Chinese language difficulties encountered by doctors in their clinical practices in Hong Kong 11 - double spaced, accepted all changes, TOC done, for submission

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1 Title Need analysis for a Chinese-language course for medical students at the University of Hong Kong Author(s) Chan, Lap-ki.; 陳立基. Citation Chan, L. [ 陳立基 ]. (2012). Need analysis for a Chinese-language course for medical students at the University of Hong Kong. (Thesis). University of Hong Kong, Pokfulam, Hong Kong SAR. Retrieved from Issued Date 2012 URL Rights The author retains all proprietary rights, (such as patent rights) and the right to use in future works.

2 Need analysis for a Chinese-language course for medical students at The University of Hong Kong Name of Student: Lap Ki Chan University Number: Specialism: Generalist Name of Supervisor: Professor Tse SK Submitted for Master of Education (Med) The University of Hong Kong Faculty of Education 1

3 Table of Content Page Abstract 4 I. Introduction 6 I. 1. What happens when doctors are trained in English but communicate with patients in 6 another language? I.2. Increasingly more universities in non-english-speaking regions are training their doctors in English I.3. The medium of instruction in medical education is different from the language of medical practice I.4. Final-year HKU medical students have a low level of Chinese medical vocabulary 8 I.5. The increased need for Chinese language competency 9 I.6. Aspects of Chinese language usage in clinical practice 9 II. Materials 10 III. Research Method 11 IV. Results and Discussion 12 IV.1. Problems in Reading 12 IV.1.1. Problems in recognizing Chinese characters 12 IV Hand-written characters 12 IV Simplified Chinese characters 13 IV.1.2. Problems in understanding the meanings of Chinese text 13 IV Chinese medical terms 14 IV Variants of Chinese medical terms 15 IV Abbreviated Chinese medical terms 15 IV Chinese academic discourses 16 IV.2. Problems in Listening 17 IV.2.1. Problems in recognizing the spoken Chinese words 17 IV.2.2. Problems in understanding the meanings of the Chinese words 18 IV Chinese medical terms 18 IV Variants of Chinese medical terms 19 IV Ambiguous meanings of Chinese terms 20 IV.3. Problems in Writing 20 IV.3.1. No perceived need to write professional documents in Chinese

4 IV.3.2. Lack of confidence in writing Chinese medical terms 22 IV.4. Problems in Speaking 22 IV.4.1. Mandarin 23 IV.4.2. Cantonese 24 IV.5. Strategies adopted by the subjects in dealing with Chinese language difficulties 25 IV.5.1. Strategies in Reading 26 IV Strategies for solving problems in recognizing Chinese characters 26 IV Strategies for solving problems in understanding the meanings of Chinese 26 text IV.5.2. Strategies in Listening 30 IV Strategies for solving problems in recognizing the spoken Chinese words 30 IV Strategies for solving problems in understanding the meanings of the 31 Chinese words IV.5.3. Strategies in Writing 31 IV.5.4. Strategies in Speaking 32 IV Strategies for problems in speaking Mandarin 32 IV Strategies for problems in speaking Cantonese 33 IV.6. Subjects view on the significance of Chinese medical vocabulary in their practice 36 IV.6.1. The perceived need to know Chinese medical terms 36 IV.6.2. Perceived reasons for using Chinese medical terms 37 V. Conclusion 41 Cited References 43 3

5 Abstract Many non-english-speaking countries and regions are establishing medical programmes using English as the sole medium of instruction, with the aim of producing global leaders who can function without communicative barriers. However, graduates from these programmes still have to use the local, non-english language to communicate with their local patients. The aim of this study is to examine whether these graduates experience any difficulty in communicating with their patients in the local language. We looked at the medical graduates of The University of Hong Kong as a specific example. The results of the study can be used for designing a local language course in these programmes. Graduates from the MBBS program of The University of Hong Kong were invited to take part, using selective, convenience and snowball sampling methods. Nineteen subjects voluntarily took part. Semi-structured interviews were individually conducted, and were based on a framework of questions in the four areas of Chinese language usage: reading, listening, writing, and speaking. All subjects indicated a certain degree of difficulty in using Chinese language in their clinical practice. In reading professional medical documents in Chinese, they had problems in recognizing the hand-written and the simplified Chinese characters. They also had difficulty in understanding the meanings of the words, in particular the Chinese medical terms, their variants, their abbreviations, and in following the complex Chinese academic discourses. In listening, they had difficulties in understanding Mandarin, especially those subjects who graduated more than 14 years ago and had little exposure to Mandarin during their school education. Even if they were able to recognize the spoken words, they may still have difficulties in understanding their meaning, just as they did in reading. In writing, the subjects did not perceive much difficulty, mainly because they could avoid writing professional medical documents in Chinese. In speaking, the subjects had difficulty with Mandarin. But the subjects did not complain of difficulties in speaking to their patients in Cantonese, despite their poor Chinese medical vocabulary, mainly because they developed strategies to avoid 4

6 using Chinese medical terms, including giving the English terms instead, using a more general term, and or giving a description or explanation instead of the name. These strategies of complete omission, code switching, generalization, circumlocution are commonly used by learners of a second language when they experience lexical difficulties. They may jeopardize doctor-patient communication. Many subjects recognized the importance of having a good level of Chinese medical vocabulary. They also think that the use of Chinese medical terms, under appropriate conditions, allowed patients to have a more accurate and concrete picture of their conditions. The present study has identified Mandarin and Chinese medical vocabulary as the areas in which medical graduates from the HKU medical programme are particularly deficient. With the increasing emphasis on Mandarin in primary and secondary schools, new graduates from the programme can become more competent. But Chinese medical vocabulary remains a problem, and should be considered in the planning of a Chinese language course for the medical students at HKU. The results may also inform medical programmes in other non-english speaking countries and regions which use English as the sole medium of instruction. Training in the local language is important when English is used as the sole medium of instruction. 5

7 I. Introduction I. 1. What happens when doctors are trained in English but communicate with patients in another language? Effective communication is an important determinant of the quality of health care. It correlates with patient satisfaction, compliance, and even patient outcomes (Sherbourne et al., 1992; Ong et al., 1995). Although non-verbal behaviours also serve critical parallel communication roles (Fielding, 1995), language is still the main component of communication, especially for the transmission of specific information in clinical discourses. There have been numerous studies on language barriers in doctor-patient communication, but most of these studies focused on limited English competency in doctors and patients in Englishspeaking countries. For example, it has been shown that patients with limited English did not receive the same level of healthcare when compared to those with a good level of English competence (Cheng et al., 2007; Saha and Fernandez, 2007; Schenker et al., 2007). Doctors who had received their medical education in non-english-speaking countries but had emigrated to English-speaking ones were also shown to have low English competence in communicating with their Englishspeaking patients, in Australia (Chur-Hansen et al., 2007), the United States (Whelan et al., 2001), and Canada (Rothman and Cusimano, 2001). Chan (2012) pointed out that language barriers can also occur when doctors are trained using English but needed to communicate with their patients in another, non-english language, a situation that is the reverse of what was most often studied and reported in the literature. And this adoption of English as the sole medium of instruction appears to be on the rise in non-english-speaking countries. 6

8 I.2. Increasingly more universities in non-english-speaking regions are training their doctors in English Many non-english speaking countries and regions are rushing to establish world-class universities through various programmes, such as in the Brain Korea 21 project in Korea (Altbach, 2000; Kim and Nam, 2007), the 211 and 985 projects in China (Ma, 2007), and the Universities with Potential for Excellence programme in India (Jayaram, 2007). One of the aims of these programmes is to train world class leaders who can communicate with people from other parts of the world without communicative barriers. These programmes naturally put a lot of emphasis on English as the international auxiliary language. For similar reasons, there are more and more medical programmes in non-english-speaking countries and regions which have adopted English as the sole medium of instruction, such as China, Hong Kong, Taiwan, Malaysia, the Middle East, etc. One very important question that has not been addressed in the literature is whether the graduates from these medical programmes, most of which do not have English as their usual language, possess adequate competence in the local language to communicate with the patients in the local, non-english language. One such medical programme is the MBBS programme at The University of Hong Kong. I.3. The medium of instruction in medical education is different from the language of medical practice Almost all of the formal teaching and learning activities in the medical programme at The University of Hong Kong, which leads to the award of the degree of Bachelor of Medicine and Bachelor of Surgery (MBBS), are conducted in English. Therefore the programme includes English language training but not Chinese language training. However, when students in the programme need to take a history from a patient in Hong Kong, oftentimes they need to use Cantonese, since 90.8 percent of the population of Hong Kong consider 7

9 Cantonese as their usual language (with usual language being defined as the language currently spoken, or most often spoken, by the individual in his or her present home) (Department of Economic and Social Affairs, Statistics Division, United Nations, 1997). After these students graduate, the language they most commonly use with their patients is Cantonese. Therefore, graduates from the MBBS programme of The University of Hong Kong are educated in English, but communicate with their patients in Cantonese. This difference between the language for medical education (English) and the language for medical practice (Chinese) raises concern about the effectiveness and accuracy of the graduates communication with their patients, and eventually about the patient outcomes (Sherbourne et al., 1992; Ong et al., 1995). I.4. Final-year HKU medical students have a low level of Chinese medical vocabulary Of the different aspects of communicative competency (Hymes, 1971), lexical competency is crucial: without grammar very little can be conveyed; without vocabulary nothing can be conveyed (Wilkins, 1972:111). Therefore this study focuses on students lexical competency. To examine HKU medical students lexical competency in medical Chinese, Chan and Tse (2011) have conducted a pilot study on the final-year medical students at The University of Hong Kong. A notebook computer was used to show individual participants a PowerPoint presentation which contained fifty slides, each of which contained the image of a commonly encountered medical entity (i.e., an anatomical structure, disease or clinical procedure). Participants were asked to give both the English and Chinese names of the entities. An audio recording was made of their answers, which were then checked for accuracy. On average, the students were able to identify the entities in 81 percent of the slides by giving either a correct English or Chinese answer. Out of these slides, 99 percent were correctly named in English, but only 32 percent in Chinese. These results indicate that the level of Chinese medical vocabulary of final-year medical students at HKU is indeed very low. 8

10 I.5. The increased need for Chinese language competency The need for medical graduates in Hong Kong to have Chinese language competency is almost certainly increasing. Hong Kong is becoming a popular travel destination for mainland Chinese, who come here not only for sightseeing and shopping, but also for high quality medical care. For example, such a large number of expectant mothers from the Mainland have come to Hong Kong to give birth that the Hong Kong government has decided to limit their entry, and this is only part of the influx of patients from mainland China. Not only do Mainland patients come to Hong Kong for health-care, but locally trained medical doctors can now go to China to practice, due to the strengthening of trade and investment cooperation between mainland China and Hong Kong as signified by the signing of the Mainland and Hong Kong Closer Economic Partnership Arrangement (CEPA). This opportunity for Hong Kong to take part in the evolution of health care and the growth and transformation of the nation of China is truly invaluable. However, are the medical graduates of Hong Kong prepared for such an opportunity? One important problem is language. Putonghua is the official spoken language in mainland China and is used in most communication with patients. Moreover, medical records, medical reports, referral letters, prescriptions, and interprofessional communications with other health-care workers are mostly in Chinese. In Hong Kong, the almost exclusive use of English as the medium of instruction in medical education raises the concern that locally trained medical graduates may not have the competency in Chinese to communicate with mainland Chinese patients and health-care workers in mainland China. I.6. Aspects of Chinese language usage in clinical practice The aim of this study is to examine whether HKU graduates, after being trained almost exclusively in English, perceive any difficulties in the use of the Chinese language in their clinical practice. This information will be most valuable in developing Chinese-language courses that will 9

11 meet the actual needs of practicing graduates in their use of Chinese language. The course would help prepare our medical graduates for their clinical practice by enabling them to become effective communicators not only in English, but also in Chinese, the main language that they use in their clinical practice and in the increasingly frequent exchanges with mainland Chinese colleagues and patients. We classified the use of Chinese language in clinical settings into four areas: (1) Reading; (2) Listening; (3) Writing; (4) Speaking. II. Materials Graduates from the MBBS program of The University of Hong Kong were invited to take part, using selective, convenience and snowball sampling methods. The respondents were selected based on four criteria: (1) They have Cantonese as their usual language; (2) They have graduated from the MBBS programme of HKU; (3) They are engaged in active clinical practice in Hong Kong; (4) They work in any one of the following specialties: orthopedics, internal medicine, pediatrics, family medicine and primary care, and ear, nose and throat. Nineteen subjects voluntarily took part in the study, at different stages of their careers (length of practice from less than 1 year to 23 years) (Table 1). 10

12 Subject Sex Years of clinical practice in public or private sector Current Specialty 01 M 23 (19 in public, 4 in private) Ear, Nose & Throat 02 M 22 (public) Orthopedics 03 M 17 (public) Internal Medicine (Pulmonary) 04 M 23 (17 in public, 6 in private) Cardiology 05 M 1 (public) Internal Medicine 06 F 5 (public) Internal Medicine 07 F 5 (public) Internal Medicine 08 F 5 (public) Internal Medicine 09 M 4 (public) Orthopedics 10 M 1 (public) Orthopedics 11 M 4 (public) Orthopedics 12 F 6 (public) Pediatrics 13 F 1 (public) Pediatrics 14 F 4 (public) Pediatrics 15 F 1 (public) Pediatrics 16 M 6 (public) Pediatrics 17 M 12 (public) Family Medicine and Primary Care 18 F 8 (public) Family Medicine and Primary Care 19 M 16 (8 in public, 8 in private) Family Medicine and Primary Care Table 1: Background information about the participating subjects. III. Research Method Semi-structured interviews of a length ranging from 20 to 40 minutes were conducted with the subjects. The framework of the interview consisted of 24 questions which are centered around the difficulties that the graduates encountered in the use of Chinese language in their clinical practice, 11

13 including reading (e.g., professional documents written in Chinese such as discharge summaries, operative records, reports, etc), listening, writing (e.g., professional documents such as referral letters, reports, etc), and speaking. New questions were asked depending on the responses of the subjects. This freedom allowed the interviewer to tailor the questions to the context and situation of different subjects in order to explore in depth the subjects difficulties in the use of Chinese language in clinical practice. The interviews were recorded for transcription. Theme analysis was performed on the transcripts, using the qualitative research software Nvivo. IV. Results and Discussion IV.1. Problems in Reading Most of the subjects indicated that they needed to read professional documents written in Chinese in their clinical practice. The documents include: discharge summaries, medical reports, radiological reports, test results, prescriptions, referrals, operation records, research papers. The problems in reading these Chinese professional documents can be broadly divided into those concerning recognizing the Chinese characters, and those concerning understanding the meanings of these Chinese characters (after they have been recognized). IV.1.1. Problems in recognizing Chinese characters IV Hand-written characters Although many medical professional documents from mainland China are already printed, some are still handwritten. Many subjects reported problem in recognizing handwritten characters in these documents, mainly because of the cursive writing style. 嘅 type 嘅 啲 (Doctor03) 啲 啲 (Doctor06) 12

14 啲 (Doctor07) IV Simplified Chinese characters Most of the subjects also reported difficulties in recognizing the simplified Chinese characters that are used in the medical professional documents from mainland China, since most of them are familiar only with traditional Chinese characters. Therefore, in reading a handwritten document from mainland China, the subjects actually needed to overcome two obstacles (the handwritten characters and the simplified characters) in order to transform the characters into those that they can read. 嘅 啲 嘅 啲 (Doctor07) 啲 嘅 嘅 啲 (Doctor13) 啲 嘅 啲 (Doctor14) 啲 啲啲 啲 啲... term 啲 (Doctor17) 咗 medical terms (Doctor18) 啲 (Doctor19) IV.1.2. Problems in understanding the meanings of Chinese text Even if the subjects are able to recognize the Chinese characters in the professional documents from mainland China, there are four kinds of problems reported by the subjects that prevented them from understanding the meanings of the documents. 13

15 IV Chinese medical terms Since all the subjects graduates from the MBBS programme at The University of Hong Kong, English was their sole medium of instruction in their medical education. There were no Chinese courses. Therefore, they have very limited knowledge in Chinese medical terminology. One of the subjects admitted that although he is a specialist in respiratory medicine, he learned that meant infiltrative changes in the pneumonia only after repeatedly running in it. 嘅 啲 嘅 infiltrative changes in the pneumonia (Doctor03) 嘅 咗 嘅 嘅 啲 terms 嘅 啲 嘅 (Doctor19) Subjects in orthopedics indicated that they oftentimes do not know the Chinese names of the bones that they work on. course pelvic bone definition 嘅 (Doctor09) A locally trained cardiologist may not be able to understand the medical terms used in a Chinese report on percutaneous transluminal coronary angioplasty, leading to failure to understand the exact pathologies and procedures that have been done on the patient who is coming to him/her for followup care. 喺 啲 啲 嘅 喺 嘅 啲 (Doctor05) 14

16 Sometimes, even if the subject knew all the words that constituted the Chinese medical terms and could figure out the meaning of the terms, the subject still found these terms difficult and cumbersome. For example, one subject said s/he found it difficult to comprehend in talking about pulmonary lobes, while s/he has no problem with right lower, but and right lower are exact translations of each other and s/he can understand each of the words in. 嘅 terms terms 啲... 啲 right lower... 嘅 啲 (Doctor06) IV Variants of Chinese medical terms Because there is no one set of standardized Chinese medical terminology, the same medical entity may have different Chinese names in Hong Kong, Taiwan, and mainland China. Even if the doctors knew the Chinese medical terms that are commonly used in Hong Kong, they might not know the version used in mainland China for the same entity. For example, lesion is in Hong Kong, but in mainland China. 嘅 lesion 嘅 lesion 喺 嘅 嘅 lesion d translation 嘅 (Doctor03) 喺 嘅 (Doctor 07) IV Abbreviated Chinese medical terms Chinese medical terms are sometimes abbreviated by medical practitioners in mainland China in writing their professional documents. The complete Chinese name of chronic bronchitis is but its abbreviated Chinese name is. 15

17 啲 嘅 (Doctor11) The complete Chinese name of cephalosporin is but is abbreviated to. 啲 啲 嘅 啲 啲 terminology 啲 嘅 嘅... 嘅 嘅 cephalosporin cephalo sporin (Doctor03) IV Chinese academic discourses The subjects also reported difficulties in reading whole sentences and paragraphs in Chinese professional documents that they came into contact with. term 啲 啲 (Doctor04) 啲 啲 啲 啲 啲嘅 啲 (Doctor02) This problem is complex and may be due to the subjects lack of training in reading Chinese academic discourses and the ways that these discourses were written. Although all of the subjects have Cantonese as their usual language and can read Chinese, they are probably more used to the narrative genre (such as newspaper or novels) than to not the genres found in Chinese medical professional documents. In the subjects medical education, postgraduate training, and clinical practices, most of the academic discourses they come into contact with are in English (such as lecture notes, textbooks, instructions, assessments, research papers, hospital notes, referrals, discharge summaries, radiological and laboratory reports, medical reports, presentations in professional conferences, etc). There are few opportunities to read academic discourses written in Chinese, and therefore when they do encounter them in their clinical practice, they have difficulty in understanding them. 16

18 The ways that many Chinese professional documents are written also add to the difficulties encountered by the subjects. Some Chinese sentences may have a structure based on a European language, thus making them usually long and awkward. The Chinese language used in the Chinese professional communication is also more formal, complicated, and detailed compared to the informal Chinese that the subjects are used to. The subjects thus may not be able to recognize the signpost language that link different concepts and ideas, and to follow the rhetorical structure of the discourse. IV.2. Problems in Listening The subjects did not report problems in listening to their colleagues. Many subjects reported problems in listening to their patients. These problems can be broadly divided into those concerning recognizing the spoken words, and those concerning understanding the meanings of those words (after they have been recognized). IV.2.1. Problems in recognizing the spoken Chinese words Many of the subjects reported that they had difficulty listening to patients speaking in Mandarin. The difficulty lay at least in translating the spoken Mandarin words into Chinese words. Mandarin was introduced as a compulsory subject in primary (Grades 4 6) and secondary schools (Forms 1 3) in 1986 and 1988 respectively. Those secondary school students who were in Form 3 in 1998, who subsequently entered the MBBS programme at HKU, would have graduated in Therefore, those subjects in our study who graduated in or after 1997, less than 14 years ago (i.e., with 14 or less years of clinical practice) are likely to have had some exposure to Mandarin in their secondary school, while those who graduated before 1997, more than 14 years ago (i.e., more than 14 years of clinical practice) did not. Out of the 19 subjects who took part in our study, there are 14 subjects with 14 or less years of clinical practice. Most of these subjects (10 out of 12) reported no major problems in comprehending Mandarin. 17

19 嘅 啲 啲 啲 senior 啲嘅 (Doctor09) The other five subjects, each with more than 14 years of clinical practice, all reported that listening to Mandarin was difficult, since they did not learn Mandarin in their secondary and university education. The problem was particularly great when the patient spoke Mandarin with a Beijing accent.... 啲 嘅... (Doctor01) 啲 嘅 啲 啲 (Doctor06) 嘅 脷 (Doctors02) IV.2.2. Problems in understanding the meanings of the Chinese words IV Chinese medical terms This problem is the same as that in reading. In listening, even if the subjects were able to recognize the spoken Chinese words, they sometimes still did not understand their meanings, especially if they constituted Chinese medical terms. One subject reported that sometimes patients would use Chinese medical terms that the subject did not understand. The patients might have heard or read about these conditions in TV, radio or newspapers and would like to get further information about them from their doctors. But the limited Chinese medical vocabulary of the doctor prevented the patient s access to such information. d terms (Doctor 07) 18

20 Nearly all of the subjects admitted that they did not know most of the drug names in Chinese, even for some of the commonly used antibiotics, such as (erythromycin) and (tetracycline). 啲 啲 (Doctor06) 咗 啲 terms (Doctor10) check tetracycline (Doctor16) 嘅 咗啲 terms terms 啲 啲 啲 啲 (Doctor18) IV Variants of Chinese medical terms This problem was the same as that in reading. The lack of a standardized Chinese medical terminology again created problems. For example, penicillin in Hong Kong is commonly translated as. But in mainland China, is used 嘅 group name generic name trade name 嘅 嘅 penicillin (Doctor03) Snoring is in Hong Kong, but or in mainland China. Targeted therapy is in Hong Kong, but in mainland China. 嘅 啲 嘅 嘅 喺... 喺 啲 嘅... (Doctor01) 19

21 嘅 嘅 d 嘅 嘅 嘅 嘅 嘅 嘅 喺 targeted therapy term 嘅 handout... 嘅 嘅 嘅 term 啲 slides variations (Doctor03) IV Ambiguous meanings of Chinese terms There are some Chinese terms that are ambiguous in meaning, and different patients may use the same term to mean different things. For example, in Cantonese, 啲 may mean alright to an elderly person, but unsatisfactory to a younger person in Hong Kong. Another example is. One subject worried that there are also such terms of ambiguous meanings in Mandarin, and it would be very difficult for them to discern the precise meaning when they communicate with patients speaking in Mandarin. 嘅 example 啲 啲 啲 嘅 嘅 啲 嘅 (Doctor03) 啲 嘅 啲 (Doctor10) IV.3. Problems in Writing Almost all subjects reported that they did not experience many difficulties in writing Chinese in their clinical practice. The main reason is because they perceived no need to write medical professional documents in Chinese. They write most, if not all, of the professional documents in English (e.g., hospital records, clinical notes, medical reports, discharge summaries, prescriptions, 20

22 referrals, etc.). But when they were asked to write in Chinese, they either refused or found it uncomfortable to do so. IV.3.1. No perceived need to write professional documents in Chinese One subject commented that the request for Chinese professional documents from Hong Kong doctors has become less common than before. This is mainly because English documents are seen as more reliable in mainland China and more people in mainland China can now read English. 嘅 嘅 啲 request 嘅... 啲嘅 啲 嘅 啲 request 嘅 (Doctor03) Some subjects emphasized that English is the official and standard language in medical education, training and practice, and it should also be the language for professional medical documents in Hong Kong. Therefore, they felt that there was no need to have to write such documents in Chinese. sure term official 嘅 report 攞 嘅 啲 medical report medical record 嘅 嘅 medical documents 嘅 standard 嘅 medical education medical system commonwealth system established 咗 medical report (Doctor09) 嘅 documentation provide... provide 啲 啱 provide standard 嘅 (Doctor15) 21

23 IV.3.2. Lack of confidence in writing Chinese medical terms Sometimes, the subjects were asked by patients to informally write down the names of the diseases that the patients are suffering or the drugs that they are taking. The subjects oftentimes lacked confidence in writing them in Chinese. 啲 terms terms 啲 啲 啲 (Doctor12) 啲 (Doctor14) Common 啲 啲 啲 (Doctor18) (Doctor02)... (Doctor10) check 啲 啲 嘅 (Doctor11) 啲 嘅 嘅 (Doctor12) IV.4. Problems in Speaking Twelve of the 19 subjects said that speaking was the area that they had the most difficulty in in their clinical practice. Their greatest difficulty was in talking with patients in Mandarin. 22

24 IV.4.1. Mandarin Of the five subjects who had graduated more than 14 years ago, and hence had little exposure to Mandarin in their secondary education, all reported that they could not communicate in Mandarin, not even to ask their patients such simple questions as how do you feel after taking the medicine?. These subjects also did not learn Mandarin after they graduated from the university. (Doctor01) (Doctor02) 嘅 (Doctor04) 喺 language (Doctor19) The other 14 subjects, who graduated in the past 14 years and hence were likely to have some exposure to Mandarin in their secondary school, reported less difficulty in speaking Mandarin. Though most of them admitted that they are not fluent in Mandarin, they could at least hold basic conversations with their Mandarin-speaking patients. okay (Doctor05) 嘅 (Doctor07) 啲 嘅 (Doctor10) 啲 咗 okay (Doctor13) okay 啲 啲 嘅 (Doctor14) 23

25 喺 啲 啲 嘅 啲 (Doctor16) 啲 啲 啲 okay 啲 啲 嘅 terms 嘅 (Doctor18) Nevertheless, these 14 subjects, who had greater exposure to Mandarin in their secondary education, still encountered some problems in speaking Mandarin. For example, one subject found it difficult to use Mandarin to ask about patient s coughing. One subject said that when communicating with patients who knew only Mandarin, s/he would ask fewer questions. 啲 啲 喺 啲 啲嘅 啲 啲 (Doctor06) 咗 啲 (Doctor17) Sometimes confusion in doctor-patient communication resulted. One subject once used Mandarin to ask a patient to (take a chest X-ray), but the patient mistook it to mean (pay a fee). 啲 啲 (Doctor03) IV.4.2. Cantonese Some subjects said that they are so used to using English as the language in medicine that, when they communicate with patients, they tend to think in English, and then translate what they wanted to say into Cantonese. The subject may not be able to fully express themselves in an articulate and easily understandable manner in Cantonese. 24

26 嘅 嘅 喺 嘅 嘅 嘅 啲 嘅 medical terms 嘅 咗 (Doctor11) 咗 啲 嘅 啲 嘅 啲 嘅 啲 (Doctor19) Although at least some subjects needed to internally translate from English to Cantonese when they communicate with their patients, none of them said that they encountered difficulties in speaking to their patients in Cantonese, even when they have to explain diseases, treatment, operations, etc. This finding is particular interesting given that Chan and Tse (2011) found that finalyear medical students have a poor Chinese medical vocabulary. The above sections of IV and IV further showed that the Chinese medical vocabulary of practicing doctors is also poor. But then why did none of the subjects in this study report difficulties in talking to their patients in Cantonese? The reason may be similar to the reason that the subjects did not report much difficulty in writing Chinese in their clinical practices, i.e., they can avoid using medical terms. The strategies they used to talk to patients without using medical terms will be discussed in the next section. IV.5. Strategies adopted by the subjects in dealing with Chinese language difficulties Nearly all subjects admitted a certain degree of difficulty in using Chinese language in their clinical practice. But the subjects have different ways of dealing with these difficulties. 25

27 IV.5.1. Strategies in Reading IV Strategies for solving problems in recognizing Chinese characters For illegible hand-written documents with Chinese characters that are hard to recognize, some subjects would ask colleagues, patients and their family members for clarification. A few subjects said sometimes patients could read the handwriting in medical records better than s/he did as the doctors who had written them might have explained the reports to them before. 嘅 嘅 嘅 啲 (Doctor03) 啲 啲 嘅 (Doctor06) Or else, s/he would ignore the written report and try to establish the patient s condition himself or herself. 啲 啲 啲 啲 (Doctor18) When the subjects encountered simplified Chinese characters that they could not understand (i.e., cannot transform them into traditional Chinese words that they can understand), the subjects would guess what those words are from the context, e.g., from the words before and after them, or from the clinical context. 啲 啲 (Doctor11) situation 啲 parameters 啲 (Doctor14) IV Strategies for solving problems in understanding the meanings of Chinese text Even after the subjects had overcome the problems of interpreting handwritten and simplified Chinese characters, they may still find it difficult to understand the meaning of the text because they 26

28 are not familiar with Chinese medical terms, their variants, their abbreviations, and the complex Chinese academic discourses. Their strategies include guessing, seeking help from un-official sources, from official sources, and ignoring. (i) Guessing Some subjects would guess what the documents said, based on their reading knowledge of Chinese, and then match the Chinese words to what they know in English. 啲 嘅 啲 (Doctor05) (Doctor11) (ii) Seeking help from unofficial sources Some subjects would seek help from colleagues or even from the patient himself or herself. (Doctor10) 嘅 clarify (Doctor19) 嘅... (Doctor16) (Doctor18) 嘅 啲 (Doctor10) (iii) Seeking help from official sources When the subjects encountered Chinese medical terms that they do not understand, some would look them up in dictionaries, either printed or online (i.e. Google translate or Google search via their mobiles). 27

29 search 嘅 (Doctor08) ( ) 嘅 (Doctor16) Two subjects would read Chinese medical journals to learn Chinese medical terms and the style of writing in Chinese academic journal papers.... 啲 (Doctor02) 啲 嘅 啲 啲 嘅 嘅 terminology (Doctor03) One subject said he would seek the help of other colleagues who may be more familiar with the kind of report at hand. 啲 嘅 (Doctor12) (iv) Ignoring Some subjects would ignore test results or reports from mainland China because of a lack of confidence in their tests and investigations. 啲 啲 嘅 啲 啲 (Doctor08) (Doctor12) Instead they would repeat the same tests and investigations in Hong Kong, especially for those that are critical, less invasive and less costly. 啲 啲 啲 (Doctor06) 28

30 啲 (Doctor07) 嘅 嘅 repeat (Doctor09) 啲 嘅 啲 invasive 嘅... 嘅 (Doctor17) 嘅 refer 啲 啲 嘅 啲 (Doctor15) (Doctor19) For radiological reports, if the patients brought along the original films on which the reports were based, the subjects would read the films themselves, so that they do not need to read the report. 嘅 啲 嘅 喺 啲 (Doctor12) 啲 啲 啲 (Doctor10) The justification of ignoring the Chinese medical professional documents is that they form only a part of the whole decision-making process, unless the Chinese documents happened to contain information that is critical to the patient s management. involve 嘅 嘅 嘅 (Doctor09) 啲 嘅 啲 嘅 嘅 29

31 嘅 啲 啲... 嘅 啲 (Doctor16) IV.5.2. Strategies in Listening IV Strategies for solving problems in recognizing the spoken Chinese words When the subjects encountered patients who only speak Mandarin, they would normally ask the patient to speak slowly, thus giving themselves more time to interpret the spoken Mandarin. 啲 嘅 d... 啲 (Doctor03) d... (Doctor06) When the subjects encountered some spoken Mandarin that s/he really could not interpret, they would ask the patients to elaborate, or ask other colleagues or the patient s family members to translate into Cantonese. Usually the patients are very willing to accommodate to the doctors requests to either speak slowly or elaborate on what they were saying. 啲 (Doctor03) (Doctor10) 啲 啲 (Doctor15) 啲嘅 (Doctor13) Sometimes, the subjects would ask the patient to write down the terms, thus eliminating the need to interpret spoken Mandarin. d (Doctor06) 30

32 ... 啲嘅 (Doctor12)... (Doctor13) okay (Doctor17) IV Strategies for solving problems in understanding the meanings of the Chinese words The strategies used are similar to those used in reading, i.e., guessing, seeking help from unofficial and official sources, and ignoring. Therefore, they would ask their colleagues or search the Internet for the English translation of some Chinese medical terms, or even check the receipts or prescriptions for medications English names. check common sense (Doctor19) 啲 啲 pharmacy 啲 啲 啲 (Doctor15) 嘅 啲 prescription 咗啲 攞 (Doctor14) 嘅 啲 (Doctor18) IV.5.3. Strategies in Writing Most subjects lack the confidence to write professional documents in Chinese and they also felt that there is no need to write Chinese in their clinical practice. When they do encounter such requests, they would refuse them and write in English instead, and leave it to the patient to find out the Chinese translation if they want to. 31

33 (Doctor18) 嘅 啲 term (Doctor16)... search 啲啩 啲 啲 嘅 (Doctor18) 啲 啲 嘅 (Doctor11) term (Doctor16) term 嘅 norm 嘅 (Doctor19) 嘅 啫 (Doctor06) The subjects might even ask the patients to contact the Hospital Authority for paid professional translation services. 啲 嘅 嘅 啲 嘅 嘅 嘅 嘅 (Doctor02) IV.5.4. Strategies in Speaking IV Strategies for problems in speaking Mandarin To solve the incapability in speaking Mandarin, the subjects would usually go find patients family members or some would seek help from colleagues for translation. Due to their lack of training in speaking Mandarin, one of the subjects stated that his usual practice was to ask in advance 32

34 whether the patient from mainland China knew English; if not, he would request that the patient brought someone who knew Cantonese with him to the clinic or hospital. (Doctor 17) 嘅 嘅 嘅 (Doctor02) One subject said that he would ask if the patient had a caretaker or not; otherwise, he would try using Mandarin to communicate. 嘅 (Doctor17) IV Strategies for problems in speaking Cantonese None of the subjects said that they encountered difficulties in speaking to their patients in Cantonese. Superficially, this is hardly surprising since Cantonese is the usual language for all the subjects in the study. But the main reason is because they had avoided using Chinese medical terms. This may be because of their low level of Chinese medical vocabulary, as had been shown by Chan and Tse (2011), as well as by the earlier sections of this study. Without using Chinese medical terms, the subjects were still able to talk to their patients using the methods discussed below. (i) Use English medical terms instead (code switching) One subject reported that s/he would use the English term instead when s/he was not sure about its Chinese translation, so that at least the patient would have some information to hold onto, to look up further information about his/her condition. patient pseudogout gout pseudogout pseudogout crystal report term (Doctor11) 33

35 term search 啲... (Doctor12) (ii) Use broader, more general terms (generalization) Some subjects, instead of specifically naming the medical entity, simply named the broad group that that entity belongs to. This is called generalization. For example, when they prescribe erythromycin, they would simply tell the patient that it is an antibiotic, without saying which one. (Doctor01) 啲 啲嘅 terms 啲 嘅 (Doctor08) 嘅 啲 啲 detail 啫 啲 term (Doctor07) (iii) Use a description instead of a name (circumlocution) Instead of giving a name to a medical entity in their conversation with patients, the subjects may simple describe the entity. For example, they may say the bone in the forearm that is on the side of the little finger instead of saying ulna. This practice is called circumlocution. 嘅 嘅 (Doctor09) Some subjects considered that the Chinese medical terms are too difficult for patients. They would use simple, non-technical language to explain to the patients. They would also fine-tune their language according to the level of education of the patient. 嘅 嘅 嘅 (Doctor04) 34

36 啲 啲 啲 啲 嘅 (Doctor11) 啲 嘅 啲 啲 啲 啲 (Doctor17) 啲 啲 common (Doctor06) 啲 啲 啲嘅 啲 terms... 嘅 啲 嘅 terms 啲 嘅 (Doctor10) (iv) Use written words to explain to the patients If the patients could not understand what the subjects were conveying, quite a number of the subjects would then write the terms or messages out for them to understand more accurately. okay (Doctor17) 啲 啲 clarify 啱 啱 (Doctor17) 啲 (Doctor18) (v) Use other aids to explain to the patients Sometimes the explanation is done with the aid of pictures or models. 嘅 model 嘅 啲 啲 (Doctor01) 啲 啲... okay... 啲 啲 (Doctor14) 35

37 嘅 啲 嘅 Google search (Doctor19) IV.6. Subjects view on the significance of Chinese medical vocabulary in their practice IV.6.1. The perceived need to know Chinese medical terms Some subjects anticipated that more patients will go to mainland China for tests and investigations, because of the relatively lower cost there. Some of these patients may come back to Hong Kong, bringing with them the Chinese reports or even consultation summaries, for definitive management. Therefore, the subjects considered it to be important for them to be able to read these Chinese medical professional documents. 喺 d 喺 啲 啲 foresee 啲... 嘅 (Doctor06) 啲 喺 啲 啲 嘅 啲 (Doctor17) Some subjects said that it was useful to know Chinese medical terms and to use them in talking with their patients. ( 嘅 ) terms 啲 (Doctor18) 啲 嘅 啲 reports 啲嘅 terms term term 嘅 norm (Doctor19) 36

38 Although some subjects felt that the appropriate use of Chinese medical terms could be useful, they seldom used them. One subject admitted that at least one of the reasons for using layman s language with patients was because s/he does not know the Chinese medical terms. 啲 嘅 terms 啲 terms (Doctor11) IV.6.2. Perceived reasons for using Chinese medical terms (i) Allow patients to have a more accurate and concrete picture of their own conditions When doctors do not have the necessary Chinese medical vocabulary, s/he will resort to such strategies as code switching, generalization, or circumlocution (Poulisse, 1993; Dörnyei and Kormos, 1998; Tse et al., 2001), as reported in section IV of this paper. These strategies may lead to poor patient comprehension of their condition, poor satisfaction, and perhaps even poor outcomes. In fact, the subjects in this study lamented that patients oftentimes do not have an accurate picture of their own condition and management plan, for which there are certainly many reasons, but the lack of specific information may be one of them. Sometimes, patients in Hong Kong were not even told the Chinese name of the disease they were suffering, or the name of the bone that has fractured. The use of more accurate and concrete terminology with patients who are able to comprehend this information can give them a more accurate and concrete picture of their own conditions and management plans. 啲 啲 (Doctor06) 嘅 啲 啲 啲 (Doctor11) 嘅 嘅 嘅 啲 (Doctor15) 37

39 嘅 啲 (Doctor18) (ii) Allow patients to seek further information There are a number of subjects who agreed that the use of Chinese medical terms in talking to their patients can allow patients to search for further information or to seek second opinions. 啲 search second opinion term (Doctor15) term search 啲 (Doctor12) 嘅 啲 嘅 咗 (Doctor13) 嘅 啲 嘅 啲 啲嘅 嘅 term term (Doctor14) 啲 啲 啲 嘅 嘅 term 啲 education level 啲 啲 嘅 嘅 okay (Doctor14) 啲 啲 not so educated 啲 okay (Doctor14) terms term 嘅 啲 search second opinion term (Doctor15) 38

40 (iii) Facilitate management One subject said that it was important for patients to know the Chinese names of drugs they are taking, not just the names of the group that an individual drug belongs to. This will allow specific and accurate communications between the patient and healthcare workers. 啲 啲 啲 啲 啲嘅 (Doctor07) One subject pointed out that, in the consent signing process, the use of Chinese medical terms can help the doctor to convey the information to the patient, and to make sure that the patients understand the details of the procedure being considered. ( ) 攞 嘅 嘅 (Doctor15) (iv) Decrease patient s anxiety One subject said if s/he was not able to tell the Chinese name of the disease to the patient, the patient may actually be alarmed, since the patient may take that to mean that the disease is rare and serious. ( 嘅 ) 啲... 咗 啲 啲 啲 嘅 啲 啲 嘅 (Doctor17) (v) Save time and resources Making patients redo their tests and investigations, despite the availability of their reports, is a waste of resources and time. 39

41 啲 啲 啲 (Doctor12) 啲 啲 啲 咗啲 咗 啲 (Doctor17) The subjects in our study suggested that the use of Chinese medical terms may be appropriate under some circumstances, and could lead to patients better comprehension of their condition, better management, and better use of time and resources. But these views seem to go against what is known in the literature about doctor-patient communication. In the literature on doctor-patient communication in the West, simple language or layman s terms are preferred over medical terms (Kusec et al., 2006; Shaw et al., 2009). This is mainly because many so-called English medical terms have Latin or Greek origins, which make them difficult even to native speakers of English. The situation with Chinese medical terms may be very different, although as yet there are no formal studies on this issue. Most Chinese medical terms are made up of common Chinese words that can be understood by people who have a reasonable comprehension of Chinese language. For example, spondylolisthesis and hypospadias are very difficult English medical terms, but their corresponding Chinese terms are quite intelligible to a native speaker of Chinese with only a secondary-school education. The Chinese name of spondylolisthesis is, in which is spine, is slide, is displace, and is disease. Therefore, spondylolisthesis is literally spine slide displace disease in Chinese, which explains the key features of the disease in plain Chinese language. The Chinese name of hypospadias is, in which is urethra, is lower, is crack, and is disease. Once again, the Chinese name of hypospadias explains the pathologies of the disease. Thus Chinese medical terms may be more acceptable to native speakers of Chinese than English medical terms are to native speakers of English. But more work need to be done to clarify this issue. 40

42 Even if Chinese medical terms are more acceptable to native Chinese speakers than English medical terms are to native English speakers, it does not mean that we can use these Chinese medical terms without regard to the circumstances, such as the patients education level. V. Conclusion Our study showed that graduates from a medical program which uses English as the sole medium of instruction have difficulty in using the local, non-english language in their clinical practice. In reading, they had problems in recognizing handwritten and the simplified Chinese characters. Even if they could recognize the words, they still had difficulty in understanding their meanings, particularly when they encountered Chinese medical terms, their variants and abbreviations. They also had difficulty in following the complex Chinese academic discourses. In listening, they had difficulty in understanding Mandarin Chinese, especially for those subjects who graduated more than 14 years ago and had little exposure to Mandarin during their school education. Even if they were able to recognise the words, they sometimes still had difficulty in understanding the meanings of the words, just as they did in reading. In writing, the subjects did not perceive much difficulty, mainly because they can avoid writing professional medical documents in Chinese. But when they did need to write a few Chinese words, say, to inform the patients of the Chinese names of their diseases, they did not feel confident to do so. In speaking, the subjects had difficulty with Mandarin, especially for those who graduated long time ago and had little exposure to Mandarin in their school education. But the subjects did not complain of difficulties in speaking to their patients in Cantonese, despite their poor Chinese medical vocabulary, mainly because they had developed several strategies to avoid using these terms. These strategies include giving the English terms instead, using a more general term, and giving a description or explanation instead of the name. These strategies of complete omission, code switching, generalization, circumlocution are common strategies used by learners of 41