2011). Certain aspects that are unlikely to have been presented in the pre-Internet age do, however, appear to have gained a permanent foothold.

Our first conclusion relates to the need to stimulate students’ thinking about medical communication, now a permanent fixture in one of the authors’ experience in the English syllabus in medical degree courses. This is part of a step-by-step approach consisting of year-by-year syllabus increments, which reflect the complexity of medical communication in the twenty-first century. The first step in this approach to medical communication in English is the relationship between physiological and pathological.

A further conclusion is that it is procedurally possible and beneficial to introduce the concept of the human body as a physiological and pathological multimodal text at this stage. The relevance of multimodality in the training of undergraduate students as regards medical communication is beyond question. The students’ responses confirm that “Grammar needs to be seen as a range of choices one makes in designing communication for specific ends, including greater recruitment of nonverbal features. These choices, however, need to be seen as not just a matter of individual style or intention, but as inherently connected to different discourses with their wider interests and relationships of power” (The New London Group 1996 [2000]: 26–27).

A third conclusion is the significance of group project work in encouraging teamwork amongst students. As our investigations show, the role of computer interaction and dedicated software systems targeting multiliteracies is essential to this end. As we will report on a further occasion, the framework we have outlined above provides a strong basis for further innovations when investigating medical communication in English in the subsequent years of the medical degree course, and in particular the exploration of specialist genres such as films and images relating to ways in which doctors, other healthcare professionals and patients interact in hospital environments.