Clinical case presentations: an overview of an exemplar medical speech event

Размещено на http://www.allbest.ru/

University of Miyazaki

Clinical case presentations: an overview of an exemplar medical speech event

Michael Guest

Miyazaki Pref., Japan

Abstract

Clinical case presentations are core medical speech events carried out in medical and teaching institutions worldwide among both students and active practitioners. While in most non-English speaking locales these events will usually be communicated in a local language they are also, on set occasions, often performed in English. In order to understand both how and why clinical case presentations are carried out in English in non- English speaking Asian locales, the author visited 8 medical universities and/or affiliated hospital s in 6 Asian countries, observing a total of 36 English clinical case presentations, followed by interviews with 25 different clinical practitioners, teachers, or medical students. The author then analyzed the collected speech event data in terms of Hymes' (1974) SPEAKING model, augmented by Swales' (1990) focus upon `moves' in genre analysis, and further informed by Bhatia's (1994) introduction of a socio-cognitive dimension to genre analysis, in order to develop a well-rounded descriptive synoptic model of how this speech event is both perceived and performed in non-English speaking English settings. It is hoped that these insights can be further applied to the development of English for Medical Purposes (EMP) materials or curricula and that this case may serve as an exemplar for other inquiries into professional, situated ESP speech events.

Key words: academic discourse, spoken discourse, genre analysis, clinical case presentations, English for medical purposes (EMP), non-native English speakers.

Аннотация

МОДЕЛИРОВАНИЕ КЛИНИЧЕСКОГО СЛУЧАЯ КАК РАЗНОВИДНОСТИ КОММУНИКАТИВНОЙ СИТУАЦИИ МЕДИЦИНСКОГО ДИСКУРСА

Майкл Гест

Университет Миядзаки, префектура Миазаки, Япония

В статье описывается коммуникативная модель одного из центральных жанров медицинского дискурса - разбора клинического случая, который широко используется как на консилиумах практикующих докторов, так и при обучении студентов-медиков. Опираясь на собственный опыт, автор отмечает, что в большинстве стран Азии и Дальнего Востока подобные обсуждения проходят не только на местном языке, но и на глобальном английском, что объясняется доминирующей ролью информирования на этом языке в медицинском дискурсе. Материалом исследования стали записи 36 разборов клинических случаев в 8 медицинских университетах с аффилированными госпиталями, сделанные автором статьи в 6 азиатских странах, а также 25 интервью с практикующими докторами, преподавателями и студентами-медиками, посвященные содержанию и структуре этого жанра. При воссоздании (моделировании) коммуникативно-дискурсивной составляющей жанра автор использовал SPEAKING модель Д. Хаймса с выделением стратегических ходов Дж. Суэлса и социокогнитивных особенностей коммуникативной ситуации, что позволило создать полимодусное описание жанра разбора клинического случая, выделить дискурсивные и лингвистические особенности его репрезентации на английском языке в сообществе профессионалов, для которых английский язык не является родным. В заключении автор отметил, что представленное описание моделирования жанра может быть использовано для разработки программ обучения студентов-медиков на английском языке (EMP) или для моделирования коммуникативных жанров иных профессиональных дискурсов.

Ключевые слова: академический дискурс, устный дискурс, жанровый анализ, обсуждение клинического случая, английский язык для медиков (EMP), английский как неродной язык.

Introduction and background

Clinical case presentations (hereafter CPs) are standardized, formalized, and situated core medical speech events. Such presentations, occasionally termed `Grand Rounds', are basically oral clinical case reports carried out between healthcare professionals, usually involving, but not limited to, doctors.

It is imperative at the outset to note that the term `speech' here does not imply simply reading a written case report aloud but rather that the choice of speech mode demands a great deal of emphasis upon editing and selectivity for prioritization, emphasis, and significance. While a written case report is invariably comprehensive and allows the reader to search out those particular items considered to be of greatest importance, CPs, being multimodal, demand selectivity of content such that a narrative flow is created for the listener/viewer, thereby allowing fellow clinicians the greatest opportunity to comprehend the clinical data in a concise, accurate, fashion.

CPs should also not be thought of as being functionally equivalent to oral conference presentations, even though the two may share some extant features (such as when exemplar clinical cases are utilized within a conference presentation), but rather serve primarily as means of in-house or interdepartmental education or edification among in-service practitioners. Such sessions are normative within the medical profession worldwide. Every institution in South-East Asia included in this study that the author contacted regarding requests for observations or interviews regularly conducted CPs, not only in the local language but also, at least to a certain degree, English.

In most cases, CPs will be carried out in the native tongue of the participants, although many institutions located outside the Anglosphere also use CPs as an opportunity to enhance their English skills (and, in some locales, require it). This is a fairly widespread practice given that most medical research worldwide is conducted in English, that most medical professionals will have some degree of English proficiency, and because a large amount of English medical discourse has already built into the speakers' L1 in the form of specialist medical terminology, often to the extent that standard medical speech encounters between non-native English speaking practitioners invariably involves a certain amount of linguistic code-switching.

By analyzing the characteristics of CPs, it is believed that light can be shed on important interactive speech features used by the medical / academic discourse community, as well as pertinent clinical functions, since such genre analysis represents a starting point for describing how texts are organized [Dudley-Evans, 1993]. As language teachers, knowledge of these forms and features will also allow us to further enable our ESP / EMP learners to participate in the international medical discourse community, particularly in the field of collaborative research, with confidence and skill since genre analysis is directly relevant to the classroom due to the importance of understanding rhetorical text structures [Hyland, 1992]. Or, as Boswood and Marriot state, “Through close engagement with the contexts of communication, ESP practitioners can further develop their ability to contribute positively and directly to the development of their students' abilities and to the development of their client communities” [Boswood, Marriot, 1994, p. 3]. DudleyEvans likewise emphasizes the pedagogical applicability of genre analysis, noting that it provides, “...a flexible prescription based on analysis that makes suggestions about the layout, ordering and language appropriate to a particular writing or speaking task” [Dudley-Evans, 1987, p. 28].

For readers who operate outside the scope of teaching medical English, I believe that this inquiry into a single speech event within a single genre / domain may also serve as an example that can be applied to those engaged in other academic / professional ESP domains, particularly standardized / formalized speech events carried out between members of any specific discourse community, particularly in light of Bhatia's descriptions of intertextuality (textual devices used beyond the domain of a single academic / professional discipline) in carrying out genre analyses of academic / professional discourses [Bhatia, 1994]. The use of Hymes' SPEAKING model [Hymes, 1974] to frame the structure of CPs also allows for Bhatia's notion of `interdiscursivity' [Bhatia, 1993] (text-external features of genre analysis) to be utilized - as it is the surrounding spoken text environment that determines much of a spoken text's internal structure.

In the present study, the author aimed to answer two core inquiries: 1) for what purposes do healthcare professionals (HPs) in non-English speaking environments carry out English CPs and 2) in what way or ways are these managed by the participants? These core inquiries further hint at several secondary questions: Is there a set form or structure to CPs that is applied in all or nearly cases? Where variation exists, what are the factors that affect variation and how are these variations most commonly manifested? To what extent and in what manner do non-native speakers of English manage these speech events differently than those who might be classified as `native or native-like'? The present inquiry builds upon and updates the author's previous research into the structure of clinical case presentations [Guest, 2017] through the application of an established framework (Hymes' SPEAKING model) that allows more a more thorough analyses of the genre. It is hoped that the resulting data and observations arising from this extended inquiry may hereafter serve as templates as well as hinting of good pedagogical practices for others teaching or learning English within healthcare professions.

Literature Survey

Hymes' SPEAKING model (1974) has been long established as a framework for the discourse analysis of speech events. The acronym covers the following speech categories:

S- Setting and scene (physical environment and circumstances of speech event)

P- Participants (also including the field or domain of discourse)

E- Ends (purpose or goal of speech event)

A- Acts (order/structure of speech acts or `moves ')

K- Key (tone/tenor of speech)

I- Instrumentalities (mode or modes of speech, including language, dialect, and register)

N- Norms (social rules of, or constraints on, interaction)

G- Genre (type of speech event)

Most of these categories have since been expanded in scope by researchers and commentators to contain further sub-categories, however, for our immediate purposes, it is not necessary to list these. Readers familiar with either discourse or genre analysis may also recognize that, over time, some of these categories have been expanded by subsequent researchers under slightly different nomenclature and/or that some boundaries between categories have become blurred.

It should be noted at the outset that the purpose of the SPEAKING model is not to establish a step-by-step methodology into discourse inquiry but rather to serve as general guidelines in terms of separating discourse categories and/or considerations as a basis for research inquiry into the analysis of speech events. As such, while the Hymes model informed the author's inquiry, particularly in terms of grounding those features crucial to understanding the form and content of specific clinical speech events such as CPs, the author's study was not absolutely beholden to every category during every CP observation.

The most well-known extensions of similar inquiries into spoken discourse, particularly in terms of application to our present study, are those of Swales' genre analysis [Swales, 1990], particular the analysis of rhetorical `moves', and Bhatia's (1994) inclusion of socio-cognitive features into the realm of genre analysis (using the term `interdiscursivity'). These approaches also both served as discourse framing and interpretative sources for the author both before carrying out CP observations as well as in the post-observation analysis of the data. These were not applied in the present study as `scientific' models per se but rather as qualitative means of describing the categories of Acts and Norms respectively.

What role does genre analysis play in applying Hymes' SPEAKING model to a particular speech event? Swales emphasized the role that genre analysis plays in establishing `.. .the importance of structuring and ordering' and the `correlations between cognitive, rhetorical, and linguistic features'. This occurs, he says, because genre allows language to be `...sufficiently conventionalised' allowing one to `...establish pedagogically-employable generalisations that may will capture useful relationships between function and form' [Swales, 1988, p. 212-213]. In other words, in order to understand discourse, one must first understand the context in which the discourse arises [Van Dijk, 1997].

Genre analysis helps to identify communicative purposes and ties these purposes to particular forms or structures. Naturally, this demands that the scope of analysis extends not only beyond the sentential level and supra- sentential levels [Winter, 1977] but also into the meta-textual and macro-structural levels of analysis [Bhatia, 2002; Bhatia V.K., Bhatia A., 2007; Hoey, 1983]. Fairclough describes such discourse as being three-pronged: including the text, the related discursive practice, and the social practice [Fairclough, 1992]. A such, Bhatia (2004) considers them to be cognitive, as opposed to a merely linguistic, structures. Such analyses, including the present study, therefore require interpretation beyond the merely descriptive levels. This would include then, as Bhatia has argued, explanations of the socio-cultural, organisational, and institutionalised or conventionalised constraints and expectations that govern specialized discourse genres, representing broader socio-cognitive factors in that, “...language use in a conventionalised setting, in order to give expression to a specific set of communicative goals of a disciplinary or social institution, which gives rise to stable structural forms by imposing constraints on the use of lexico-grammatical as well as discursive resources” [Bhatia, 1993, p. 23].

It should be noted, however, that this should not imply that genres are static, but simply, “...recognised and sufficiently standardised” [Bhatia, 1993, p. 29] in a manner that most members of the speech community share. Bhatia (2002) later argues that these text-external, extra-linguistic factors also introduce the increased possibility of genre innovation and exploitation, or, as Hart earlier put it, “Genre analysis is pattern seeking rather than pattern imposing” [Hart, 1986, p. 280].

Such structures are conventionalised in `speech communities' (or `discourse communities') which share rules for the conduct of speech, allowable patterns of usage, or the appropriacy of utterances [Hymes, 1974]. At professional levels, this includes displaying discourse expertise in terms of the use of a particular lexis, established notions of relevant content, an agreed set of common or public goals, and mechanisms of intercommunication among members, Swales states that, “...exemplars of a genre exhibit various patterns of similarity in terms of structure, style, content and intended audience” and that, “the exemplar will be viewed as prototypical by the parent discourse community” [Swales, 1990, p. 58].

That genres are not dynamic rhetorical structures and therefore allow for manipulation by members, as a form of `social cognition', has been further pointed out by Berkenkotter and Huckin [Berkenkotter, Huckin, 1995]. And while the implication is that conventional constraints will be placed upon `allowable' contributions, these constraints can be, “...exploited by expert members of the community to achieve private intentions within the framework of socially recognised purpose” [Bhatia, 1993, p. 13].

Before beginning our analysis, it is also worth noting that Hymes (1974) distinguishes between `genres' and `speech events', even though their characteristics often coincide, with `genre' being the broader term whose properties may be applied beyond a single speech event (although Saville-Troike (1982) significantly equates genre with `communicative events'). Couture (1986) makes a further important distinction between genre and register, noting that the former operates at the syntactic / lexical level, whereas the latter operates at the level of discourse. This dichotomy, too, has been incorporated into the author's description.

Research background and methods

For the purpose of gathering authentic data on the management and performance of CPs, the author visited 8 clinical institutions (hospitals and/ or medical faculties at universities) in 6 different Asian countries in which English is not used as an official or colonial language nor as a standard language of tertiary instruction. These included: Japan (University of Miyazaki), Vietnam (Can Tho University and Hong Bang International University), Indonesia (Brawijaya University), Myanmar (Yangon Medical University), Taiwan (Cheng Kung University), and Thailand (Thammasat University and Chiang Mai University). These research visit purposes were twofold: to observe actual English CPs and note their generic features and to interview local HPs regarding the role and function of English CPs at the institution, or more widely, across the respective countries.

In total, 36 CPs were observed, connected to 10 different clinical departments: Obstetrics- Gynecology, Surgery, Pediatrics, Family Medicine, Community Medicine, Anesthesiology, Respiratory, Endocrinology, Nursing, and Ophthalmology. During these observations, the investigator / author took case notes based on a self-developed checklist outlining the following features (Fig. 1).

Not all categories listed in Figure 1 below were filled in upon each observation as not all items were addressed in every CP, in which case they were marked n/a. Only 3 of the CPs were recorded due to difficulty in gaining recording consent. In 5 of the observations I was presented with the local standardized English written document used by the speakers in order to formulate the CP.

Fig 1. Author's Checklist for Investigation of Case Presentation Structure

Follow-up interviews were conducted with full consent of the presenters and/or departmental representatives. These interviews (6 were recorded, the rest notated by hand) generally followed a pattern involving the following preestablished questions (Fig. 2 and 3).

The above line of inquiry was far less concerned with quantifying particular incidences of speech forms or interview responses than it was with spotting developing or significant qualitative trends, which might have more immediate application to understanding the deeper structure and/or the socio-cultural environment of the CP speech event, as well as related ESP/EMP teaching pedagogy. The next section outlines and discusses some of the most compelling features that these observations and interviews unearthed.

Findings and discussion

The clinical categories that serve as a synopsis for the majority of CPs, based on the author's observations and interviews, typically included the categories listed below in Figure 3 (updated and revised from [Guest, 2017]). These were the items most regularly noted in performance and, on four occasions corresponded to the particular institution's written worksheets / check sheet used to augment the oral presentation.

Precise nomenclature might vary slightly from setting to setting but, generally speaking, these constituted the core categories used in most CPs, with the presentation of each item within a CP marking a specific generic `move'.

However, CPs involving a deviation from a standard / synoptic CP form drew particular attention. In practice, many of these moves were circumvented, omitted, or relegated to the speech event periphery. Many of the most significant variations on this canonical form and speculation on the reasons underlying them, which constitutes a central component of the inquiry, are discussed in the Acts section below.

Using Hymes' SPEAKING acronym (with Genre here occupying the primary position due to its fundamental relevance) as a baseline parameter, a synoptic outline of the CP speech event, based upon observations made in this study, are as follows: genre, setting and scene, participants, ends, acts, keys, instrumentalities, norms.

Genre - Clinical case oral presentations.

Setting and scene - 1) Departmental conference rooms at hospitals or medical universities. 2) Standard university classroom settings, both lecture and seminar / tutorial style.

1. Do you perform clinical case presentations in English or in your indigenous / local language? If both, what are the percentages?

2. In what situations do doctors carry out English case presentations at your medical / educational institution as opposed to using the local / mother tongue?

3. What elements are typically included in a case presentation?

4. Is there any formal style or template used for doing case presentations?

5. At what points do students usually learn how to do case presentations, mother tongue and/or English?

6. How are these taught and/or practiced?

7. What aspects of my (attached) model are you familiar or unfamiliar with?

8. Do you have any wish or need to upgrade education in this particular area? If so, what or how?

Fig 2. Author's Interview Questions

• ID (basic patient data)

• Chief Complaint (CC)

• History of Present Illness (HPI): primary and associated symptoms

• Physical Examinations (including palpation; visible manifestations; vital signs; Review of Systems / RoS: e.g. Cardio-Vascular, Respiratory, Central Nervous etc.; HEENT: Head Eyes Ears Nose Throat)

• Current medications / allergies / ongoing treatments /complications

• Past Medical History (PMH / PMx): including surgeries, hospitalizations, underlying conditions, injuries / trauma, treatments / therapies

• Family History (Sx)

• Social History (Sx)

• Investigations (lab tests / imaging / biopsy etc.)

• Summary (e.g., problem list / pertinent findings)

• Post-admission developments

• Initial/Provisional / Differential diagnoses (Dx)

• Assessment and treatment / therapy / management plan

• Follow-up / Outcomes / Operational findings

• Treatment successes / failures / adherence

Fig 3. Synopsis of Clinical Case Presentation Categories or `Moves'

3) During student clerkship rounds in the hospital patient wards.

CPs were most often performed as departmental sessions in small meeting or study rooms within the hospital, usually in the early morning. Presenters tended to be younger doctors or residents, often those who had recently experienced an `interesting case' or were actively carrying out research. In some institutions, CPs were performed daily, in others only once every week or two weeks. Bedside teaching sessions were held in the wards with small groups of uppergrade students and an instructor. These were carried out in a much more impromptu fashion than the formalized intra-departmental CDs. Standard teaching seminar rooms within the attached university constituted the third setting, that of interactive discussion CPs. student medical speech english

The CPs observed in the present study did not fall into a single consistent structure. Rather, the extant purpose of the particular presentation determined both the form and structure of the speech event. Some presentations attended were peer-to-peer `interesting case' presentations, meant largely to edify and inform peers (particularly residents). Some were evaluative, with senior clinicians present who subsequently critiqued and further advised presenters regarding the presentation contents. Some were bedside teaching sessions held between a clinician and upper-grade medical students, the latter of whom were carrying out case presentations as a part of their rounds in clinical clerkship sessions. Some were actual scheduled teaching classroom scenarios with medical students who had been assigned teacher-chosen case data to report upon in a standard classroom. In four observed CPs, the presentation revolved around the discussion of published research external to the hospital / university. In these sessions, the presenter focused upon recent English research papers for discussion and exposition but with particular emphasis upon the exemplar case(s) that had been presented as evidence in the research paper.

In 12 cases, CPs were performed individually, in 14 cases as pairs / trios, and in 10 cases as fully interactive sessions between a leader (preceptor) and a small number of participants (preceptees).

The speech functions of the CPs ranged from monologues, to elicited dialogues, to team evaluative responses, and group discussion. These factors also drastically affected both the content, order, and structure of the case reports (which further negatively impacted the author's intention to note and classify features and speech moves according to pre-established categories.)

The majority (26) of presenters provided multimodal presentation resources (PowerPoint, lab results, imaging samples, textbook data, online websites, medical documents) to augment their presentations while others, typically those of the interactive discussion type, referred primarily to PowerPoint slides and/or printed data sheets (generally provided to participants in advance). In short, the roles and functions of CPs within university hospitals appear to be multi-faceted.

Once-per-month required English CPs for each department were standard at Thailand's Thammasat University Hospital and Cheng Kung University Hospital in Taiwan. Brawijaya University (Indonesia) and Hanoi Medical University (Vietnam) required that doctors perform all CPs in English, although this standard was not always strictly met. Based on interviews, it appears that the balance between English and L1 CPs ranged from 10-90%, with the average being approximately 40% delivered in English.

Some institutions required presenters to adhere to an established clinical format based on `global standards'. Such clinical case presentation formats include all the synoptic categories described earlier but are subsumed under an established discourse superstructure such that the presentation of the data does not necessarily follow the order of the synopsis. Five institutions followed the SOAP format (Subjective Observation Assessment Plan) closely. The SNAPPS presentation model (Summarize, Narrow, Analyze, Probe, Plan, Select) was employed at two of the facilities I visited. Eight CPs followed a locally established format, whereas most others allowed for formal flexibility as determined by the clinician depending upon the type of case. These invariably followed the synoptic form.