English as a Lingua Franca for healthcare: Professor Jennifer Jenkins
The teaching of English at all educational levels and in respect of most if not all specialisms/special purposes, tends to be premised on the notion that one kind of English (the standard English of its native and ‘native-like’ speakers) is the most widely useful. However, this premise is questionable even in a mother tongue English country such as the UK where, as Stephen Nickless points out, English is used in medical encounters not only with native speakers but also as a lingua franca”, in which “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”. He goes on to observe that maybe his “refugee colleagues will be better at this intercultural medical communication” than he ever was in his years as a general practitioner (EALTHY Magazine, no. 4 p. 7).
These points resonate strongly with the findings of research into English as a Lingua Franca, or ELF. As is well known, English is the primary language of globalisation, and hence the world’s primary lingua franca. This has resulted in the growth, year on year, of the number of non-native English speakers and, hence, the increasing diversity of English use. Whether we are native or non-native English speakers, we need to be able to cope with this intercultural diversity at both productive and receptive levels. That is, we need to be able to adjust, or accommodate, the way we speak so as to be understood by our particular lingua franca listeners and to tune our own ears into ways of speaking English that are different from our own, not least in the case of intercultural medical encounters.
In this talk, I will present the findings of ELF research and highlight the aspects of ELF communication that have particular relevance to English for healthcare. These include the acceptance of ‘non-standard’ ways of using English, the avoidance of idiomatic language, and the use of accommodation involving both English and the use of other languages.
ESP, the teachers and their purpose: the case of medical communication: Professor John Skelton
“Medical communication” (MC) is a term most associated with teaching fluent speakers of a language, “English for Medical Purposes” (EMP) with less fluent speakers. What is not well understood is the similarity between the two. My central contention is that good EMP teachers can use their understanding of education and language to work effectively at all levels of fluency. I shall endeavour to illustrate this argument by presenting cases from our work with fluent and less fluent students at Birmingham.
In some areas - academic reading, or conference presentations – best practice teaching may be identical to both fluent and less fluent students. The apparent dissimilarities come, naturally, with less able speakers. Even here however there are major contributions which EMP teachers can make. The ethos of contemporary clinical education is to prioritise aspects of professional development, such as the ability to reflect, to be and appear ethical and compassionate, support colleagues, understand how to work within an institution (eg a hospital), etc. Good EMP practitioners should understand they are likely to have, or find it easy to acquire, expertise in many of these areas, by virtue of their training as educators, and their interest in language – through which, after all, these competencies are mediated.
I believe we underestimate what we are capable of. For example, these professional competencies are needed in all professions, not just medicine. Perhaps too often ESP teachers are regarded as “just” English teachers: we should develop a rationale which gives us confidence to resist this perception.
Communicative Competence in English for Nursing: Susan Bosher
A variety of materials have been developed in recent years in the field of English for Nursing, organized by tasks that nurses need to be able to accomplish successfully in the clinical setting. However, the connection between these tasks and the broader theoretical framework of communicative competence is often missing. To bridge this gap, Bosher will first discuss a model of communicative competence that was developed for use in English for Nursing (Pawlikowska-Smith, 2002). This model, which consists of five competencies: linguistic, textual, functional, socio-cultural, and strategic, was used in the development of the CELBAN (Canadian English Language Benchmark Assessment for Nurses), a nursing-specific language proficiency test developed for use with internationally educated nurses who were seeking to re-enter the nursing profession in Canada (Epp & Lewis, 2008). Examples of each competency (linguistic, textual, functional, socio-cultural, and strategic) will be provided, based on the findings of numerous needs analyses and research studies in English for Nursing (Bosher & Smalkoski, 2002; Cameron, 1998; Epp & Lewis, 2008; Hussin, 2002, 2008; Malthus, Holmes, & Major, 2005; Marston & Hansen, 1985; Seydow, 2012). This framework provides a useful way to categorize the various tasks and skills that are essential for communicating effectively in the clinical setting and can be used to develop ESP materials as well as assessments for the health-care setting. It also provides a framework for analyzing the use of English as a lingua franca in the health-care setting.
Speaker: Prof. Reima Al-Jarf
Affiliation: King Saud University, Riyadh, Saudi Arabia
Multiple Equivalents to Medical Terms and Translation: Problems and Solutions
At my college, we prepare translators. Students take several translation courses including medical translation. Translation of medical texts poses several challenges to student translators due to multiple Arabic equivalents to English medical terms. For medical terms such as clinical, intensive care, polyp, and osteoporosis several Arabic equivalents exist. A corpus of medical terms with multiple Arabic equivalents was examined to find out the types, sources of, and factors affecting the availability of multiple Arabic equivalents to medical terms. It was found that Arabic multiple equivalents are characterized by the following: (i) When 3 or more equivalents exist, one is a loan word or an Arabized word, and 2 are synonyms; (ii) some are regional varieties, i.e., different equivalents are used in different Arab countries; (iii) use of different Arabization patterns; (iv) use of different Arabic derivational patterns expressing different shades of meaning; (v) the English word has several meanings used in different contexts; The presentation proposes several teaching strategies to help medical student-translators choose an appropriate equivalent such as: (a) Evaluating all equivalents in terms of ease of use, popularity, accuracy, context and country where an equivalent is used; (b) examining the semantic, morphological, and syntactic context in which a term is used; (c) which equivalent is popular and common in a particular country and/or the sub-field in which a term is common; (d) whether the target audience is a specialist or non-specialist. While translating a medical text, an unfamiliar Arabic equivalent can be briefly defined or explained in a footnote. If a loan word is more common than an Arabic equivalent, the Arabic equivalent can be used in the translation, with reference to the loan word made in a footnote. Reference to regional varieties can be also made in a footnote. Results and strategies will be discussed detail.
Speaker: Emma Brooks
Affiliation: UCL Institute of Education, UK
“Okay, in Spanish?”: communicative practices in a superdiverse London hospital
My thesis investigates the range of linguistic and semiotic resources used in a multi-lingual health setting and how these language practices may affect participant understanding and perceptions of experience. Using the concept of superdiversity, I have adopted a linguistic ethnographic approach, within the context of antenatal medical consultations in a multi-ethnic south London hospital. Although there is a plethora of research in health communication and perceived inequities, few have looked at health interactions in a superdiverse context. Much has focussed on the experience of patients who have English as an additional language, whereas a significant proportion of health professionals, working at the setting in question, were born outside the UK, and/or are also bi-/multilingual. In the context of my ongoing research, I suggest that just as such the linguistic and ethnic diversity of the hospital workforce mirrors the complex textured landscape of the local population, the micro language practices of a medical consultation index the wider linguistic practices of staff and patients, as well as the broader context of the hospital and superdiverse population. This poster will present initial analysis of antenatal consultations, interviews and field notes which appear to reveal a ‘micro’ reflection of the wider heterogeneous population and of some of the communicative practices it has been suggested typify linguistic superdiversity, such as translanguaging and conviviality.
Speaker: Ebtesam Abdulhaleem
Affiliation: The University of Warwick, UK
First-year Medical/Healthcare Students’ Proficiency Levels and Writing Skills required in an EFL Context.
English is the main medium of instruction (EMI) for EFL students attending medical and healthcare colleges at Saudi universities. First-year students are expected to have a high level of English proficiency in all the different English skills including writing. However, there is no clear definition of what high proficiency refers to and what specific skills they are expected to have in coping with the different English requirements in their first year of medical and healthcare colleges. Therefore, a focus on writing with a needs analysis study is conducted to identify the student’s writing proficiency in their first year. To get better insight, more details on the student’s writing skills with further indications of their proficiency levels becomes a requirement. For this reason, the Common European framework of references for languages (CEFR) with its can-do statements was used as the main tool to conduct the needs analysis study. A mixed method approach based on the CEFR scales was used in this study. Proficiency levels needed were quantitatively identified as perceived by medical and healthcare students and their academic staff. The qualitative data was obtained from focus group discussions with students from the different medical and healthcare colleges as well as interviews with the academic staff. The study found that the majority of the students needed to obtain a minimum B2 level in the CEFR scales in order to cope with the university demands. The lack of proper English course for Specific Purposes (ESP) is found to be one of the top difficulties students face in their first year. Basic medical terminology was found to be the most lacked skillset. It also found that the academic staff tends to lower their standards especially towards those enrolled in medical and healthcare colleges with lower proficiency levels.
Speaker: Zhenya Gundasheva
Affiliation: Trakia University, Stara Zagora, Bulgaria
Etymology revisited: healing memory for medical expressions
The aim of the proposed poster is to report the results from a linguistic challenge which took place in a course in English for Veterinary Medicine. We introduced the notion of “etymology networks” which included inquiries about medical terms. As an independent project students had to create a map of related terms and expressions. Learners not only included terms with identical morphemes, but also tried to “translate” creatively common expressions into medical jargon as an amusing way to incorporate their knowledge of Greek/Latin roots into Bulgarian. They were also given information on the mythological and historical origins of the medical expressions, and thus were immersed in the culture of healers and scientists since the ancient times. Learning about etymology gave them a sense of identity and belonging to a special community and contributed to their professional and personal growth.
Speaker: Stevan Mijomanović & Sofija Mićić Kandijaš
Affiliation: Faculty of Medicine, University of Belgrade, Serbia
Medical, Technical, and Semi-technical Terms in English and Serbian
Medical language is not restricted only to doctors and health professionals. Patients, as laypersons, use medical terms and often adopt the terms used by health professionals. Medical terms can be medical, technical, and semi-technical. In our paper medical terms include terms that denote diseases, signs and symptoms, and combinations of everyday and technical terms. Technical terms imply terms used exclusively by medical professionals. Semi-technical terms incorporate terms that have different meanings in general and medical language. In this paper we give an overview of some of the most common examples that illustrate erroneous translation equivalents not in accordance with the linguistic system of the Serbian language. Due to the given situation, we offer appropriate translation equivalents. Our findings can be applied for lexicographic and didactic purposes, which is extremely important in medical education. In conclusion, we find these results valuable for further research in medical bilingual studies.
Speaker: Nataša Milosavljević
Affiliation: Faculty of Medicine University of Niš, Serbia
Application of contemporary approaches and methods in teaching medicine and medical English
In recent years medical studies in English have been organised at the Faculty of Medicine University of Niš. Considering the fact that English is the lingua franca of medicine, proficiency in English will enable students, future doctors to establish contact and participate in scientific exchange with colleagues abroad.and become equal members of global medical community. It is believed that the methods and strategies used in teaching medical English could be helpful when it comes to medical subjects. The instruction models including case studies, problem-based learning, task-based learning and project-based learning provide an ideal setting for shared learning among teaching staff. Specialist teachers use English as a tool for acquisition of medical knowledge and achievements. On the other hand, it is necessary for Medical English teachers to be acquainted with basic medical terminology depending on the specific context. Such a relationship proved to be highly challenging and inspirational for life-lasting personal and professional development.
Speaker: Yukako Nozawa
Affiliation: Wasada University, Japan
Repair of non-understanding in history taking: an analysis of communication between medical students and simulated patients in English as a Lingua Franca
This study investigates how Japanese student doctors and simulated patients from overseas co-construct understanding by repairing non-understanding situation during primary care consultations in English as a Lingua Franca (henceforth ELF). Doctor-patient communication has been robustly researched as significant to medical care (e.g., Kaplan et al., 1989; Roter, 2000), and conversation analytic perspective has revealed how doctors and patients contribute to cooperative and collaborative practice (e.g., Heritage and Maynard, 2006). This study particularly focuses on the strategies of repair and the relationship between repair type and strategies and embodiment of empathy and patient-centred care from intercultural perspective by using conversation analysis. In this study, the medical interview sessions were conducted by approximately twenty medical students and several simulated patients. The conversation data of the sessions were audio-visual recorded and transcribed for subsequent analysis. The presentation will illustrate the common repair and initiation types and strategies, and indicate how the difference of repair sequence could affect the embodiment of empathy and patient satisfaction.
Speaker: Tom Rausch
Affiliation: Queen Mary, University of London, UK
The Construction of Risk and Emotional Talk in a Pan-African Heath Organisation in the Fight against Infectious Disease: A Linguistic Ethnographic Study
In the context of an infectious disease outbreak, effective risk communication within health organisations and with the public is essential to the fight against infectious disease. Previous studies have identified a discrepancy between the media and major health organisations in the framing and presentation of risk around infectious disease to the public. While the framing and discursive construction of health risk by the media has been given considerable attention, this process within health organisations has been exposed to limited study. This project is thus interested in how risk around infectious disease is discursively constructed and presented in the intra-organizational and external communication of a health organization.To pursue these ambitions, a linguistic ethnographic study is undertaken in a pan-African health consortium using English as a lingua franca annd founded during the most recent Ebola outbreak in West Africa. Drawing on the literature on risk, social constructionism and Appraisal, the study analyses the internal (discursive and thematic content analysis of intraorganisational board and working-groups meetings) and external (thematic content and frame analysis of conference/workshop speeches, public interviews, published articles) communication of the organisation. Supported by interviews with NGO members, the study examines the discursive construction of risk and the role of the language of emotion in this process, as high-risk contexts such as pandemics, and risk assessment have been identified to be substantially influenced by appraisal. The study aims to contribute to a more encompassing understanding of how messages about health dangers are constructed and framed internally, and how this lies in connection with a health consortium’s public presentation of health risks. With this poster, I would like to present preliminary results of the ongoing analysis of this project.
Speaker Catherine Richards
Affiliation Swansea University, UK
For your own good: The use of modal verbs to express obligation and requirement in patient information leaflets
This presentation reports on research carried out into the patterns of modal verb use in written patient information, with a specific focus on modal verbs used to express obligation and necessity. A 200,000-word corpus of written radiography patient information in English was analysed for occurrences of both core modals and semi-modals. This quantitative analysis was then followed by a detailed, contextualised analysis. Results showed an unexpectedly high rate of modals of obligation, along with modals in general, and a strong preference for should and need to over have to and must, with need to used three times as often as have to and four times as frequently as must in the corpus. These results were not found in a corpus of radiography or a corpus of consumer information where should appeared as the most frequent modal verb of obligation with have to, need to and must being used with similar frequencies. The high overall rate of modal forms in patient information supports the view that it is a genre of discourse that contains elements more commonly found in spoken language, as does the frequency of need to, a semi-modal that has seen an explosion of use over the last decade, particularly, though not exclusively, in spoken discourse. The results of the study illuminate the means by which patient information can express a control act (i.e directive, request or advice) in a non-threatening manner through the choice of certain modal verb forms over others: need to, for example (and to a lesser extent have to) is often used in patient information to present an obligation as a recommendation presented for the sole benefit and good of the patient. The findings also suggest that the interpretation of modal verbs in English by native and non-native warrants further investigation.
Speaker: Désirée Verdonk and Hans Platzer
Affiliation: University of Applied Sciences Wiener Neustadt, Austria
The role of vocabulary size in reading medical science journals
Vocabulary size is key for adequate reading skills, with Laufer (1989), Nation (2001) and Milton (2009) reporting that knowledge of 95% of running words is necessary for text comprehension. This 95% coverage has been associated with a knowledge of 5000 word families (Milton 2009) and appears to be based on fictional or general interest texts, while vocabulary coverage in science journals is less well-researched. Consequently, this paper investigates the impact of vocabulary size on third-year students' comprehension of papers in radiology technology. The student sample (n=28) achieved an average vocabulary size of 7500 words (min. 5300; max. 10200). However, 7500 word families only ensure knowledge of 89% of running words of a representative radiology paper, with 5000 words generating 86% coverage, i.e. below the necessary 95%-threshold. Nonetheless, students did not report comprehension problems, nor did a reading quiz give rise to concerns. Consequently, a further factor supporting students' comprehension must be at play, which is presumably the presence of radiologic and anatomic terminology, which should be familiar from students' technical subjects. Indeed, if this terminology is assumed to be known, 5000 words families from general English generate knowledge of 94% of the running words in the relevant paper, with 7500 words generating 95% coverage, and hence adequate understanding. This study therefore concludes that knowledge of at least 5000 word families from general English needs to be complemented by the relevant technical terminology to achieve 95% knowledge of the running words in a representative medical science paper.
Speaker: Veronica Willcock
Affiliation: Acibadem University School of Medicine, Turkey
Writing for an academic audience is a particular skill that even native English speaking university students must learn. This lack of writing skill can lead to plagiarism, which is a huge issue in the academic writing produced by university students, particularly in their second or third language. Very often it is not deliberate, but due to factors such as time constraints, a lack of confidence in language ability, and cultural differences surrounding the topic. The Medical English Programme at Acibadem University School of Medicine has employed several different writing tools and techniques in our curriculum to combat extensive plagiarism present in student produced work. These tools and techniques have covered every angle of the academic writing process from initial research, organizing, structuring and phrasing, to preparing final drafts for publication. The poster will show the effect these tools have had on the level of plagiarism of first and second year students in the 2016/2017 academic year.
Speaker: Petra Zrníková
Affiliation: Jessenius Faculty of Medicine in Martin Comenius University in Bratislava, Slovakia
Overgeneralization Errors in Slovak Learners of English
The presentation is based on the theory of contrastive analysis of two distinct grammar systems of which one belongs to the West German family group of languages and the other one to the Slavic languages. The session is aimed at the most common mistakes made by Slovak medical students who have achieved English proficiency at the level B2/C1. The students were participants in the preparatory course for examination in the UNIcert III (C1) certification system. The system was established in Germany. The certificate, focused on academic mobility, is recognized mostly in the Central Europe. The candidates should be fully capable of meeting the linguistic requirements of a work placement or period of study in the country of the target language without the need for additional explicit language training. From our point of view, errors are normal and inevitable features indicating strategies that learners use. We believe that errors should be taken as evidence not of failure but of progress in language acquisition. The key issues are follows. 1) Comparison of English grammar system with other languages – the most common mistakes that learners make. 2) Teaching strategies and types of activities. 3) Criteria and descriptors of writing skills assessment. The analysis revealed that the most common mistakes are punctuation, spelling changing lexical meaning, misuse of articles and discourse markers.
Interpreting the voice of medicine: Healthcare in a multilingual and multicultural environment. Envisaging access to healthcare as a universal right, the EU Commission White Paper of 2007 states that ‘Health is central in people's lives and needs to be supported by effective policies and actions in Member States’. Access to healthcare necessarily depends on effective communication between patients and healthcare professionals. However, when the two parties do not share the same language (either native language or lingua franca, such as English), communication may be compromised. This is where healthcare interpreters come in. These professionals usually work in hospitals and healthcare institutions, facilitating communication between foreign patients and local healthcare operators. This panel intends to offer an outlook on the role and tasks of healthcare interpreters, providing an insight into the multifaceted aspects of the profession and the various challenges multilingual and multicultural communication poses. Presentations will deal with multilingual healthcare communication in multivariate settings, ranging from classic doctor-patient consultations to remotely interpreted interactions and simultaneously interpreted healthcare-related conferences.
Eugenia Dal Fovo (University of Trieste)
Interpreter-mediated doctor-patient interaction: the case of Italy.
Interlinguistic exchanges of various nature and in very diverse communication contexts of society have been increasing in frequency quite steadily in the past few decades, and have embraced almost every aspect the everyday-life world of social care, courts, schools, and healthcare. When foreign individuals do not know the language of the country they live in, their access to social and healthcare services can only be ensured through the presence of an interpreter. Interpreter-mediated communication, where interpreters work face to face with their clients, poses a series of challenges that sensitively differ from those pertaining to monolingual interaction. As far as the world of healthcare is concerned, interpreters working in hospitals and healthcare institutions are pivotal in facilitating communication between foreign patients and local healthcare operators. This study aims at investigating healthcare interaction first and foremost as a form of institutional talk-in-interaction, which, when interpreter-mediated, requires an adjustment of discourse practices and configuration, with a shift in the distribution of powers in terms of turn allocation and interaction coordination. Real-life recordings of interpreter-mediated doctor-patient interactions were collected in the city of Trieste, Italy, over a period of two years, and were subsequently transcribed and analysed. The focus of this study is the use of English as lingua franca by non-Italian-speaking patients and its implications on interpreter-mediated doctor-patient interaction. Recurring phenomena in the examined interactions are identified and studied from a functional point of view, with particular attention dedicated to the repercussions of ELF on the interlocutors’ behaviour, interpreters included. Analysed communication instances are considered as a specific kind of discourse, rather than a mere deviation from the norm - i.e. monolingual doctor-patient interactions and/or interpreter-mediated doctor-patient interaction between native speakers, and are observed not only in terms of language transfer, but also in terms of empathy display. The results of the study, which are still preliminary in nature, have been presented to healthcare interpreting trainees at the University of Trieste: they have been discussed in the classroom and used to devise role-play exercises that simulate interpreter-mediated doctor-patient interactions (with English-Italian language combination). Simulations were recorded and analysed, in order to identify the major difficulties in simulating responsibility-taking and raising trainees’ awareness as regards their role in communication.
Simo K. Määttä (University of Helsinki)
Boundaries, agency, and empathy in healthcare interpreter-mediated communication
Within the public service environment, interpreting is based on various boundaries. First, language itself is bounded: we conceptualize languages and language varieties as bounded entities. This is the basis for the identity function of language. Language professions such as translation and interpreting are also based on this language ideology. At the same time, the very goal of interpreting is to break communicative boundaries in a situation in which the migrant and the public service provider do not speak the same language. Interpreting can therefore be conceived as a tool for the politics of hospitality, and the interpreter’s function is to ensure that migrants can exercise their agency. The extent to which migrants can exercise their agency depends largely on the interpreter’s agency. Several boundaries restrict the scope of the interpreter’s agency: professional code of conduct, role expectations, and self-preservation. These boundaries are particularly salient in sensitive settings such as interpreted encounters related, for instance, to mental health. Therefore, in sensitive settings, the connections between boundaries, agency, and empathy become acutely visible. Healthcare interpreters often emphasize the importance of interpreting the affective dimension of language in sensitive settings: they stress the importance of showing empathy and building rapport with the migrant as an ethical responsibility because it is an essential tool for breaking communicative boundaries. For the interpreter, empathy therefore emerges as an essential tool for enabling the migrant to have greater agency. Nonetheless, the relationship with the migrant has to remain professional: interpreters have to protect themselves from excessive alignment that may lead to vicarious traumatization. However, professional codes of conduct fail to take into account affect and focus on the referential dimension of language. Consequently, healthcare providers may regard visible empathy on the part of the interpreter as excessive alignment display and collusive behavior.
In this paper, I will explore such conflictual situations in extreme cases. In these situations, rather than being a tool for linguistic justice and politics of hospitality, interpreting runs a constant risk of being a tool for linguistic injustice, therefore generating ethical stress to the interpreter. The paper is based on participant observation as a public service interpreter and translator, and semi-structured interviews of public service interpreters.
Claudio Bendazzoli (University of Turin)
English as a native, non-native, and working language in healthcare conferences mediated by simultaneous interpreters: a case study
English is now regarded as the international lingua franca, enabling native speakers of other languages to understand each other in international and intercultural situations (Jnekins 2007; Seidlhofer 2010). This unprecedented spread of a shared means of communication has had a profound impact on the translation and interpreting (TI) industry (Albl-Mikasa 2010, 2013; Reithofer 2010; Taviano 2013), creating new challenges and opportunities at different levels in terms of both training and professional practices. In this paper I analyze a healthcare conference involving native speakers of Italian, native and non-native speakers of English, and two professional interpreters (with English as their active working language and Italian as their native language). The different language configurations are discussed not only from a linguistic perspective, but also in terms of floor and information management, highlighting advantages and limitations of medical English used as a working language and as a lingua franca.
Speaker: Claus Brockmeyer
Affiliation: FHS St. Gallen, Switzerland
Learning to do a “Vinnie” – and to go beyond
This workshop replicates the teaching of cardiopulmonary resuscitation (CPR) and the use of an Automated External Defibrillator (AED) to nursing students at Bachelor level at the FHS St. Gallen, University of Applied Sciences. The approach is based on a Content and Language Integrated Learning methodology (CLIL). In addition to the practical aspects of CPR, we also include more detailed knowledge about anatomy, physiology and clinical findings in a patient requiring resuscitation efforts. Furthermore, we focus on a deeper understanding of Basic Life Support principles, as well as selected aspects of Advanced Cardiac Life Support. The content is primarily delivered in English as the target (foreign) language. To facilitate students’ understanding, there are occasional episodes in German, the mother tongue of the majority of students. In the classroom, we use materials and tasks typical for language learning, e.g. gap filling papers, pictures and videos. Naturally, a manikin and an AED Trainer come into play for hands-on experience.
Speaker: Sylvia Goetze Wake & Kristin Andrikopoulos
Affiliation: Universite de Lausanne, Switzerland
Roles, rules and realisations: exploring intercultural communicative competence in the medical English classroom
By defining a number of concepts in intercultural communication, this workshop aims to lead participants in an exploration of identity and interaction between multiple cultures. We will begin by revisiting the question of cultural identity, exploring teachers’ and students’ “individual cultures” with an aim to go beyond the traditional (national) view of cultural identity. This mind-set of multiple identities will then be extended to patients and how they are viewed and referred to in various health care settings. As a way of opening up the topic of intercultural communication skills, we will analyse the resulting unique culture that is created in each of our own classrooms. We will challenge the assumption that rules, procedures and expectations are self-evident, drawing on the research and ideas of Adrian Holliday to provide a theoretical basis. Each participant (and their students in the future) will be encouraged to become aware of and verbalise their own experiences and preferences in the classroom. Finally, we will apply our discoveries about diverse classroom practice to the medical environment of the students, giving participants the opportunity to create practical, context-based models. Our ultimate goal is to encourage participants to reflect on their own practice with medical professionals (both as a teacher and possibly as a patient) as well as on their intercultural experiences in the classroom and the field of health care.
Speaker: David Stamm
Affiliation: ZHAW Zurich Univeristy of Applied Sciences
Developing Reading Strategies in Bachelor of Science in Nursing programme
A majority of students in the B. Sc. in Nursing programmes in Switzerland start studying after their Federal Vocational Baccalaureate (Berufsmaturität), where they reach a level of English equivalent to B1 in the CEFR. At rather an early stage in their bachelor studies students will have to read academic texts in English that go far beyond their general language skills. Even more advanced learners of English often consider such academic texts as ‚difficult’ or ‚unreadable’. In order to bridge this gap, specialised language courses have been developed that introduce nursing students to a number of reading strategies and support them in tackling their academic reading tasks in their core subjects. In this workshop we will present and discuss a number of hands-on reading strategies that have been tried out with a number of classes at ZHAW (Zurich University of Applied Sciences). A brief look at vocabulary-learning strategies in the academic context will be followed by a number of exercises at text level that should help intermediate students to come to terms with formal academic texts, i.e. abstracts or (parts of) longer studies. The input part will be followed by a discussion and exchange of best-practice ideas.
Speaker: Clark Stoppia, Switzerland
Cultural Intelligence (CQ) What is it and why is it important for care givers.
This presentation with mini workshop will explain what CQ is by breaking it down into its four sub-dimensions; Action, Drive, Strategy and Knowledge. The explanation will be demonstrated though a series of actual CQ reports. Additionally, the evolution of IQ to CQ will be touched upon. Throughout the presentation there are several short videos that further illustrate all these points. The seven cultural values used in CQ are discussed. The mini workshop will give the participants the opportunity to work with the four sub-dimensions of CQ in a real case of their own choosing. Cultural Intelligence is the Intelligence that we all need when we come into contact with people from other cultures. Please note this is other cultures not impersonal country/nation box labels. Care givers have interactions everyday with people of other cultures, some of these interactions are deeply personal and demand sensitivity. CQ should be part of this sensitivity training for all care givers at any level from nurse helper to senior doctor. Even what is considered simple communication is a cultural maze. In many countries yes should be best understood as no in a North-Western European culture. The opposite can also be true. At the end of the presentation each participant will have been exposed to a way to evaluate both their own culture and the culture of the person they are attending to and to have learned more than the knowledge of different cultures but also the strategy, action and drive to handle other cultures and their own ability to grow and work in culturally diverse situations.
Speaker: Larry Zoumas, Sweden
Create Your Own Medical English Elearnings
In this hands-on workshop teachers will get instruction on how to create their own elearning materials which they can use with their students as well as share with other teachers around the world. Simply by entering vocabulary terms and definitions teachers can create a unit of material containing Vocabulary, Multiple Choice and Gap-fill activities. The participants can later record or upload sound files to automatically create Listening and Speaking activities. There is no programming involved.
Also available is the ability to add a Reading activity, which can also have audio attached as well. Simply by creating a Reading and adding some comprehension questions, the system will automatically generate a Writing activity which they teacher can grade interactively. For examples of the kinds of units teachers can create please see www.MedicalEnglish.com. All existing units were created with this authoring tool.
Speaker: Virginia Allum, UK/Australia
Challenges of working with international CALD
Discussion of the challenges of working with international CALD (Culturally and Linguistically Different) staff and students in the UK, in particular the influx of CALD professionals from the EU and also refugees. It has been noted that some CALD students who are enrolled in health professional courses make inadequate progress in their courses. This may reflect a lack of understanding of the importance of having their needs satisfied or may be a symptom of insufficient university support in the area of cultural competency. There is ample anecdotal and academic evidence of this. Whereas previous medical English courses have focussed on language acquisition and competence, there is a growing appreciation of the need for an awareness of cultural sensitivity and an understanding of hospital culture. The discussion will start with a short presentation outlining the background of the issue and suggesting some possible solutions. A previous presentation and discussion on this topic to Gold Coast University Hospital Nurse and Southern Cross University Nurse Educators, as well as Lecturers from Griffith University (Australia) was well received with a lively discussion of possible solutions held afterwards. It would be hoped that this could be replicated at the EALTHY Conference 2017.
Speaker: Dr. med. Silke Collins-Tracey
Affiliation: Bern, BZ Pflege, Switzerland
Expressing empathy in a second language
Showing empathy towards people who are ill is a highly motivating factor in choosing the nursing profession. To show an interest and understanding of another person’s suffering can be a challenge as well as a privilege. Showing empathy can be regarded as an innate skill, but one that can also be learned and/or enhanced. Empathy in the healthcare setting consists of four attributes: cognitive, emotional, behavioural, and motivational. Any programmes to enhance and enrich the ability to show empathy via strategies and methods must therefore address these attributes. This can be done by early clinical exposure, by exposure to role models, literature and the arts, as well as with role-plays. Research has shown a decline in the expression of empathy by medical personnel in recent years, particularly since other aspects of healthcare (e.g. administrative tasks, technically-focused diagnosis) leave less time for pure nurse-to-patient contact. If showing empathy is not always easy at the best of times for a native speaker, it will inevitably be harder to show this vital, human skill in a hectic healthcare setting, in which the patient and the nurses do not share the same mother tongue. In most such cases, English is the language in which healthcare professionals communicate with a patient whose mother tongue is different from that prevalent in this particular setting. This ‘dialogue’ will demonstrate how the skills of showing and enhancing empathy can be incorporated into the teaching of English for the nursing profession. This is done by presenting empathy-enhancing skills that can be demonstrated in the classroom (e.g. role playing, practising communication skills, showing empathy through certain expressions and non-verbal skills), as well as by conscious reflection about one’s role in a healthcare setting that requires the use of English as the common language.
Speaker: Claudia Schlegel
Affiliation: BZ Pflege, Bern, Switzerland
Successful roleplaying in English for Healthcare
There is ample evidence, that communication skills training indeed improves healthcare professionals ‘communicative competence. Communication skills can be trained with role-play. Role-play is a way of working through a situation, a scenario or a problem by assuming roles and practicing what to say and do in a safe setting. This kind of learning experience has several benefits and advantages when it is well implemented. Teachers can supplement their teaching methods with role-playing in any context where it seems relevant. When teachers use role-playing as instruction, students have the capability of developing deeper involvement and knowledge about a issue. As an educational tool, role play and simulation are very developed in medical education. The goal of this session is that teachers who teach English for healthcare providers get an idea how to implement role-play into their teaching concept.
Research & Practice Oriented Presentations
Speaker: Prof. Reima Al-Jarf
Affiliation: King Saud University, Riyadh, Saudi Arabia
Teaching and learning with online medical animations and videos
Many students, enrolled in colleges and universities that use English as a medium of instruction, have difficulty understanding lectures in specialized courses delivered in English such as medicine, dentistry, pharmacy, biology, biochemistry, anatomy, physiology and others. They also have difficulties reading specialized texts and learning specialized terminology. To help students enrolled in English for medicine courses improve their listening, speaking, reading and writing skills, expand their knowledge of medical terminology and fill the gap in their background knowledge, English for medicine courses can be supplemented with online medical animations and videos. The presentation will show the following: (i) the advantages of integrating medical online animations and videos; (ii) the relationship between medical animations and videos and meaningful learning; (iii) give a sample of websites where online medical animations and videos can be downloaded; (iv) show a sample of online medical animations and videos; (v) describe the criteria for selecting online medical animations and videos; (vi) medical video genres and themes; (vii) where to post animations and videos; (viii) outline the skills that can be developed through supplementary online medical animations and videos; and (ix) give examples of activities that use animations and videos to develop listening, speaking, reading, writing skills and medical terminology knowledge; (ix) phases of teaching and learning with online medical animations and videos: Before watching the animation, while watching the animation and after watching the animation; and (x) describe the teacher's role. It will conclude with some recommendations such as creating an online medical animations and video repository.
Speaker: Nahed Arafat
Affiliation: School of Languages and Cultures, Sheffield University, UK
The complexities involved in teaching and training of medical professionals
Health care professionals regularly deal with people from different ethnic and cultural backgrounds who may have unanticipated cultural needs and with whom they may not share a common language. In addition, health professionals as well as interpreters in the medical field have repeatedly voiced concerns about the difficulty to communicate information to patients due to the untranslatability and/or unavailability of equivalent words in patients’ languages. Drawing from my own experience as a mental health worker, interpreter and a PhD researcher in the School of Languages and Cultures, this presentation aims at highlighting the varieties of meanings embedded in words and cultural references that patients may use when reporting their emotional experiences. It also points out the importance of bringing real life stories as articulated by patients into teaching and training modules. Furthermore, this research provides an opportunity for medical health professionals and researchers to understand how linguists can be involved in providing more insights into the issues facing the medical profession, particularly where language and cultural differences are an added challenge. This includes the need to review medical education and teaching interpreting training to ensure the provision of better inter-cultural communication and medical interpreting services.
Speaker: Begoña Bellés-Fortuño
Affiliation: Universitat Jaume I, Castellon, Spain
Popular Science Articles vs. Scientific Articles: a Tool for Medical Education
During the 19th century the need to make science more accessible to the public resulted in the emergence of a new type of written genre, the popular science article (Meadows, 1987). In this study, I will contrast the structure of scientific RAs and popular science articles as well as some linguistic features such as the use of discourse markers and evaluative language in both genres. Here, I analyse a corpus of four articles: two popular science articles taken from one of the top ten websites on popular science called Science Daily and two scientific articles published in a prestigious medical journal, The Lancet. The topic in the articles is the same: arthritis. To be able to compare and contrast the articles more effectively, corpus analysis tools have been used to analyse the linguistic features above mentioned. This article aims at showing how popular science articles can be used as pedagogical material for the teaching of Medicine, as they are more easily understandable for students (Parkinson & Adendorff, 2004) and therefore bringing about a more intuitive learning process. On the other hand, scientific articles are a source of medical knowledge and should be taken into consideration accordingly. However, medical students in their first years at university who have never been exposed to academic and scientific articles may find the reading and understanding of this academic type of written genre difficult and arduous.
Speaker: Emma Brooks
Affiliation: UCL Institute of Education, UK
“How do you feel?”: the role of language in medical consultations in a superdiverse population
In an attempt to address poor maternal and infant outcomes and to encourage women from minority ethnic communities to access antenatal provision, the local Public Health lead for inequalities commissioned bespoke antenatal classes for women who speak English as an additional language. Following the success of the classes, and additional qualitative research which highlighted difficulties with the readability of patient literature, funding has been extended to encompass discrete health classes for the 800 strong ESOL student population, at the adult education college where I am employed. Health topics were selected by targeting local health concerns such as immunisation, diabetes and screening programmes. Graded and differentiated material has since been delivered through series of termly workshops: student feedback reflects knowledge acquisition and behaviour change. In turn, interview data is used to inform an annual seminar which is part of the graduate GP training programme. Raising awareness of language in the consulting room, this seminar explores the role of communication in addressing health inequalities. In an ethnically, linguistically and culturally diverse society it is ever more likely that practitioners and patients will communicate in a lingua franca. As such, it is vital to explore alternative methods of communicating information to ensure patient understanding and informed choice. This session will share teaching resources developed for learners with little or no literacy, whilst simultaneously using their feedback on patient information and consultation experience to raise awareness of possible barriers to successful communication.
Speaker: Katarzyna Dynia
Affiliation: Medical University in Łódz, Poland
Certifying Medical English Exams - ACERT
University students who learn Medical English mention the need for a form of testing that would reward them with a language certificate displaying the level of their skills in the area. In response to this need Medical University in Łódź, Poland, decided to introduce ACERT- a new language exam that has been developed by SERMO- The Association of Academic Foreign Language Teaching Centres. The aim of the presentation is to show not only the exam, which evaluates students' Medical English skills at several CEFR levels (B2- C1), but also to describe the preparation process prior to implementing this form of standardised assessment. So far the exam has been organised at two Medical University Departments: Medicine and Biochemistry, next two- Dentistry and Pharmacy are to be included next year. What are the benefits for both parties: students and academics? How do both sides evaluate this form of testing? What is the national and international recognition of ACERT? A very practical presentation, packed with task examples, opinions, reflections.
Speaker: Falina Norred + Daniel Forgrave
Affiliation: University of Calgary in Qatar
Finding the Correct Form for Written Digital Feedback in Asynchronous Writing Appointments
Our writing centre at a branch campus in Qatar adopted asynchronous e-feedback to address the particular needs of nursing students who work full-time and balance family lives. The written feedback we provide has been developed through a process of trial and error and anecdotal feedback from our students; it includes error identification, metalinguistic explanation, and provision of further resources to support self-efficacy. We are currently assessing the effectiveness of the written feedback we provide. The question of appropriate feedback on written composition has been widely debated, yet the discussion in the literature is primarily restricted to either language learners or writing composition curricula and focuses on the question of whether and how to give feedback. Little has been written that provides alternative models for feedback beyond grammar correction or error identification. What research there is on online writing support focuses on approaches that aim to reproduce the face-to-face writing centre appointment; however, our experience has shown that face-to-face interaction is not always possible nor is it always desirable or culturally accessible. Our concern and focus is the provision of asynchronous digital written feedback using the Microsoft Word commenting function to advance the academic writing skills of non-native English speaking students. Our goal is to refine and improve the form of asynchronous feedback in a way that is usable and moves the student towards autonomy. The efficacy of this type of feedback with regard to practice and pedagogy will be presented based on our personal practice and research. Participants will be encouraged to further this discussion through their own experience and understanding.
Speaker: Samantha Gouyette
Affiliation: Universite de Lausanne, Switzerland
Collaborative learning to develop reading skills using online tools
This presentation will explore issues faced in the module “Understanding and analysing scientific articles in Nursing Sciences”, developed by the University of Lausanne Language Centre. Students in the course were of mixed levels and at different stages in their Masters’ programme. The questions which arose in early stages of the course planning were: Which skills should be developed? Should the focus be on language, reading strategies or scientific methodology? What material could be used? A collaborative online environment (in Moodle) proved useful in allowing students to work in an active and autonomous way while benefitting from each other’s experiences. They were asked to support each other’s reading comprehension via online discussions (in forums), had to collaborate on written summaries (in wikis) and were encouraged to record their learning in a journal. The teacher’s role was that of a facilitator giving feedback, clearing up misunderstandings, and promoting discussion. This form of “blended learning” made it possible to devote classroom time to discovering different reading strategies and developing the language required to understand the structure of scientific articles. Ideas and comments welcome.
Speaker: Michael Guest
Affiliation: Faculty of Medicine, University of Miyazak, Japan
FAPS: The Crucial Role of Formulaic Academic Phrases in Spoken Medical Discourse
The crucial role that competence in using formulaic phrases in academic writing is well established. Less well-known is the role that they play in clinical speech events, particularly in establishing academic credibility, where they serve as an indicator of membership within the international medical discourse community. For non-native English speaking medical professionals in particular, competence in deploying these academic formulaic phrases in both clinical and academic encounters can help expedite entry into the international medical community. However, although these forms deserve the attention of English for medical professionals (EMP) teachers, the teaching of lexis in medical discourse has traditionally focused more upon lower-frequency and narrow-range specialist terminology. After a brief outline of the role and function of formulaic academic phrases in spoken medical discourse, this presentation will report on a short study undertaken among undergraduate medical students in Japan which indicates that learners tend to focus on acquiring arcane specialist terminology rather than those higher-frequency formulaic academic phrases that are applicable across health-care related disciplines. Moreover, even when they are aware of such phrases, the knowledge tends to be passive, meaning that learners are often unable to deploy them effectively in clinical speech events. This may well hinder their ability to fully participate in established English medical discourse community speech events, such as those common to academic conferences, in-service study/research groups, and clinical case presentations, in the future. As a result, this presentation concludes with a call for EMP teachers to give greater emphasis to learner acquisition of these spoken forms within their own teaching curricula.
Speaker: Katja Hämäläinen
Affiliation: Helsinki Metropolia University of Applied Science Nursing and Health Care, Finland
Combining Professional Language Teaching and Learning with Simulation: Patient Cases for Emergency Care Students
Language teachers as any other teachers have always aimed at using authentic written material to provide students with opportunities to see how languages are used in real-life situations. Simulation takes this one step further: instead of written material, students have a chance to practice their language and communication skills in a situation they are likely to face later in reality. In my presentation, I shall present a language learning session where emergency care students practiced their English (L2) language and communication skills as well as their emergency care skills. The group consisted of second-year emergency care students who studied English as their obligatory L2 language and attended a course in Professional English for Paramedics. The course was taught and led by an English teacher, and a teacher in emergency care was present in simulation, which was one of the teaching methods in the course. The simulation environment presented a home with normal furniture. The language teacher played the patient’s role whereas the emergency care teacher took care of technology and provided information on the patient’s vitals when necessary. The students working in pairs played the roles of paramedics who came for a home visit with some pre-information of the patient and the emergency dispatch code. Each pair had a different patient case. The level of emergency care and language skills needed in the case varied, so each student had a chance to a stimulating and rewarding simulation experience. In the presentation, I shall present the patient cases in more details. Moreover, I shall describe what it took to design and implement language teaching sessions in simulation in co-operation with another teacher, the teachers’ experiences of it and what kind of responses the students gave afterwards.
Speaker: Éva Demeter and Csilla Keresztes
Affiliation: Medical Communication and Translation Studies, Faculty of Medicine, University of Szeged, Hungary
The language of effective doctor–patient communication: an approach of teaching history taking to medical students in English
The medical interview or clinical history taking is one of the most important clinical tasks performed by clinicians on a daily basis. As part of our medical curriculum, medical students should be familiar with this task and acquire advanced communication skills during their university studies.When taking the medical history two main elements are involved: history taking content and history taking process. History taking content is commonly referred to as information gathering, it is concerned with the “what” part of the medical interview; eliciting specific information about the patient’s symptoms, from the presenting complaint to the wider context of the patient’s social and occupational history. History taking process, however, is the method by which information is elicited, and thus is more concerned with the “how” of the medical interview. A fine balance is needed to combine the content and process in order to effectively acquire adequate clinical information without considering either one as an alternative for the other. Evidence suggests that if history taking is done well, it improves patient satisfaction, compliance, symptom relief, and it also results in better health outcomes. We present the linguistic perspective as an integrated part of history taking process and the main goal of our history taking course. We also offer a few tips of how medical English teachers can contribute to better communication of their students who are non-native speakers of English and come from multicultural environment.
Speaker: Lukas Merz
Affiliation: Faculty of Health Sciences, Palacký University in Olomouc, Czech Republic
The HELP project – outcomes and experience
The presentation would like to highlight the innovative aspects of an international Erasmus+ project HELP (Healthcare English Learning Programme), discuss the rationale for the project and advertise its product: a free, innovative, media-supported modular learning programme for healthcare English and intercultural competence for Higher education students and healthcare professionals on the B1/B2 level of CEFR. The project is taking a broad approach for both formal and informal learning setting (workplace) in an attempt to accommodate the needs in communicative skills, professional language and intercultural competence of any healthcare profession. The paper will also deal with an extensive need analysis that was carried out before the material development which uncovered some thought-provoking discrepancies between students’ and teachers’ preferences regarding the form and content of learning healthcare English and intercultural competence. The designed learning material comes in three different forms: an online learning platform running LMS Moodle, a traditional textbook with media attached and a mobile app for Android devices. The presentation will share the experience and feedback gathered in the piloting phase from three different types of users and will invite the audience to get involved, try the materials themselves or share it with students or healthcare professionals. (www.help-theproject.eu)
Speaker: Chris Moore
Affiliation: Specialist Language Courses (SLC), UK
The Realities of a Virtual Medical English School
Teaching medical professionals has its challenges, not least place and time. At SLC, we teach groups of nurses in hospitals around the UK and individual doctors and nurses across the world, from India to the Philippines to the UAE and Saudi Arabia. Getting expert teachers in front of doctors and nurses in remote locations with changing shifts and considerable professional demands to deliver a course on a regular schedule is tough. To meet these challenges, we have set up what is in essence a school in the cloud. We have virtual classrooms, a team of 15 teachers, a director of studies, a virtual staffroom, cloud-based timetables, online materials libraries, attendance tracking, and an on-going assessment cycle. We currently deliver 100s of hours every month in this way. Creating and maintaining this virtual school has been challenging at times to say the least. However, the growth of broadband and digital services combined with highly mobile professionals means that virtual classrooms may be a key element of the future of Medical English education and therefore a necessary challenge for teachers and educational institutions to understand. This talk looks at the journey we have been on and examines the realities of virtual classrooms – from choosing the right software to setting up in hospital training rooms, inducting teachers, engaging students, developing a pedagogy that works, developing materials and troubleshooting the unpredictable. As part of this, I’ll present case studies of our programmes and show video footage of group classes in action.
We encourage questions and contributions from the audience and aim to inform, enlighten and inspire you to experiment with virtual classrooms – now and in the future.
Speaker: Timea Németh, Alexandra Csongor
Affiliation: Department of Languages for Specific Purposes, Medical School, University of Pécs, Hungary
The Use of Digital Tools in Teaching English for Medical Purposes
Several factors have affected higher education during the last few years across the globe, including Hungary. Teachers are facing unprecedented changes and challenges in the 21st century. Due to fast developments in technology digital competences are of major importance nowadays. The increasing significance of digital skills and new opportunities for online collaboration entail new methods in teaching and learning English for Medical Purposes. In order to meet the expectations of the digital native generation, we are regularly integrating various collaborative and educational tools into our classroom practice, such as Quizlet, Kahoot, TedEd, and Padlet. Moreover, previous studies suggest that students are eager to use online tools when studying medical English. These methods can enhance the dynamics and quality of language teaching in a medical context. The aim of the presentation is to share our experience at the Medical School of the University of Pécs, Hungary regarding the use of Web 2.0 technologies for teaching English for Medical Purposes.
Speaker: Patrick Painter
Affiliation: Express Publishing, UK
Specialisation for the 21st Century Workplace
The 21st century workplace has been transformed by globalization and digitalization. To achieve success, learners must develop the specialized English skills and the 21st Century Skills employers require. Career Paths offers a unique approach to ESP by developing students’ vocational English abilities while simultaneously improving their abilities to communicate, collaborate, think critically, and create in both physical and digital contexts.
Speaker: Laura Tommaso and Marianna Lya Zummo
Affiliation: University of Molise, University of Palermo, Italy
Teaching medical students online consultation: reframing the doctor-patient exchange
After qualifying, doctors are expected to refine and develop professional knowledge and competences with a greater emphasis on the communication and consultation skills needed to create and maintain a good doctor-patient relationship. The ‘doctorability’, which is the act of legitimating the patient’s decision to seek medical care during the doctor-patient exchange, has been first studied by Heritage and Maynard (2006). However, the concept has been adapted to the new frames offered by the digital context and, as such, Stommel (2010) talks about the ‘forumability’, which refers to the users’ negotiations and legitimization within the group contributing to health fora. Using Digital Discourse Analysis (Herring 1996, 2007) and Digital Conversation Analysis (Gibson, 2009; Giles, Stommel et al. 2015) approaches, this paper addresses issues regarding the expression of the user’s ‘doctorability’ and examines the strategies used by the virtual doctor to reframe the exchange. Through the detailed linguistic analysis of selected excerpts from online dialogues taking place between doctors and patients, our primary aim is to provide new insights into the iterative patterns to be offered to students of Medicine and Health-related Faculties in order to emphasize the need to include in the medical English course syllabus the major dimensions of online medical discourse from the linguistic point of view.
Speaker: Mark Waistrell
Affiliation: Accent International, UK
“It ain’t what you do, it’s the way that you do it.” (Or “The Return of the Prodigal Son”)
This session looks at the pragmatics of teaching English for Healthcare. Whilst much of research focuses on theory, materials and linguistics, there appears to be a lack of attention to the most important factors in any learning environment – the students, the teachers and the interface between them. What do they actually need? What do they actually want? Does a focus on materials get in the way? How can we best achieve effective learning, rather than improved teaching? Do we really address the specialist needs of this specialist area?