Ahead of his plenary session at the forthcoming International Medical English Conference (10 Sept) in Norwich, Dr Stephen Nickless talks about his involvement with the Refugee Council medical programme.
I speak very good English. My general vocabulary is huge – at least 38,000 words plus thousands of collocations, phrases and expressions. My medical vocabulary adds another 20,000 words though I only need most of those when reading letters and journals or attending lectures. My grammar (spoken and written) is instinctive and invariably ‘correct’ (if ‘correct’ is the Standard English spoken by 10% of the UK population!). But on the Kilburn High Road, where I worked as a GP, most of this was wasted.
Once a week I would see an educated native English speaker who could really appreciate my fluency and erudition. Most of my patients, if they spoke English at all, spoke it as a second or third language. I told friends that I could ‘mime diarrhoea in all 180 languages spoken in Brent’¹.
By ‘trial and error’ I learned to communicate safely, sensitively and effectively using skills I was not taught at medical school. I began to listen more carefully, to speak more slowly, to pronounce more clearly, to use simpler vocabulary, to avoid idiom and jargon. I learned to summarise frequently, to check that I had understood and been understood. I learned to organise complex messages in ways that made sense and could be remembered. I learned to read body language and facial expression, to use gesture, to draw pictures, and to write notes that patients could take home.
And I was interested in people, their lives, how they saw the world, what mattered most to them. What were the circumstances that had brought them, enthusiastically or regretfully, to London? At first there were Holocaust survivors, Ugandan Asians and Persian emigres. Later came those fleeing wars in Kosovo, Iran, Iraq, Somalia, Sudan and now Syria. And there have always been people who spoke something a bit like English – the varieties spoken by Indians, South Africans, Americans and Australians!
Aged 60 my retirement project was to do the CELTA at International House. There I learned that I had somehow taught myself to ‘grade my language’, ‘to accommodate’ and ‘to converge’ with my interlocutor. Though I had never heard of ‘register’ or ‘discourse communities’ it seems that I could easily navigate these choppy waters. On occasion I would even ‘code switch’, with an apologetic smile, using words like merde or Scheiße when stools, faeces or shit had not been understood. And occasionally, when available, I used professional interpreters.
I now work as a volunteer at the Refugee Council. Once a week I and my GP colleagues meet with a group of doctors – women and men – from the Middle East and Africa. After years of uncertainty and unemployment they have permission to settle in the UK. They are preparing themselves to work in the NHS and we are there to support and encourage them. They are the survivors – motivated, resilient, intelligent, eager to learn and to work. They include Paediatricians, Obstetricians, Cardiologists, Neonatologists and experienced Trauma Surgeons with battlefield experience.
One, from West Africa, speaks seven languages including Japanese and Italian. An Afghan and a doctor from Sudan converse most easily in Russian. In Kabul and Baghdad medicine is taught through English but practised in Dari, Pashto or Arabic. In the Refugee Camps in Pakistan the NGO medical staff use English as a lingua franca. All now have good academic English, IELTS 7.5+, but most would struggle to understand colloquial doctor-patient discourse in Kilburn or specialist doctor-doctor discourse in the local hospital. This is where we can help because we are fluent in both.
Mostly we meet to talk medicine. For advanced learners ‘just chatting’ is an effective way to identify lexical gaps and unnatural form. It’s a good way to improve fluency². We discuss cases – clinical and ethical. We study articles in the BMJ. We watch videos of GPs at work. We role play using retired GPs as patients. We teach them to express sympathy and uncertainty. The British are unaccustomed to ‘blunt speaking’ so we practice softening, intensification and indirect communication. In Afghanistan neither alcohol nor abortion are legal so we discuss both. We talk about UK Medical professionalism, patient-centred practice, informed consent, mental capacity, Fraser competence and the duty of candour. And we correct, reformulate and extend the language that we hear.
In London the Building Bridges Partnership³ has developed a pathway for refugee health professionals. It provides careers advice, language lessons, intensive courses to prepare for professional exams and work-experience placements in GP practices. Once registered and licensed to practice our col-leagues move on to special hos-pital posts with close clinical supervision and extra education-al support.⁴ ⁵
My conclusions? In much of the UK doctors need to be able to communicate confidently with native English speakers. In our multicultural cities, where English is used as a lingua franca, all doctors need a high level of language awareness and a deep understanding of the strangeness of our own culture (general and professional) when viewed through the eyes of others. And it helps if they themselves have struggled, in anxious circumstances, to make themselves understood in the French or German that they learnt at school. And maybe my refugee colleagues will be better at this intercultural medical communication than I ever was.
Dr Stephen Nickless practiced as a General Practition-er in a linguistically diverse community in London. He now facilitates weekly educational sessions for refugee doctors preparing to work in the NHS.
¹London Borough where 18% of the population describe themselves as white and British
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