Abstract
This book reports the results of a three-year study of communication between patients and healthcare providers in five emergency departments (or emergency rooms) in Australia. The underlying impetus for the project was the growing realization of the critical importance of communication to patient safety and the delivery of effective care, particularly in the rapid pace and intensity of emergency medical care. The researchers, representing a number of research areas, including applied linguistics, vocational education, nursing, learning and change, and English language studies, collected 1,093 hours of observation data, including 150 interviews with medical staff and patients, and recordings of 82 cases of patient progress through the emergency department systems, resulting in a corpus of some 1.4 million words.
The study was the immediate outcome of an investigation by the New South Wales Department of Health into acute care services, highlighting the need for in situ research into communication practices in emergency departments. The book is thus directed mainly at health professionals and health educators rather than applied linguists or language testers. Nevertheless, it will be of extreme interest to people in our field, as it is perhaps the most comprehensive study of medical English in emergency departments, with data collected in real time as patients progress through the various procedural layers of the hospital system. The data and recommendations will be of value to language testers as they define constructs of medical English for test development. Since the book is not written for language testers, those wishing to employ the language use examples and analyses for developing tests of medical English will need to interpret or translate the findings and turn the real world tasks and language into test tasks that will elicit language performances from which levels of language ability can be inferred. Testers using this book will have to take into account a number of pertinent factors in addition to the analysis of the target tasks and language, including the test purpose, the abilities to be measured, and the characteristics of the test takers. In addition to the research findings in this book, the research procedures themselves will be of interest to specific-purpose language researchers, as the book documents methodology for qualitative data collection and ethnographic analysis of social, organizational, and interdisciplinary clinician practices and discourse analysis of communication among clinicians and between clinicians and patients.
The book contains seven chapters, the first being an account of the role of communication in healthcare contexts and a review of research on patient-centered care, patient experience and satisfaction in emergency departments, and communication practices in such departments. This chapter also contains a discussion of the research and analytical methods and a description of the five emergency department research sites. Chapter 2 provides details of the context of communication in the emergency department setting, including the consequences of the following: (1) operating on a 24/7 schedule with no upper limits on the number of patients taken on; (2) the potential lack of continuity and familiarity between patients and multidisciplinary teams of clinicians; (3) noise levels, lack of privacy and comfort; (4) the use of emergency departments as training sites; (5) the need for rapid turnover in patient processing; and (6) linguistic and cultural diversity. These factors result in a complex communicative context that requires specific strategies for explaining procedures and their own health situation to the patients in terms that they can comprehend. Chapter 3 takes the reader through the patient’s journey through the emergency department system, from entry and initial determination of the urgency of the patient’s presenting condition, admission and initial medical observation, and pain control if necessary by nursing staff, initial medical consultation, usually by a junior physician, involving history-taking and scheduling of medical tests and procedures, followed by a final medical consultation, usually conducted by, or in the presence of a more senior physician, involving a diagnosis, a treatment plan, and disposition, either hospital admission or release with instructions for medication and treatment.
Each of these stages of care brings challenges for communication, both between levels of medical staff and between staff and patients, which the authors document in the next chapter. They identify four potential communication “risk points”: failure to attend to communicative cues the patient offers in describing the nature of the medical problem, failure to listen to the patient’s narrative and allowing the complete story of concerns, failure to provide constant information about present and subsequent steps in the process, and failure to communicate the diagnosis and treatment plan in terms meaningful to the patient. Chapters 5 and 6 discuss effective strategies for collecting information from the patients and providing them with information about procedures and treatment and for developing rapport and empathy with the patients, the interpersonal aspect of patient care. Finally, Chapter 7 provides recommendations for emergency departments for developing an effective communication culture that will make it more likely that stakeholders in the emergency medical field – patients and clinicians alike – will understand their own and each other’s communicative behaviors, resulting in increased patient safety and well-being.
The communication issues that this book documents are clearly of critical importance. The authors cite statistics suggesting, for example, that communication failures contributed to a substantial proportion of some 400,000 preventable patient deaths in 2013 in the United States, and that Australia spends upwards of $2 billion a year in compensation for preventable patient harm, one third of which is attributable to poor communication. Though the research findings and recommendations in the book are aimed at medical communication training, there is no doubt that there is a concomitant need for the development of tests of communicative competence, for both native and non-native English speaking clinicians. The book provides numerous descriptions of the context of emergency department medical care, examples of patient–clinician talk, and discussion of aspects of strategic competence, all of which will be of interest and of use to language test developers. For example, the authors describe the experience of an 80-year-old patient who, in the course of a five-and-a-half hour visit to the emergency department, interacted directly with two ambulance officers, 10 nurses, two physicians, one radiographer, one orderly, and one communications clerk. This illustrates the complexity of the communicative context, not only in terms of the variety of participants, but also in terms of varied physical locations, purposes, topics, and types of language used. There are a number of examples of clinician–patient talk, sometimes contrasting more effective and less effective ways of communicating. The example below illustrates a relatively new nurse working with an elderly patient:
You in any pain at all Dulcie?
No. Me feet are frozen, I don’t know why.
OK.
Oh, gawd.
I’ll keep that in mind. [chuckles]
Need a bed warmer.
Be back soon. [Nurse leaves at 12:03 pm returns at 12:35 pm] (pp. 45–46)
This exchange illustrates a failure to attend to what is to the patient important information – her cold feet and request for a bed warmer. The response “I’ll keep that in mind,” accompanied by a chuckle, suggests that the nurse isn’t taking the information too seriously, and indeed he ignores entirely the follow-up request for a bed warmer. Finally, the nurse leaves without any explanation of why, what may happen next, or when he may return, apart from a vague “soon.” It seems to me that this type of data and analysis will be invaluable to English for medical purposes assessment developers, and the book is full of such information.
As noted above, Chapters 5 and 6 contain suggestions for and examples of communication strategies that may be used to collect medical knowledge from patients and share it with other clinicians, and for enhancing the interpersonal relationship with patients. For example, recommended strategies for developing rapport and empathy with patients include introducing yourself and describing your role, using inclusive language, using colloquial language, giving positive, supportive feedback, recognizing the patient’s perspective, interspersing medical talk with interpersonal chat, sharing laughter and jokes, and demonstrating intercultural sensitivity. These suggestions, which are derived from the discourse analysis of recorded interactions, are accompanied by copious examples and explanations. Again, this type of information should be extremely useful to specific-purpose test developers.
The book is not without its faults. Academic readers might wish for a more up-to-date discussion of the theoretical underpinnings of the research and the methods of ethnographic research and discourse analysis. For example, “move analysis” is mentioned at least twice in discussion of methodology, but no explanation of what this entails is offered. There is no discussion of non-verbal communicative behavior, such as gesture, bodily orientation, facial expression, or eye contact; nor is there any discussion of gender issues and how they might affect communication. Some medical terminology is not explained, at least not at the first instance of use. For example, the term triage is used a number of times but is not explained until p. 32; and in one transcript, the following expression appears without explanation:
Do you do lines? (p. 35)
Finally, there is very little discussion of the effect of English as a second language or intercultural factors, though some of the clinicians and a number of the patients were in fact second language English speakers and had come to Australia from elsewhere.
However, I think this book, though clearly not written with English language assessment in mind, will be a hugely effective resource for test developers in the field of medical English, and particularly for developing assessments in emergency department training programs.