Language Assessment in Medical Contexts

A Language Testing Scenario for Group or Individual Study
Prof. Glenn Fulcher

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Language Assessment for Medical and Health Care

There has long been evidence that a failure to communicate between medical staff, emergency services personnel and patients, can lead to the provision of inappropriate or even harmful treatments. Flores et al. (2003) and Flores (2005) summarize some of the research in this area. There are two separate contexts of interest in the current debate. First is the need to ensure that medical or emergency staff who do not speak the primary language of the country in which they are seeking to work have adequate command of that language to function safely. Second is the concern to provide patients who do not speak the language used by the health services with interpretation facilities. We will look at the first context, and then go on to consider medical interpretation.

Most medical language testing concerns English. Whenever misdiagnosis, mistreatment, or even fatalaties occur there is an outry. This Newspaper Report that blames a death on both language and clinical skills is not untypical. There are also reports like this one that suggest large numbers of other medical staff do not have the language skills to operate safely in hosopitals, which lead to calls for compulsory language classes and assessment.

One language test that has been specifically designed for medical staff is the Occupational English Test, the development of which you can read about in McNamara (1996). This test follows the primary principle of language testing, namely that of specifying test purpose, so that validity evidence may be collected to show that the test provides information upon which sound inferences regarding likely performance may be made. Or as Bachman (1990) puts it: "The single most important consideration in both the development of language tests and the interpretation of their results is the purpose or purposes the particular tests are intended to serve." The specific purpose of assessing medical English has therefore driven validation research (eg., McNamara, 1997; McNamara & Lumley, 1997). While this test is used in Australia, in the United Kingdom the General Medical Council uses IELTS, which was not designed specifically as a test of medical English. The only validation evidence of which I am aware comes from a standard-setting exercise for nurses (O'Neill et al, 2007), which does not in and of itself constitute strong evidence of usefulness for purpose. Whenever there are calls for medical staff to be assessed using tests like IELTS (as in this story) we have to ask whether scores derived from general work or academic language tests are likely to provide evidence about whether a medic is (for example) able to discuss medical cases with colleagues, write patient reports, explain diagnoses, or discuss courses of treatment with patients. This raises the whole question of the need to design tests that are specific to the high stakes purposes for which they are being used, and the potential negative consequences of using tests developed for one purpose being "retrofitted" to another (Fulcher and Davidson, 2009). It is clear that if we are not to see stories like this in the future, it is essential for the profession to develop tests for which their is clear validation evidence for their intended use.

Now let's take a look at the second context, in which a patient does not know the primary language of the health service providers. This short video clip illustrates the problem very clearly. The patient cannot communicate with the hospital staff, and we are presented with two scenarios. In the successful scenario the hospital has access to a medical interpreter who speaks the patient's first language. In this case a test would need to provide evidence that they could communicate accurately between the their L1 and English.

There are a number of medical interpretation tests available on the market, including this one, which has a YouTube Video explaining the component sub-tests that make up the instrument, and its intended uses. However, most of these tests have been developed for use in the United States, and many countries around the wrold do not provide any kind of interpreter services. Why is this the case?

This short video explains the legal and ethical framework within which the provision of medical interpretation takes place, and which requires the ability to interpret in medical settings to be tested and certified. Under Title VI of the 1964 Civil Rights Act it is illegal to "...exclude from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance" on the grounds of national origin, and hence the language you speak.

Notice the focus on the legal requirement to provide "meaningful access" to services, which includes language interpretation in health care settings. It also recognizes that cost is a factor in service provision.

One way to deal with cost issues is to have centers of qualified medical interpreters who can be virtually present in any hospital location. This video, from, demonstrates a technical solution to the provision of medical language services from the Language Access Network. As you watch the video notice the emphasis placed on ensuring the accurate transfer of information between patient and health professionals, which includes not only the exercise of linguistic skills, but of interpreting facial expressions and body language.

Language testing for medical staff coming from other countries and for medical interpreters is a high-stakes context, in which it is essential to make judgments about readiness for practice that are highly predictive of likely on-the-job performance.

For Discussion

  1. The provision and testing of medical interpreters is not universal. If you are working in a multinational group, which countries represented do and do not make such provision? Is there a problem in countries that do not (for example, when tourists who do not speak the language are taken ill)?
  2. Make a list of problems that might occur if a patient cannot communicate with emergency or medical staff (a) on first contact, and (b) during treatment.
  3. If you were asked to design a language test for doctors wishing to work in a second language, what constructs would you test, and what task types might you include on your test?
  4. If you were asked to design a language test for medical interpreters, what constructs would you test, and what task types might you include on your test? You may wish to look at the MITI Medical Interpretation Test Video before you do this activity.
  5. Look at the links on the right side of this web page. Choose one that looks interesting to you. What issues does it raise for the language training and testing of medical staff or medical interpreters?
  6. Search for language tests that claim to be useful for making decisions about ability to communicate in medical settings, such as the IELTS. Look at the sample materials online. From a content perspective, do you think the tests are likely to be content relevant to this particular domain?
  7. Open your favourite search engine and type in 'medical English courses'. Select one or two. Who is the course targetted at? Do you think it would meet their needs? If the learners are assessed, how are they assessed?

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Useful Links and Resources


Researching Medical Communication

Conversation analysis and discourse analysis has been used extensively to study communication in a medical setting, often with the intention of improving medical communication education as well as test design. Here are additional references that may help with getting started in analysing medical discourse. There are many more articles and books available, so you should conduct a search on relevant keywords.