Abstract
Although language assessments for medical professionals in the UK are changing, there is still a need for them to demonstrate their proficiency in English before working in the National Health Service (NHS). When providing English for specific purposes (ESP) courses for retraining refugee doctors, we need to consider all the potential barriers that every language learner faces, as well as professional barriers that may challenge them as a specific group. The following article examines the linguistic (and psycholinguistic) barriers that confront this intelligent, motivated and diligent group of people, and puts forward a model that teachers, course planners and material designers may use for their English language training.
I Introduction
Although the International English Language Testing System (IELTS) test is an assessment of a learner’s English to establish whether they are able to cope with the rigours of entry into Higher Education, it has been used for other purposes for which it is not intended. One such example is its use in assessing a doctor’s English as a step towards registering with the General Medical Council (GMC). Although IELTS was considered a ‘best fit’ as a screening device for doctors, its use in this context was sometimes considered inappropriate. In response to such criticisms, an announcement from the Nursing and Midwifery Council (NMC) in 2017, the GMC announced in 2018 that they too would accept the Occupational English Test (OET) Medical as evidence of an applicant’s level of English in place of the IELTS test (OET, 2018). In the case of displaced medical healthcare professionals (DMHPs) from outside the European Union (EU), this language assessment forms the first in a number of professional and linguistic assessments that need to be successfully completed before they can work in their chosen careers in the UK. The subsequent step would be for doctors to take the Professional Linguistic Assessments Board (PLAB) exams 1 and 2 (GMC, 2018a).
While it is too early to measure the impact of these recent changes, data from the British Medical Association (BMA, 2008) in Figure 1 shows that previously, the IELTS test presented the biggest challenge for DMHPs in their progress towards employment.
Progress towards employment for BMA registered refugee doctors.
Although the recent changes in the assessment of DMHPs are designed to reduce the linguistic barrier that the IELTS test represented, there is still a need for these professionals to understand and be understood in English. Subsequently, this study has found there is a need for language training leading up to and alongside dedicated examination classes, which can be strikingly different to medical training. In turn, this can create an additional barrier for DMHPs who wish to learn English for specific purposes (ESP).
The research was designed to examine the beliefs of the participants about the causes of their own stabilized language errors. In some ways, the study took on characteristics of an ethnographic study, as described by Hyland (2012), attempting to assess the needs of the learners through thick description from the insiders’ perspective and collecting data from a number of sources. It was hoped that by involving the learners in their own analysis of their problems, it would avoid the criticisms of the more traditional pedagogical analyses, where decisions are made by educators. The findings may be generalized across other displaced groups who fall within ESP learning, provided that they are being assessed with a similarly ‘high stakes’ examination. The resulting model is one that should arguably be considered in the teaching and training of displaced professionals. At a time when the National Health Service (NHS) is in dire need of doctors (BMA, 2017), it is essential that the barriers that DMHPs face are addressed.
II The context of the study
In order to ensure that DMHPs are fully trained and suitably qualified to work in the UK, the most recent GMC guidelines include a minimum level of English: Level B in the Medical OET Medical. This is the equivalent in the IELTS test of an overall band score of 7.5 with a minimum score of 7.0 in each skill: listening; speaking; reading; and writing (GMC, 2018b). While language skills at this level are undoubtedly essential for safe and effective practice in medicine, it is frustrating for medical healthcare professionals who have trained for many years to be held back by not being able to achieve this minimum requirement. It is also a loss to the National Health Service (NHS), as training a doctor from the beginning is a costly process (Keaney, 2007). Retraining previously qualified DMHPs allows highly intelligent and motivated refugees to integrate and contribute to their host society, restoring their dignity and alleviating the financial burden. This study affirms the decision to move away from the academic IELTS test to the more medically oriented OET Medical and offers suggestions for good practice in training DMHPs.
III Barriers to learning languages for all adult learners
In order to examine barriers to language learning, we must consider the most widely-researched and reported barrier to progress in language learning, fossilization. Long (2005) illustrates the extent of the popularity of the theory of fossilization in mentioning that ‘fossilization’ is the only SLA term which has ever been entered into a non-specific dictionary. Birdsong (2005, p. 174) describes fossilization as a ‘protean, catch-all term that begs for a unitary construct to refer to’. Although the term has become somewhat flexible over the decades since it was provided, in this article I will use Selinker’s (1972) definition of ‘fossilization’ as follows:
Fossilizable linguistic phenomena are linguistic items, rules and subsystems, which speakers of a particular native language will tend to keep in their interlanguage relative to a particular target language, no matter what the age of the learner or amount of explanation and instruction he receives in the target language. (Selinker, 1972, p. 215)
Han’s (2004) work goes the furthest in summarizing the literature on fossilization and she lists 50 putative causal factors of fossilization. These causes have been categorized under six headings: Environmental; Knowledge Representation; Knowledge Processing; Psychological; Neuro-biological; and Socio-affective. They were used to inform the conceptual framework for the data analysis and part of the research design for this project. With regard to terminology, for the sake of this research the more optimistic term ‘stabilized language errors’ (SLEs) will be used. A discussion of each of Han’s factors will follow.
The first of Han’s (2004) domains, ‘Environmental’ factors refer to the circumstances surrounding a language learner. The barriers range from a lack of quality input to a lack of any instruction at all. The input that a learner receives is crucial to their progress. Kumaravadivelu (2006) illustrates this point and emphasizes the need for learners to seek out input and receive corrective feedback. In other words, the concept can be reduced down to the simple equation: zero input equals zero progress. How a student deals with the feedback that they are given links to the ‘Psychological’ factors of fossilization, which will be discussed later.
Han (2004) also links some factors from her second domain, ‘Knowledge Representation’, with a lack of instruction. She observes that an instructor is able to help to point out and clarify particular instances where a learner’s first language (L1), or even when prior learning, is interfering with their current second language (L2) learning. Representational deficits of their language faculty as discussed by White (2005) can allow a learner to believe that they are closer to their goal in language learning than they actually might be. In the context of this study, the book describing common errors made in the interlanguage of learners with a variety of L1s, Learner English (Swan and Smith, 2011), was used to identify problems of this type. Other factors regarding ‘Knowledge Representation’ include a lack of access to Universal Grammar (UG) and ‘learning inhibiting learning’. The latter relates to the neural pathways that are created in learning in a particular fashion and the possibility that a different learning style may challenge this neural entrenchment.
Han’s (2004) next domain is referred to as ‘Knowledge Processing’. Klapper (2006) describes this shift from ‘declarative Knowledge’ or knowledge about the facts and rules to ‘procedural Knowledge’, knowledge about how to articulate the rules, as being a central theme for Knowledge Processing. Any imperfections in knowledge or misunderstandings about the implicit processes could lead to language being internalized incorrectly. ‘Knowledge Processing’ also represents the ability to ‘notice’ and analyse the contrastive features between the L1 and L2, as well as the skills of assimilating linguistic information. Klein (2003) describes these difficulties in what he calls the ‘Matching Problem’. Simply put, learners often experience difficulties when attempting to approximate their output to the input that they receive.
‘Psychological’ factors refer to learners’ attitudes towards language learning. Klein’s (2003) observations on learners’ strategies in ‘getting away with errors’ is starkly obvious to any second language instructor who has observed their students mumbling utterances in order to communicate their message. Other strategies that can inhibit L2 acquisition are avoidance of the more challenging aspects of interlanguage development, timidity and a prioritization of communicative skills over form. In addition, test takers will naturally use a lot more strategies that relate directly to the format of the test they are taking. Although not prescriptive, Zheng (2010) claims that choosing the right strategy can not only facilitate learning but also overcome fossilized language errors. Conversely, an inappropriate strategy can lead to problems. The last of the ‘Psychological’ factors identified by Han (2004) is the transfer of training. Wang (2011) gives the example of the traditional format of the product-focused writing class in China against the more passive, teacher-centred methods of writing classes in the West.
The factors that are categorized under Han’s (2004) fifth domain, ‘Neuro-biological’, include matters regarding an extant inhibited capacity for learning, either naturally or brought about by mental or physiological trauma. Similar to the lack of access to UG, which is categorized under the ‘Knowledge Representation’ domain, these factors are more difficult to rectify without a holistic approach to potential solutions. Accordingly, the majority of these factors relate to age and its accompanying maturational constraints.
The final domain as categorized by Han (2004) is the ‘Socio-affective’ domain. The majority of the literature on SLEs concludes that language learning cessation or plateaux are caused by socio-affective influences, such as a satisfaction of communicative needs (Long, 2005), a lack of acculturation (Han, 2004), will to maintain identity (Schumann, 1986) or other socio-psychological barriers (Tarone, 2006).
While all of these problems can work together to present significant barriers to learning for language learners from any background or in any context, this study aimed to investigate what were the specific barriers to DMHPs. In my experience, DMHPs were highly motivated and invested in their studies, and the above reasons for the cessation of language learning did not seem to fully account for the barriers that confront this group. Nonetheless, the DMHPs exhibited features of their interlanguage as described by Selinker (1972) above.
IV Specific barriers to learning for DMHPs
In order to maintain DMHPs’ currency in knowledge and professional practice, it is important to minimize any gaps in their employment. Organizations such as the Welsh Asylum-seeking and Refugee Doctor (WARD) group try to assist with the transition from doctor to refugee and back again (Wales Deanery, 2010). If the gap is too great, Smyth and Kum (2010) warn of ‘deprofessionalization’, whereby a person can become so out of touch with their profession that they may need to retrain. Dr. Tanin (Kader and Tanin, 2004) describes similar obstacles in retraining for less senior posts after displacement from Afghanistan in the early nineties, when competition for any post was fierce. Dr. Tanin goes on to state:
For five years, I repeatedly felt ignored, despite my experience, enthusiasm for work and my knowledge of different cultures and languages. Ignored because the system was based on an ignorance of those professionals who are seen as a burden rather than an asset for the economy; ignorance of employers who rather accommodate their own choices; ignorance of a culture which sees refugees with a black and white judgement of tabloid media and xenophobic thoughts of extreme right. Refugee doctors, like other refugees, have been discriminated against. (Kader and Tanin, 2004, p. 50)
This statement echoes the work of Norton (2000), who states there is a ‘paradoxical position’ that immigrant workers find themselves in: opportunities to practise can improve language skills; however, language skills are needed to seek out these opportunities. A significant shortcoming that Norton (2000) observes is that many studies that observed these paradoxes did not provide opportunities for adult immigrant language learners to offer their own perspectives and therefore they were left ‘voiceless’. For this study, the participants’ views were foregrounded in the spirit of providing such learners with a voice.
In discussing language and identity, Norton (2000) also promotes the views of Weedon (1997, cited in Norton, 2020, p. 5) in moving away from viewing language learners as a series of binary characteristics (motivated / demotivated, introverted / extraverted, etc.) and considering a poststructuralist perspective of learners that encompasses their histories, contradictions and capacity for change over time. Block (2014, p. 15) discusses poststructuralism and, while he describes it as being ‘vague at best’, he cites Smart’s (Smart, 1999, cited in Block, 2014, p. 15) definition as ‘a “critical concern” with a multitude of issues’. Block (2014, p. 91) also states that ‘It is in the adult migrant experience that identity and one’s sense of self are most put on the line.’ The loss of their history, culture, and language means that there is often a sense of urgency for adult migrants to fill the void which migration has caused. In the case of the participants of this study, the impact of their life, professional and educational history was likely to be as significant as, if not more significant than, their learning preferences.
In addition to the aforementioned loss of support systems that all adult migrants experience as language learners, there is an additional loss of status for DMHPs. With limited language skills, DMHPs are disadvantaged not only in losing access to certain social resources, but also to the opportunity to contribute to their profession. As Mayr (2008) puts it:
Social power is defined as power belonging to people who have privileged access to social resources, such as education, knowledge and wealth. However, analysts do not see power and dominance merely as imposed from above on others, but maintain that, in many situations, power is ‘jointly produced’. (Mayr, 2008 p. 11)
As such, DMHPs with developing English language skills are not only less able to instigate or contribute to professional conversations which they would ordinarily be involved in their first language, but they would also become outsiders from the profession as their access to these social resources diminish.
Another element of DMHPs’ loss of status comes from the challenges of enforced migration, which do not necessarily prioritize the development or maintenance of language skills. For many, being unable to work or study can lead to a stagnation of their professional and linguistic skills. Furthermore, they are often persuaded to take low-skilled jobs to deter them from claiming benefits, thus compounding the effects of ‘deprofessionalization’. Enabling DMHPs to rejoin their professions will allow them to meet integration agendas and contribute to their host society.
The study was designed to take place over two phases and involve various groups of participants including DMHPs and expert witnesses. A brief discussion of the methods used will follow.
V Conducting the study
The perspectives of DMHPs provide insights into the factors that they thought might have caused their language errors. In reflecting elements of Hyland’s (2012) ethnographic needs analyses, an important principle of the study was to collect the reflections of the participants and to have the voice of DMHPs at the core of the study. The first research question aimed to identify the participants’ SLEs within the examples provided by Swan and Smith (2011) for the specific language groups featured in the study, as well as Common Mistakes in IELTS at level 7 (Moore, 2011). The second aimed to gather the perspectives of DMHPs on their own barriers to learning English and subsequently corroborate their reflections with the views of expert witnesses, in the third and fourth research questions. As a result, the following research questions were designed:
What are DMHPs’ perceptions of their own common SLEs?
In the participants’ views, what is the impact of life histories, educational histories and other experiences on SLEs?
What are the participants’ responses to the emergent findings of the study in research questions one and two?
What are the views of expert witnesses on the training and language skills of DMHPs?
These questions aimed to enable DMHPs to voice their perspectives. In addition, stakeholders such as IELTS trainers working with refugees, people involved in setting policies for DMHPs, and researchers into this under-researched field may be able to use the findings to understand the issues that directly affect the participants. In order to understand these issues, careful selection of research methods was required.
The project was conducted over two phases. The first phase involved sending a set of linguistic self-assessment questionnaires to all clients of the Wales Asylum-seeking and Refugee Doctor (WARD) group, and subsequent language tests and interviews with those currently studying towards their language assessments. The second phase was to return to the interviewees and discuss the results from Phase One in a focus group. Subsequently, the findings from Phase One and the focus group discussion were presented to a group of expert witnesses for their views. The expert witness group included: the teacher who delivered IELTS classes to the DMHPs in the study; another teacher of DMHPs who has multiple publications on IELTS training and DMHPs; another author who was involved in a consultation on the suitability of IELTS for the purposes of the GMC; and the Director of a comparable organization supporting DMHPs in the north of England.
The sample group for Phase One is described in Table 1. Table 1 shows information for all 22 participants’ identities and their experiences in using English, according to the 13 questionnaire respondents and nine interviewees. It is important to note that there is some overlap between the two groups. Although follow-up open answer interview questions were sent to all questionnaire respondents who provided their email addresses, just one participant, Dr. I.E. responded to these questions. For the sake of the analysis of the identities of the participants, Dr. I.E.’s responses to the questionnaire data were recorded. However, his comments to the open answer interview questions were recorded for Research Question 3.
Personal details of the questionnaire respondents (grouped by first language).
Notes. PMQ = primary medical qualification.
One of the principal concerns was whether the doctors had enough knowledge of English to participate in the research. The letter of consent was worded in simple English and tested via the Fleish–Kincaid Grade level test (Grossman, Piantadosi, and Covahey, 1994) in order to keep the level of English close to that of a 10-year-old, as recommended by MacKay and Gass (2005). Prior to collecting the data, it was also considered that in the cases of low-proficiency learners, translations would also be offered. Due to the high proficiency of the respondents, these were not requested.
In order to identify the SLEs that are the barriers to gaining qualifications, an audit of language problems was conducted. In the first instance, this audit was a self- assessment from the target group themselves. So as to avoid the assumption of fossilization, which was criticized by Long (2005), the participants were asked to assess and reflect upon the language traits that they exhibited. It was expected that they would be aware of their linguistic shortcomings through feedback that they received in their exam training and other language courses. The data collection measures, i.e. a questionnaire on interlanguage errors and a diagnostic quiz on the same interlanguage errors, were designed to yield information on both the types of problems they experience according to common interlanguage errors between their L1 and English (Swan and Smith, 2011), and common errors in IELTS scripts at level 7.0 or above (Moore, 2011). A third data collection measure, namely a mapping exercise asking interviewees to link their interlanguage errors to putative causal factors of fossilization (Han, 2004), was also used. Figure 2 reflects the aims of the project and the areas that were explored, namely the kinds of SLEs that the participants exhibited and their possible causal factors, relating to Han’s (2004) six domains.
Conceptual framework for the study, drawing on Han’s (2004) putative causal factors.
The diagram in Figure 2 shows how the data on each domain was combined to form an overall profile of the participant groups’ views, as well as how an understanding of these may reveal insights into improving their professional communicative competence. Instead of assumptions being made by the researcher, the project was designed to ask the people who exhibited these language problems and to engage in a reflective dialogue about their SLEs. It attempted to understand why they felt that they could not easily overcome them. It examined the relationship between the participants’ views on their own SLEs and the generalized characteristics of the aforementioned interlanguage errors. Refugees are often redispersed around the UK without warning. In order to maximize the number of participants, two groups of were considered: refugee doctors who were no longer attending the IELTS training sessions were sent questionnaires and those who were still attending the classes were given quizzes and interviewed.
The following data collection instruments were used:
A questionnaire that asked respondents to analyse which interlanguage errors they felt they exhibited, according to Swan and Smith (2011) and Moore (2011);
A quiz on the same interlanguage errors, provided to the interviewees, returned and analysed prior to the interviews;
A mapping exercise which asked the interviewees which of Han’s six domains (Environmental; Knowledge Representation; Knowledge Processing; Psychological; Neuro-biological; and Socio-affective), the interlanguage errors could be attributed to.
The quiz on interlanguage errors was designed to assess the participants’ ability to detect errors. Questions with a medical theme, based on a range of common errors in IELTS at Level 7 and above (Moore, 2011) were given to the interviewees. Each common error was tested with two questions for each area, and in order to avoid participants guessing via a process of elimination, each question would feature either one or two errors to be identified, as in Table 2. For the sake of accessibility, Han’s six domains were simplified into statements, for example ‘My classes, the people around me and/or my location.’ for the ‘Environmental’ heading.
Example of errors to be identified.
The project featured six forms of data: questionnaire responses; follow-up question replies; diagnostic language quizzes; semi-structured interview transcripts; focus group transcripts; and expert witness transcripts. The next step in designing the project was to consider the methods for analysis of the data collected over the two separate phases from four groups: questionnaire respondents; interviewees; focus group and expert witnesses.
VI Results and discussion
In Phase One, the findings showed that attempting to pass the English language assessment represented a hiatus in professional practice but that there did not seem to be a link between age and success. It also seemed that a high level of motivation was able to compensate for a lack of English language learning in early life. In addition, the data suggested that different people defined the phrase ‘learning English’ differently, and as such, the participants’ language learning experiences needed further exploration.
A further point that arose from the data was that the majority of the questionnaire respondents had achieved the level of English required by the GMC. Despite this, they identified themselves as having more problem areas in English learning than the interviewees, who had not yet achieved the required exam score, demonstrated in the results of the diagnostic language quiz. It is possible that this difference arose from the different forms of data collection, where the questionnaire respondents were asked to analyse their own errors, whereas the interviewees’ errors were analysed via the diagnostic quiz. This was a surprising finding as it is difficult to understand why those with verified IELTS scores of 7 and above would assess themselves more harshly than the standards evidenced by those who had not yet reached their target of 7 in IELTS. Another possibility may be that the harsh self-assessment of the questionnaire respondents reflects the on-going challenges that they have faced post-IELTS.
The impact of life histories, educational experiences and other influences was evident throughout the interviews. Many of the interviewees felt that they had experienced some challenges in using English in social situations. Many of them based their decision to come to the UK after displacement on their English language skills but some struggled with using the language as it is spoken in the UK, particularly informal usage. Half of them described some degree of culture shock upon arrival and this manifested itself in different ways. Most of the participants felt that they needed a greater degree of contact with native speakers in order to improve their language skills further. Many felt that their early English language lessons were not adequate, but all of the interviewees felt motivated to continue attempting to meet the linguistic requirements of the GMC, with one participant describing her experience in trying to pass the test as being ‘like a tree with weak roots that is expected to repeatedly produce fruit’.
The data indicated that the number of errors that are attributable to common errors in IELTS at level 7.0 and above was slightly higher than the number of common errors between the first and the target languages for each of the language groups that made up the participant group. The data revealed that none of the participants, in either the questionnaire or the interviews, felt that the causal factors in Han’s (2004) ‘Neuro-biological’ or ‘Socio-affective’ domains were responsible for their language problems. This can be seen in Figure 3 below, which details the sources for the three top SLEs for three of the interviewees. This came as a surprise because, in my position as an IELTS trainer working with refugee doctors, many had divulged problems with experiencing depression and the side-effects of the associated medication. It is also significant that according to Han (2004), ‘Socio-affective’ factors make up the vast majority of reasons for the cessation of learning a language. However, there were a number of statements made after the mapping exercise stage in the interviews which alluded to these domains.
Hexagon mapping exercise for Dr Bader, Dr Cadi and Dr Irene.
All participants felt that ‘Knowledge Representation’ and ‘Knowledge Processing’ were the main difficulties. However, the questionnaire respondents ranked these two problem areas slightly differently to the interviewees, who selected ‘Knowledge Representation’ as the main problem, followed by ‘Knowledge Processing’.
With regard to the types of linguistic problems that this specific group of learners experienced, there was little that could not be explained by the challenges that confront all learners in terms of interlanguage or the inherent complexity of the English language at the early stages of proficiency or ‘C1’ or above in the Common European Framework, as described in Moore (2011). It is also unsurprising that the participants identified input and intake (‘Knowledge Representation’ and ‘Knowledge Processing’) as the most fundamental factors; these are the steps which every language learner needs to go through in order to achieve their desired level of proficiency. The other factors: ‘Environmental’; ‘Psychological’; ‘Neuro-biological’; and ‘Socio-affective’ were also discussed by the DMHPs but there was a discrepancy between their perceptions and the data gathered from Phase Two. In particular, elements of the ‘Psychological’ and ‘Socio-affective’ domains arose.
The findings from Phase Two indicated that upon deeper investigation, the interviewees confirmed that there were some socio-affective barriers that inhibited their progress. These were chiefly connected to the impact of displacement, looking after their families and attempting to retrieve the status that they had lost at the time of displacement. As well as corroborating the work of Norton (2000), these challenges were also recognized by the expert witnesses, who agreed that greater support for DMHPs was needed. Both participant groups in Phase Two also agreed that, while IELTS was not a perfect fit for the purposes of the GMC, it was the best available option at that time and a necessary step towards requalification in the UK. Understandably, this situation was sometimes met with a negative attitude from those who were facing the challenge of the IELTS test, but they remained motivated to succeed. It is in response to observations such as this that the OET Medical has now replaced the IELTS test and it is hoped that the requirements of the GMC are better met, with the test-takers exhibiting less negativity towards their assessments.
The focus group confirmed that they felt that they did not face problems categorized under the ‘Neuro-biological’ domain, apart from some members mentioning depression in a general sense. They also exhibited a positive attitude to overcoming this and using these difficulties as motivating factors. The expert witnesses did not agree on other ‘Neuro-biological’ factors such as the impact of ageing. The expert witnesses said that recognition of the barriers that DMHPs faced was important and could be supported through further research. They also felt that the refugee doctors needed to recognize their personal barriers to learning English and integrating into UK culture: both medical and social. They made the further point that, with greater flexibility in their learning styles and acknowledgement of the challenges that they face, DMHPs stood a greater chance of success.
One such barrier is deprofessionalization, or as Smyth & Kum (2010) put it, ‘a loss of professional status’, which is a major barrier for other professionals who are having to retrain due to displacement. This can arise from a sense of a loss of status, identity or even culture, leading to potential allegations of the use of these tests as being akin to modern Shibboleth tests (McNamara, 2005). These barriers are broadly categorized in Han’s (2004) taxonomy as a ‘change in the emotional state’, a ‘will to maintain identity’ and a ‘lack of acculturation’, respectively. The first may be considered a ‘Psychological’ barrier and the others fall within the ‘Socio-affective’ domain. In the case of DMHPs, these are potentially starkly different from the experiences of other language learners as their status as doctors can be very high in their home societies, and their desire to maintain their identities is likely to be stronger. Acculturation, in this case, can be the acclimatization from this status of high regard to the status of a refugee. As such, when considering the training of refugee doctors, these factors should be acknowledged with more prominence.
As previously mentioned, another problem is the contrast between the rigidity of medical training versus the flexibility that is required in successfully learning a language to a high degree of proficiency. Again, this is arguably featured in the ‘Psychological’ domain of Han’s (2004) taxonomy, as the ‘transfer of training’, but the life-preserving nature of medical training demands that doctors interpret situations according to very rigid guidelines and this rigidity is heavily encouraged in Primary Medical Qualifications. Similarly, the expert witnesses felt that there was an element of ‘Psychological’ inhibition inherent in the rigidity of training for medicine versus the flexibility needed for language learning, i.e. a ‘reluctance to take risks’, according to Han (2004). In this sense, we can again refer back to Smyth & Kum’s (2010) discussion on deprofessionalization, which in this context is ‘taken to mean the structures which act to remove individuals from their professional habitus’.
As such, an adaptation of Han’s models has been proposed for teachers, trainers and other stakeholders working with the linguistic training of DMHPs. While in Han’s original taxonomy, which covers all studies of learners, a ‘loss of status’ relates to ‘Socio-affective’ barriers and ‘rigidity versus flexibility’ relates to ‘Psychological’ barriers, the impact of these features can be seen to weigh differently on the subjects of this study. Accordingly, the specific model in Figure 4 has been created to acknowledge the impact and contributing factors of ‘deprofessionalization’.
A model of the additional barriers that confront DMHPs in learning languages.
This is a model for inclusion into needs analyses for training courses for DMHPs and can be used by language teachers working with DMHPs, course providers designing English for specific purposes (ESP) courses for refugee healthcare professionals, and authors designing ESP materials. Many teacher trainers will be aware of the barriers that confront learners, linguistically, socially and culturally; however it is important when dealing with such groups to consider the professional barriers that confront our learners too. Practitioners over the last 50 years will be very familiar with the benefits of student-centred learning and teaching, yet to cater to DMHPs, it is very important to consider their prior learning and specific socio-cultural backgrounds in the poststructuralist way that Norton (2000) describes, alongside the regular challenges that confront language learners. These considerations can reinforce an intercultural approach to teaching (Dervin and Liddicoat, 2013) and work towards empowerment of refugee professionals. In doing so, frustrations can be overcome, alongside misgivings and inhibitions being reduced, as we have seen in the recent changes to the form of assessment for overseas doctors hoping to join the GMC. Notwithstanding, wherever possible, these considerations should be made at the point of entry, rather than at the final stages of language learning (i.e. in exam training before assessment). In addressing the transition that DMHPs face, we can begin to develop intercultural communicative skills, for example the use of humour at conference presentations, to foster integration at a much earlier stage. If an ESP course design takes DMHPs’ status, professionalism and dignity into account, the course can not only prepare them for linguistic assessments, but can also account for their success in their workplace, being able to communicate with patients in a more natural way, understanding their patients’ non-medical terminology and potentially conducting beneficial research in their field.
The study itself was not without its limitations. The main limitation was the scale. The response rate to the questionnaires was slightly lower than expected, with 13 responses being reported in the data, and this meant that there were fewer participants overall. Had the number of respondents to the questionnaires been higher, themes identified and conclusions drawn from the data might have been more representative of the experiences of DMHPs who form the client base of the WARD group. Han’s (2004) six domains were chosen as a broad net to feature the widest survey of studies into the cessation of learning a language to date. However, Han’s list is not comprehensive in terms of the complexities of language assessments themselves and this could be an implication for future research. There may also have been a weakness in the study in having to summarize the causal factors under the six domains into a few exemplars and without jargon. In removing the details, it is possible that the subtlety of each of the causal factors was lost. The reason for the simplification was to remove overly technical terms and allow the participants to grasp the concepts of research into language training, as well as to encourage their responses to the questions that they were being asked without being caught up in the details.
While the focus group aimed to yield further results on the participants’ life and educational histories, as well as the effects of any ‘Neuro-biological’ factors and ‘Socio-affective’ factors, there were inevitably some discussions on ‘Environmental’, ‘Knowledge Representation’, ‘Knowledge Processing’ and ‘Psychological’ factors. Although this only served to add to the data collected in Phase One, it may have reduced the responses to Phase Two in the limited time that was available for the focus group session. This did not detract from the purpose of the focus group. In fact, the participants volunteered some substantive observations on their educational experiences, life histories and in particular, ‘Socio-affective’ factors, which were picked up in the analysis of Phase Two, therefore adding to the richness of the data collected.
VII Conclusions
The announcement from the GMC to accept the OET Medical has gone some way to removing the psychological barrier presented by the participants’ feelings of negativity towards the IELTS test. Anecdotally, teachers and DMHPs report that fewer people are complaining of a sense of deprofessionalization; however, this does not help those who are not ready for OET Medical studies and are learning English at less advanced levels. Ultimately DMHPs still need to study the English language before they can join the GMC. If they are not assessed at an acceptable level, they will need to continue to study English, but with a genre-specific lean towards medical English. This is a highly positive step towards reducing deprofessionalization for DMHPs. The main recommendation that can be made is that teachers of learners aiming towards a professional or occupational qualification try to thematize their materials based on the professionals in the group e.g. introducing genre-specific lexis or phraseology that directly applies to the specialisms of the learners in their group. In doing so, learner confidence would be built and deprofessionalization could be mitigated or avoided altogether.
Future research may be to conduct a similar project on a larger scale. The research design is methodologically straightforward enough for the project to be generalized across a broader sample base, provided that access to a broader sample would be possible. Another strand for future research would be to track, monitor and analyse results from test-takers from 2018 onwards to identify the impact of changing the assessment format from IELTS to the OET Medical. This in turn could link to pilots where DMHPs and other displaced professionals could be instructed using the above model from an earlier stage than exam preparation.
