Clinical Case Presentations in Non-Anglophone Medical Milieus – How do they work?

Clinical case presentations (also known as ‘case reports’ or ‘grand rounds’ and hereafter referred to as CPs) are standard clinical speech events carried out in medical institutions worldwide. As such, they should be included in the repertoire of every EMP teacher. However, because these interactions are performed between practitioners, those involved in the language training aspects of healthcare might have little knowledge as to the functions these events serve and how they are typically managed, particularly if and when they are divorced from the Anglosphere clinical workplace. This article thus aims to briefly explain some of CPs’ key functions and characteristics.

Over a period of one and a half years (late 2017- early 2019), I observed a total of 26 English clinical CPs held at university or university-affiliated hospitals in Japan, Taiwan, Indonesia, Thailand, Myanmar, and Vietnam, none of which employ English in any official capacity. These observations were carried out will full consent from all hospital and academic staff concerned. I further conducted a total of eight interviews regarding the role and management of English CPs with clinical staff, in each of the above locales.

Why carry out CPs in English?

While the majority of CPs performed within the medical Anglosphere appear to be for intra-departmental teaching purposes, the edification of colleagues and peers, CPs were used in a wider variety of functions in the non-English institutions I visited. The extant functions of the CP sessions I noted were almost evenly divided between the assessment/advisory type (8 cases, usually with residents/trainees performing in front of senior adjudicators), practical training in clinical clerkship type (6 cases of bedside round CPs, with upper-grade medical students performing for a single preceptor physician), ‘interesting/unusual case’ studies type (6 cases, peer-to-peer, non-adjudicated), and specific English-skills training type (6 cases, training within specialist or elective programs). At one location, Thammasat University Hospital in Thailand, each of these four types were used.

Naturally, in most circumstances, peer-to-peer clinical speech in non-Anglophones locales will be carried out in the local language or mother tongue of the speaker, which begs the question as to why English was often used as the mode of expression for CPs in such locales. Interviews revealed that a number of factors lay behind the choice. The most common among these were some combination of the following:

1. Preparation for further production in English, i.e., research papers, conference presentations, international collaborations
2. As a feature of summative assessment in specialist courses requiring English proficiency
3. The belief that medical content is more effectively or easily expressed in English (textbooks and online research not being available in local languages; in-service practice already involving code-switching between clinical English terms and first-language modes of expression.)
4. *The belief that demanding expression in English activated deeper modes of critical or analytical thinking that guided presenters into using accepted rhetorical formulas and schemas (*As one clinician interviewee said, “When we present in English we are forced to be disciplined in our analysis and careful regarding detail. When we do it in Thai, it’s easy to become vague and sloppy.”)

It is notable that no interviewee thought of CP sessions primarily as an opportunity for brushing up underused spoken English skills – although it was understood that this might be a natural by-product of more clinically-oriented goals and purposes. Rather, the ability of clinicians to analyze data and develop a suitable treatment/management plan, which demands problem-solving and critical thinking skills, were given precedence over concerns about formal English accuracy.

Interestingly, on several occasions, once the CP proper had been completed, the follow-up discussion became a mishmash of code-switching as discussants deliberated not on the English forms used in the CP but on the acceptability and accuracy of the diagnosis or proposed treatment/management plan. Since such exchanges were entirely unscripted and spontaneous, allowances were made for the inclusion of the mother tongue.

Did the CPs correspond to a standardized formula?

A comprehensive synoptic CP would tend to contain the following core sections:

• ID (basic patient data)
• CC (Chief Complaint)
• HPI (OPQRST– onset provoking factors quality region +radiation severity time — associated symptoms, risk factors/complications)
• Physical Examinations (including review of systems, vital signs, HEENT, palpation, visual symptoms)
• PMH (past medical history – including surgeries, hospitalizations, underlying conditions, trauma/injuries, allergies)
• Current medications/recent or immediate past history (IPH)
• Family History (FH/Fx)/Social History (SH/Sx)
• Investigations (labs/imaging/biopsy etc.)
• Summaries (list of problems and pertinent findings), initial/provisional diagnoses, post-admission development
• DD/Dx (differential diagnosis), assessment (operative approaches), and management plan
• Follow-up (including treatment successes/failures, post-operative findings)

However, and of particular interest for healthcare English instructors, in no actual case observed did the clinical presenters adhere precisely to this formula. Rather, pertinence to the type of clinical case often demanded that large sections of this synopsis be omitted or severely truncated. Overly comprehensive presentations, in which irrelevant or insignificant details were included, occurred only among student presenters who were likely being careful not to omit any item of possible interest in the presence of their instructors. Unfortunately, however, such an approach had the upshot of obscuring or minimizing the more pertinent data.

In many cases, data arising from history taking interviews was elicited through audience/peer participation. In most other cases, the first seven sections listed above (ID through SH) were covered in a span of less than a minute with the bulk of the presentation focusing upon the investigations, treatment/management, and follow-up. This feature may be of significance to those English instructors whose backgrounds are from outside healthcare fields as they may tend to overemphasize the more layman-friendly history data at the expense of the often more clinically-compelling and pertinent post-history taking sections. Summaries of pertinent findings and related problem lists (the ninth section listed above) took up far more presentation time on average than most of history taking data.

The type of clinical department in which the CP was being performed also had a significant impact in terms of prioritizing presentation order. Below are three brief examples:

1. In anesthesiology CPs, the history of the patient was almost negligible. 90% of such CPs focused upon the events surrounding treatment, where the anesthesiologist’s role is paramount.
2. In surgery, the physical examination tended to serve as a baseline for further explanations and was thus given greater emphasis.
3. In OBGYN/Pediatrics, recent developments and changes post-admission were given priority as regular updates on the status of the mother/fetus are paramount.

Local religious and social considerations also figured occasionally in the FH/SH sections, while traditional medicines/treatments were occasionally referred to in the treatment section.

Considerations for EMP Instructors

At a linguistic level, a number of interesting phenomena were noted. First, in every one of the CPs observed, the presenter was a non-native English speaker. As a result, often, articles, verbal agreement, plurality, and other formal features of English were omitted or rendered in a non-standard form. In almost no cases however did this impede the communicative content of the clinical data, and, on the rare occasion when clarification was called for, negotiation ensued. In many cases, speakers assumed non-standard English forms consistent with emerging English as a Lingua Franca (ELF) speech. This further suggests that formal English accuracy not be confused with communicative clinical efficacy.

Also of particular interest to language instructors may be the number of occasions in which speakers failed to use an appropriate academic/professional register. While specialist field English terminology was second-nature to almost all participants, standardized sub-technical phrases, or what might be referred to as ‘formulaic academic phrases’ were often not deployed by novice presenters, distinguishing them markedly from the more proficient presenters. Appropriate examples of such phrases included:

‘The presence of X indicates the likelihood of Y’

‘SH was significant for high alcohol intake but was otherwise unremarkable.’

However, one prominent example drew an immediate repair response from an adjudicator:
Presenter: …stuff will come out.
Adjudicator: …foreign agents will be discharged.

This, then, is an area in which the EMP instructor might be of particular value to non-Anglophone healthcare workers.

Finally, the use of abbreviations and acronyms were particularly widespread in speech when delivering CPs. Among those regularly noted were: HEENT (head, eyes, ears, nose, throat), PTA (prior to arrival), GA (gestational age), NS (not significant), PR (peripheral), and CBC (complete blood count). Although practitioners tend to acquire these forms in vivo, EMP teachers should at least become familiar with the most common forms.

In short, CPs are a core speech event within many clinical settings and it is therefore imperative that non-Anglophone clinicians master this skill in order to manifest their membership within the international medical discourse community. If EMP teachers understand how this speech event is structured and managed, they can better aid in having their clinical learners achieve this goal.

Mike Guest has been Associate Professor of English in the Faculty of Medicine at the University of Miyazaki, Japan, for twenty years. He has recently published a novel, The Aggrieved Parties.