Developing cultural awareness and intercultural communication through multimedia: A case study from medicine and the health sciences

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System 38 (2010) 560e568

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Developing cultural awareness and intercultural communication through multimedia: A case study from medicine and the health sciences Jan Hamilton 1, Robyn Woodward-Kron* Clinical Communication and Learning Development Program, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 179 Grattan St, Parkville VIC 3010, Australia Received 8 March 2010; revised 26 July 2010; accepted 1 August 2010

Abstract Awareness of how different cultural beliefs may influence one’s own and others’ linguistic choices is fundamental to successful spoken communication, particularly in intercultural professional settings such as contemporary healthcare. The aim of this paper is to outline how this sensitivity can be enhanced through teaching that develops reflectiveness as practice for analyzing and understanding the interrelationship of language, communication and culture. The setting is an intercultural ESP learning context supporting international students in undergraduate medical and health sciences education. A multimedia tool was developed as a trigger for the teacher to assist learners to explore, understand, and take into account the interrelationship between language, culture and communication in healthcare settings. The multimedia tool includes a series of ‘voxpop’ style interviews with students to give voice to the students’ perceptions and experiences of their clinical experience in Australia. Simulated interactions of these ESP learners in clinical settings provide triggers for classroom discussion, build reflective practice skills, and develop the requisite language competence and clinical communication skills. The discussion includes strategies for implementation and evaluation of the multimedia supported methodology. Ó 2010 Elsevier Ltd. All rights reserved. Keywords: Intercultural communication; English as an additional language; TESOL; Clinical communication; Reflective learning practice; Multimedia; Medicine

1. Intercultural communication and cultural awareness In intercultural communication, language and culture can negatively impact on the success of the interaction. When this occurs in professional settings such as healthcare, misunderstandings and communication breakdowns can have serious implications for health outcomes and patient safety. While the interrelationship between culture, language and communication has been theorised and has informed education and training sessions (e.g., Scollon and Scollon, 2001),

* Corresponding author. Tel.: þ61 3 8344 3072; fax: þ61 3 9348 1850. E-mail addresses: [email protected] (J. Hamilton), [email protected] (R. Woodward-Kron). 1 Tel.: þ61 3 8344 3071; fax: þ61 3 9348 1850. 0346-251X/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.system.2010.09.015

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it remains a challenging construct with which to engage English for Specific Purposes (ESP) learners. For English for Specific Purposes teachers, the relationship between language, communication and culture is constantly brought into question as we engage with the task of teaching language from within a specific content domain that has its own ‘culture’ such as the ‘hospital culture’. Added to this is another cultural layer, that of ‘ethnicity’, such as ‘Asian health culture and health beliefs’, or ‘Western health culture and health beliefs’. For ESP teachers, a major challenge is to raise awareness amongst learners of the ways in which these multi-layered cultural domains inform language choices in professional communication. At the heart of this challenge is the question of how to best explicate the context surrounding language choice, that is, the interpersonal expectations, intentions, and beliefs which underpin daily exchanges between interactants in professional communication. The notion of appropriacy in language choice, which has been a guiding principle in language-teaching syllabus design over the last 30 years, relates to this match of socio-pragmatic action and pragma-linguistic choice (e.g., Kasper, 1997; Yates, 2004). An appropriate or successful communication exchange in a professional communication context is measured in terms of its effectiveness, in the first instance, to establish and conduct a professional relationship in order to achieve a second more specific objective, such as diagnosing a patient’s illness. An understanding of this context therefore precedes the communication event and influences its socio-pragmatic success. Teaching these layers of culture, however, extends the knowledge base of the conventional language teacher, whose primary concern has been viewed as being more confined to the mechanics of grammar, syntax, coherence, cohesion, vocabulary, and intelligibility, albeit ‘appropriate’ in choice (Savignon, 2007). Furthermore, this task of interpretation and explication of ‘culture’ may cause what Singh and Doherty (2004) describe as a moral dilemma for English language teachers; teachers may feel they are possibly spreading a cultural homogenisation: a merging or loss of traditional cultures into a globalised, essentially Western world culture through the promotion of Western standard English (Pennycook, 1997; Yates, 2004). Related to this concern about how to teach culturally appropriate interactions for ESP settings such as healthcare is the issue of learner identity construction. English language learners may feel compelled to adopt the cultural norms and behaviours of the English-speaking Western culture, thereby reinforcing notions of themselves as possibly linguistically and also culturally ‘deficient’ (Belcher, 2006; Bhatia, 1997; Haggis, 2006; Savignon, 2007). Norton (1997) has described the relationship between language and identity construction as fundamentally linked; each time a language learner speaks, [she/he] “is constantly organizing and reorganizing a sense of who they are” (p.420). Northedge (2003) recognised the potential danger of this link and argued that for English as additional language speakers to participate effectively in their professional fields, they need to learn to be able to recognize any differences in their own and others’ cultural identities as well as move back and forth between these cultural and language identities without feeling a sense of loss or guilt. Byram (2000) described this ability as intercultural competence. He also recognised the need for additional language users to critically analyse their own and other cultures and to have an understanding that their thinking is “culturally determined rather than believing that their understanding and perspective is natural” (Byram, 2000, p.2). 1.1. Intercultural communication and teaching ESP These theoretical insights raise the question of how language teachers should assist learners to understand the relationship between culture, intercultural identity construction and language production to enable them to function in the new language/workplace setting without compromising their personal and cultural identities. Yates (2004) argues for the explicit teaching of English pragmatic and linguistic conventions to English language learners so that they are able to effectively interact in the English-speaking community. However, she warns against the dangers of teachers interpreting cultural norms ‘naively or prescriptively’ and of seeing culture as static and monolithic rather than dynamic and evolving. Scarino et al. (2007), in their exploration of an intercultural off-shore delivery communication skills learning context, found that language and culture play a mediating role in shaping the teaching process itself, in particular how teachers from both international (western) and local (off-shore country) backgrounds perceive and operationalise their roles. They concluded that for a learning process which delivers knowledge from one cultural context to another to be effective, it should be viewed and implemented as a collaborative self-exploratory effort by teachers and learners and one which recognizes and addresses their own linguistic and cultural influences on teaching and learning at every stage of the delivery process.

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This paper examines these issues in the context of undergraduate medical and health sciences education. The paper describes a multimedia tool and accompanying methodology of reflective learning practice to assist learners to explore, understand and utilise the interrelationship between language, communication and culture in healthcare settings. 1.2. The health sciences context Two forces have shaped worldwide healthcare provision, both of which have clear implications for the use of language in healthcare communication and for the teaching of language to trained and in-training healthcare professionals. Firstly, there has been a paradigmatic shift in the approach to healthcare, predominantly in the West, which has had an impact on healthcare provision and medical school curricula in western countries. This shift is from the conventional ‘doctor-centred’ to a ‘patient-centred’ approach to healthcare. It has been brought about due to research into the efficacy of healthcare provision, which has found significant inadequacies in patient understanding of and satisfaction with healthcare professionals, with resultant detrimental effects on patient compliance with healthcare treatment, health outcomes, national healthcare costs, and litigation actions (Duffy et al., 2004; Epstein and Hundert, 2002; Kim et al., 2004; Rowe et al., 2002). A major source of these problems has been identified as poor communication practices between health professionals and patients, and as a result, communication skills have now become regarded as a key clinical competency and focus of training by peak health provision and education bodies in western countries (Duffy et al., 2004; Epstein and Hundert, 2002; von Fragstein et al., 2008). Health professionals are now expected and are being taught in clinical education and training contexts to utilise a range of more subtle and complex communication strategies in order to effectively gather and provide information during clinical encounters with patients, which in turn makes the communication act itself more challenging (Janicik et al., 2007). The ‘patient-centred’ approach, which has these complex communication skills at its core, is analogous to the ‘student-centred’ as opposed to the ‘teacher-centred’ approach to teaching in education (Skelton et al., 2001). This approach aims to give the patient a more active and more vocal role in healthcare interaction and treatment decisionmaking (Pruitt and Epping-Jordan, 2005; Yedidia et al., 2003). The doctorepatient relationship is less hierarchical and more focused on the doctor exploring the patient’s psycho-social health and emotions. This has implications for how doctors and patients conceptualise their respective roles and expectations of a clinical encounter. It is when interactants have different expectations of the interaction that communication breakdowns can occur (Silverman et al., 2003). Discourse studies in doctorepatient interaction (Roberts et al., 2005; Suchman et al., 1997) have provided insights into the process of these communication breakdowns. Suchman et al. (1997), for example, developed the notions of ‘empathic opportunity encouragers’ or ‘empathic opportunity terminators’ to characterise the way doctors choose to respond to psycho-social cues offered by patients in consultations, arguing that these differential response types influenced the flow of information exchange and ultimately the success of such communication. The second major change in healthcare provision has been the recent worldwide movement of healthcare-providing and healthcare-seeking populations around the world. This has been due to a number of factors: a shortage of health professionals in western countries, which has attracted a large flow of professionals from non-Western linguistic and cultural backgrounds into Western health systems; the expansion of aid-related healthcare provision to the developing world; and the mass migration of multilingual and multicultural populations into other countries, people who subsequently become health patients in those countries (Pruitt and Epping-Jordan, 2005). The flow-on effect of these two forces is that health encounters in many countries are now communicatively more complex and interlinguistic/intercultural in nature. Research has found that intercultural clinical communication encounters may be problematic, particularly when dealing with health issues relating to authority, physical contact, communication styles, gender, sexuality, and family beliefs and practices (Carillo et al., 1999). Also of concern have been misunderstandings and ambiguities in practices relating to the ‘patient-centred’ healthcare delivery approach, both for trained doctors (Hall et al., 2004; Roberts and Sarangi, 2005), student doctors (Liddell and Koritsis, 2004; Roberts et al., 2003; Wass et al., 2003) and patients (Roberts et al., 2005; Roberts and Sarangi, 2005). Wass et al. (2003), in their discourse analysis of student examination performances of simulated clinical interactions, found that students from ethnic minority backgrounds tended to distance themselves from patients and use a ‘medical’ rather than ‘social’ doctor communication style which resulted in relatively lower examination scores. Wass suggested that these students used this style because it was less demanding in terms of communication skills and because they perceived it to be the appropriate one for a doctor to adopt. These areas of miscommunication appear to stem from different cultural understandings, attitudes and practices. Roberts and Sarangi (2005), in their discourse analysis of

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communication breakdowns in intercultural doctorepatient consultations, described how cultural differences could influence people’s expectations and subsequent communication behaviour. Findings from studies such as these have led to a growing recognition of the need for intercultural training of health professionals from both first and additional language backgrounds (Carillo et al., 1999; Morell et al., 2002; Pruitt and Epping-Jordan, 2005). 2. The study setting: English as additional language health science students Australian health sciences courses differ from other tertiary level study programs such as computer science, commerce or arts since in the former courses, the students are heavily and continuously immersed in their future workplaces e hospitals and clinics e before, not after they complete their study programs. Assessment of students’ clinical skills is based on judgments of how well they function in these community settings performing clinical tasks through communicating with the general patient population. Overseas-born students, often only recently arrived in the country, may be unfamiliar with local colloquial language, cultural referents and practices and health sciences systems (Barker et al., 1991; Bosher and Smalkoski, 2002; Chur-Hansen and Barrett, 1996; Frank, 2000), and as a result these overseas-born students may not achieve as well academically as their locally-born counterparts (Liddell and Koritsis, 2004; Wass et al., 2003). In the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne, the setting for this study, overseas-born students comprise up to one third of students in some courses of study. To address the language and intercultural communication needs of these students, who are generally aged between 18 and 28 and primarily come from south-eastern Asian countries, the International Student Support Program (ISSP)2 was established (Hawthorne et al., 2004). 2.1. Developing an intercultural communication multimedia tool As part of the activities of the ISSP, an interactive DVD-ROM (Woodward-Kron et al., 2007a) was developed to support the pre-clinical and clinical components of undergraduate and postgraduate courses in medicine, nursing, physiotherapy, audiology and dental science. The DVD-ROM was informed by literature from the health professional education and English for Specific Purposes, the collective experience of staff teaching in the program, and a research project that drew on personal and focus group interviews with 32 international health sciences students studying at the University (Woodward-Kron et al., 2007b). This study’s interview data identified emergent themes relating to aspects of Australian clinical practice and also to Australian behaviours and beliefs which had an impact on students’ learning and clinical communication. Main themes identified were: the practice in Australian clinical settings of a patientcentred approach to healthcare; the management of clinicianepatient and health professional relationships and specific aspects of Australian culture such as the pervasiveness of alcohol, the dynamics and structure of family relationships, and Australian colloquial language in health communication. Interviewees also described the strategies they had developed for addressing linguistic and cultural dissonance such as actively seeking to build social relationships with their Australian-born peers. 2.2. The learningeteaching methodology These data sources informed the pedagogical framework of the DVD: its philosophical underpinning, content and learning methodology. The developers’ aims were to produce a resource that would foster effective communication in a specific real world context from an ‘intercultural’ stance, that is, one which recognised that communication in a health-science setting is a jointly-produced activity between the health professional and the patient, and which involves the negotiation of two possibly different personal and cultural perspectives. This view affirms the recognition and validity of accepting difference rather than adapting to one linguistic and cultural ‘norm’. By adopting this view, we sought to avoid framing the student learner as ‘deficient’. We recognised that in order to achieve effective interaction, these learners needed to become familiar with the context in which they were learning and communicating: the “secret rules of language” (Yates, 2004:3) of socio-pragmatic and linguistic expectations which inform and 2 The program was renamed in 2008 to the Clinical Communication and Learning Development Program (CCLD) as the program had expanded to address the clinical communication learning needs of locally born as well as international students in the medical and health sciences faculty.

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produce successful communicative acts (Bachman, 1990) and facilitate membership of a particular social community (Bhatia, 1997). The ‘patient-centred’ approach to healthcare, the guiding principle in the curriculum across all health sciences in the Faculty, supported this philosophical approach and so formed the main framework around which the tool’s content was organised. The learning methodology of this resource utilised a ‘reflective’ approach that aimed in the first instance for the learners to understand their own learning experience and the influence of their cultural backgrounds on learning and communicating in their health sciences course. This also involved facilitating in the learner a consideration of the local environment e in this case the Australia health system and its patients, many of whom come from culturally and linguistically diverse backgrounds (Australian Bureau of Statistics, 2006) by asking learners to identify any perceived differences in attitudes and behaviour and how these differences may have an impact on the learners’ own functioning as health professionals. The second component of this reflective process aimed for the learners to become familiar with the linguistic realisations of the various socio-pragmatic behaviours they observe and participate in during health encounters so that they would be able to make informed and appropriate linguistic and paralinguistic choices in future interactions with patients and colleagues. This reflective approach draws upon research into teaching pragmatics in the EFL and ESL classroom (see Kasper, 1997 for a review) and which recommends explicit teaching of pragmatics through awareness-raising observation tasks for learners to develop this understanding (Dufon, 2004; Yates, 2004). In the health sciences field, reflectiveness has been recognised as an important aspect of professional practice that should be explicitly taught (Epstein, 1999; Ker, 2003; Meier et al., 2001; Rosen et al., 2004). Smith (1998), in her longitudinal qualitative study of nurses, described the value of reflective practice in fostering integration of nursing practice experience and academic knowledge, reassessing old perspectives and moving from a position of an acceptance of information to one of questioning and critiquing arguments and professional assumptions, in particular their relevance and appropriateness for nursing practice. A multimedia tool was chosen as the delivery mode in order to utilise technological advances in educational resources. This made it possible to incorporate a range of teaching resources (videos, powerpoint presentations, soundfiles, written texts, and photographs) into one portable package that could be used in both individual and classroom learning contexts. Its hyperlinked content enabled a complex linking of related materials throughout the site and also gave the learner autonomy over navigation through the materials. Most of the material presented comprised videotaped interviews and simulations of healtherelation interactions, that is of visual and aural sources rather than of written text, which aimed to enable the learner to focus on developing listening and speaking skills, both of which are important in clinical health profession communication. Dufon (2004), in her description of a video-based learning resource, identified a number of advantages of using video to teach pragmatics over conventional written textbooks or classroom practice. These include factors such as being able to use permanently recorded naturalistic or seminaturalistic interaction which is available for repeated viewing; the relative ease of teaching important aspects of spoken interaction such as stress, intonation and paralinguistic features of posture, gesture, clothing and proxemics and also the opportunity for learners to be observers rather than participants and so be able to analyse interlocutors’ speech and actions more fully. This method has been reported to be effective in health science contexts where videotaped real performances have been used for reflective teaching practice by students with their teaching staff (Lang et al., 2000; Morell et al., 2002; Roter et al., 2004). 2.3. The learningeteaching content There are four sections to the DVD-ROM: Overseas-born students talk; studentepatient consultations; library; glossary. These will be discussed in turn. 2.3.1. Overseas-born students talk This section includes a series of videoed health science student interviews in which real students reflected upon their impressions of moving to and being international students in Australia, and of their experiences in the clinical component of their courses in Australian hospitals. These students described and speculated upon differences between ‘back home’ and Australia in terms of people, customs, beliefs and behaviours, both in the general community and in clinical settings. They also identified challenges in communicating and described strategies that they found helpful in facilitating the communication process. Attached to each videotaped sequence showing students discussing one

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particular topic e for example, ‘cultural differences’ or ‘Australian English in clinical settings’ e were a set of related questions which aim to generate descriptive, comparative and evaluative thinking and responses from the learner. We chose this mode of content delivery and learning because there is very little material available of this type which presents the learners’ rather than the teachers’ perspective (Woodward-Kron et al., 2007b). We posited that the learners would engage with material that was visually and aurally appealing, ‘real’ insofar as videoed sequences can mirror real time experience, and relevant, given that the student participants were the same cohort as the learners. The talk was spontaneous rather than scripted, and presented the students as they speak in real life: perceptive and articulate, though not necessarily grammatically correct, and revealing their enthusiasm and humour, qualities which are not typically shown in conventional academic representations of international students. The aim in this section was to develop reflectiveness of thought and in particular intercultural awareness rather than to teach accuracy in speech. In these video clips students expressed positive views, such as the generosity of Australian patients to help the students’ linguistic understanding and humorous exchanges in clinics. They also made negative comments about the pervasiveness of alcohol in Australian society and occasional difficulties in establishing close friendships with local students. These self-selected topics and critical views illustrated the complexity of the communication tasks, particularly the intercultural elements and the students’ efforts to overcome linguistic and cultural misunderstandings. Of note were the numerous language-learning and communication strategies identified by students and also the interest expressed by these students in actively teaching their peers, which supported the view of them being competent rather than deficient language learners (see also Johns, 2001, for another example of this approach). 2.3.2. Studentepatient consultations This section contained four videotaped simulations of health consultations: three in a medical setting and one in a physiotherapy setting. These interactions simulated the type of communication exchanges students perform in the clinical component of their undergraduate courses. The clinical assessment process of these students’ learning uses the same simulated clinical exchange format that is used to assess their clinical competence and communication skills. In each video sequence, a real overseas-born student interacts with a ‘patient’, played by an actor. The student performs a communicatively complex clinical task such as taking a social history from a patient, taking an alcohol history, explaining medical information to a child and parent or reviewing a patient’s chronic back pain. Overseasborn students often find these tasks problematic for various reasons, including those relating to lack of cultural familiarity with these topics or practices and the linguistic and paralinguistic subtleties required for sensitive questioning (Frank, 2000; Woodward-Kron et al., 2007b). While the scenarios were loosely framed in order to focus on particular health topics, the language and paralinguistic behaviour used by the interactants were encouraged to be spontaneous to capture authentic spoken interaction. The learning material incorporated into this section was developed through a ‘text-driven’ process by firstly analyzing the completed video sequence, secondly identifying appropriate teaching points and finally developing learning tasks that arose from the spoken interaction. Each of the four video interactions is analysed separately by being broken down into chronological segments of action and spoken text which are then analysed through a set of ‘reflection tasks’. These reflection tasks involve question prompts that aim to elicit the learners’ thinking and understanding of their own and other interactants’ cultural and linguistic behaviours. The reflection tasks correspond to the applied linguistics concept of language ‘functions’, that is, the communicative acts that may be performed through language by health professionals during a consultation. For example, in one video, a student doctor, when explaining complex medical information to a child patient and parent, performs the following medical (through language) functions: seeking permission to speak, talking with children, establishing rapport, judging a person’s mood, affirming parent competence, clarifying information, using language simplifying strategies, responding to parent distress, managing conflict and closing the consultation. Performing these medical functions requires not only a sophisticated understanding and manipulation of language, but also sensitive interpersonal and communication skills. Discourse analysis of real health professionalepatient interaction has demonstrated the potential for communication breakdown even when both interactants are from the same cultural background (Suchman et al., 1997), but in particular when they come from different cultural backgrounds (Roberts et al., 2005). This section of the DVD-ROM aimed to give learners the opportunity to reflect upon linguistic exchanges in spoken text ‘chunks’ in virtual time. Hyperlinked to each page of question prompts are ‘Feedback’ buttons that provide an interpretation of the specific incident being analysed. This interpretation may involve explaining aspects of general interpersonal communication theory or practice, or specifically Australian

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general or clinical cultural practices. The teaching strategy aimed to provide learners with the general communication and specific cultural knowledge they need to know in order to understand patient behaviours. There were also additional hyperlinked ‘language focus’ tasks that provided sentence level language support relevant to each reflection activity. These included for example: using casual and formal speech, making introductions, using verbal encouragers, pauses and stress and giving listening feedback. These provided advanced language learners with micro-level language-learning opportunities in a health science context. For example, in the video-trigger paediatric asthma management consultation in which a student doctor explains to a child patient and his mother what to do in the case of a severe asthma attack at home, the whole interaction was segmented into ten reflection task activities/medical task language functions. One segment, ‘Responding to parent distress’, started by encouraging the learner to consider the parent’s behaviour by focusing on body language. It then asked the learner to provide an appropriate communication response. Three options were offered e two unsuitable and one suitable e with a ‘Feedback’ button linked to each option. The feedback explained why each response was appropriate or not. For this medical and language function to be successfully performed, it requires sophisticated interpersonal, cultural and linguistic competence. Firstly, the medical student needs to be alert to non-verbal information conveyed by the parent in order to recognize that she is distressed. Secondly, the medical student needs to understand that it is part of her role as a ‘patient-centred’ doctor to enquire about this distress and that it is appropriate to take an active role in solving the parent’s problem, since this will facilitate the child patient’s at-home care. Thirdly, it requires an understanding of Australian social organization e in this case, the existence of isolated, sole parent families e and of colloquial language used by the parent (e.g., ‘sleepover’). The medical student needs to be able to use sensitive verbal and non-verbal language skills to elicit information from the parent and provide a response which is helpful without causing offence. For many overseas-born students from, for example, some Asian and African backgrounds, this specific cultural understanding may be limited since in their own cultures, the notions of a medical doctor enquiring into a person’s social background, or of the existence of unsupported sole parent families may be unfamiliar and therefore difficult to manage (Woodward-Kron et al., 2007b). The language tasks linked to this reflection task are ‘Listening feedback’ and ‘Understanding gist’. The first task provides information about how to offer appropriate verbal feedback tokens (e.g., ‘Yes.Mmm.) and corresponding non-verbal responses (e.g., eye contact, nodding) with a practice exercise in which the learner is provided with a soundfile utterance from the recorded scenario to which she/he should respond using the different feedback strategies suggested. The second task identifies a colloquial term used in the scenario e ‘sleepover’ e and explains the strategy of analyzing the context and the meaning of the earlier part of the utterance in order to understand its meaning. If this fails, a follow-up strategy is suggested, that is, of not interrupting the parent speaker to seek clarification, and reasons are given for this which relate to the ‘patient-centred’ notion of allowing the patient/parent to tell their story without interruption. These learning tasks illustrate the intertwining of not only language, communication and culture, but also the merging of the ESP and health science disciplines and the possibility of and necessity for collaboration in these fields. 2.3.3. Library and glossary These sections include additional information about Australian culture and colloquial language. The Library contains newspaper articles and multimedia resources on such topics as overseas-born students in Australia, Aboriginal health, sport in Australia, alcohol in Australia and healthcare workplace issues. This section aims to provide learners with background knowledge about Australia health culture and health systems, the latter a sometimes forgotten aspect of a health professional’s clinical competence (Bosher and Smalkoski, 2002; Frank, 2000). The Glossary is a set of alphabetically listed Australian colloquialisms (for example, ‘cactus’ (meaning ‘no longer working’); ‘pigging out’ (meaning ‘over-eating); ‘preggers’ (meaning ‘pregnant’)) with their definitions and an attached soundfile for students to hear each item’s pronunciation in contextualized text. While these particular learners may have a well-developed level of communicative competence in academic English, their understanding of the general and colloquial language used by often elderly and less-educated public health patients and relatives tends to be less sound and can be problematic in clinical contexts (Chur-Hansen and Barrett, 1996). 3. Implementation This package has been used in learning settings with both pre-clinical (university-based) and clinical (hospitalbased) students from various disciplines (medicine, physiotherapy, dentistry and nursing) and in a number of teaching

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contexts (orientation sessions, lectures, small group and independent learning). While its audiences have on occasion included locally-born students from English-speaking backgrounds, its main utilisation has been with overseas-born students. It has also been taken up by International Medical Graduates in some Australian state health systems. Currently the DVD-ROM is being evaluated by a project team (Hamilton and Hill, in preparation) in terms of its value as a learning tool in a classroom-based teaching intervention for final year paediatrics students.

4. Conclusion The complex intertwining of language, communication and culture has implications for the teaching of language in an ESP context. It requires recognition of the powerful effects of the latter two spheres on language use and the subsequent need to broaden the debate about what constitutes an ESP curriculum in terms of philosophical approach, content and methodology. The notion of ‘interculturality’ as a pedagogical approach has relevance and salience for both teachers and learners of additional languages as it recognizes and values the notion of cultural plurality. The resource package described above represents one attempt to merge these three spheres of language, communication and culture in an ‘interculturally’ principled curriculum process which enables learners to incorporate their own identities into communication acts in their chosen fields. References Australian Bureau of Statistics, 2006. Yearbook Australia. Cultural diversity: language (electronic version). Retrieved May 14 2008, from. http:// www.abs.gov.au/AUSSTATS/[email protected]/bb8db737e2af84b8ca2571780015701e/636F496B2B943F12CA2573D200109DA9@ 3Fopendocument. Bachman, L., 1990. Fundamental Considerations in Language Testing. Oxford University Press, Oxford. Barker, M., Child, C., Gallois, C., Jones, E., Callan, V., 1991. Difficulties of overseas students in social and academic situations. Australian Journal of Psychology 43 (2), 79e84. Belcher, D., 2006. English for specific purposes: teaching to perceived needs and imagined futures in worlds of work, study, and everyday life. TESOL Quarterly 40 (1), 133e156. Bhatia, V., 1997. The power and politics of genre. World Englishes 16 (3), 359e371. Bosher, S., Smalkoski, K., 2002. From needs analysis to curriculum development designing a course in health-care communication for immigrant students in the USA. English for Specific Purposes 21 (1), 59e79. Byram, M., 2000. Assessing intercultural competence in language teaching. Sprogforum 18 (6), 8e13. Retrieved 22 February 2010, from. http:// inet.dpb.dpu.dk/infodok/sprogforum/Espr18/byram.html. Carillo, J., Green, A., Betancourt, J., 1999. Cross-cultural primary care: a patient-based approach. Annals of Internal Medicine 130 (10), 829e834. Chur-Hansen, A., Barrett, R.J., 1996. Teaching colloquial Australian English to medical students from non-English speaking backgrounds. Medical Education 30 (6), 412e417. Dufon, M., 2004. Producing a video for teaching pragmatics in the second language classroom. Prospect 19 (1), 65e83. Duffy, D., Gordon, G., Whelan, G., Cole-Kelly, K., Frankel, R., 2004. Assessing competence in communication and interpersonal skills: the Kalamazoo II report. Academic Medicine 79 (6), 495e507. Epstein, R., 1999. Mindful practice. The Journal of the American Medical Association 282 (9), 833e839. Epstein, R., Hundert, E., 2002. Defining and assessing professional competence. Journal of the American Medical Association 287 (2), 226e235. Frank, R., 2000. Medical communication: non-native English speaking patients and native English speaking professionals. English for Specific Purposes 19, 31e62. Haggis, T., 2006. Pedagogies for diversity: retaining critical challenge amidst fears of ‘dumbing down’. Studies in Higher Education 31 (5), 521e535. Hall, P., Keely, E., Dojeiji, S., Byszewski, A., Marks, M., 2004. Communication skills, cultural challenges and individual support: challenges of international medical graduates in a Canadian healthcare environment. Medical Teacher 26 (2), 120e125. Hamilton, J., Hill, K. Knowing, noticing, doing e using a multi-media DVD-ROM to teach clinical communication skills, in preparation. Hawthorne, L., Minas, I.H., Singh, B., 2004. A case study in the globalisation of medical education: assisting overseas-born students at the University of Melbourne. Medical Teacher 6 (2), 150e159. Janicik, R., Kalet, A., Schwartz, M., Zabar, S., Lipkin, S., 2007. Using bedside rounds to teach communication skills in the internal medicine clerkship. Medical Education Online 12, 1e8. Johns, A., 2001. An interdisciplinary, interinstitutional learning communities program: student involvement and student success. In: Leki, I. (Ed.), Academic Writing Programs. Teachers of English to Speakers of Other Languages, Alexandria, VA, pp. 61e72. Kasper, G., 1997. Can Pragmatic Competence be Taught? (Electronic Version). Retrieved May 1 2008, from. http://www.nflrc.hawaii.edu/ NetWorks/NW06/ Second Language Teaching & Curriculum Center. Ker, J., 2003. Developing professional clinical skills for practice e the results of a feasibility study using a reflective approach to intimate examination. Medical Education 37 (Suppl. 1), 34e41.

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