Language Disadvantage in Medical Settings Impact Case Study
Language Disadvantage in Medical Settings
Celia Roberts
1.Summary of the impact
Changes in selection, assessment and training to take account of language/cultural factors in
an increasingly diverse health service have resulted directly from research led by Celia
Roberts. Drawing on sociolinguistic theory to identify the role of language in producing
inequality in institutional settings, this research has led to changes in General Practice
selection and licensing examinations where overseas trained doctors are disproportionately
likely to fail, and to the production of widely used training materials both for British doctors
serving a multilingual population and for overseas trained doctors new to the NHS.
2.Underpinning research
The key research insights relate to how institutions manage linguistic diversity, drawing on
theories of linguistic capital. The research uses micro-sociolinguistic analysis of talk and
interaction to provide evidence of the linguistic penalty suffered by large numbers of black and
minority ethnic groups in gatekeeping selection interviews and health consultations. The
largely hidden role that language and cultural factors play in indirect discrimination and
disadvantage are masked by equal opportunity policies and objective systems. These do not
take account of the role of language in subjective evaluations and reduce language issues to a
simple matter of speaking English or not (Roberts 2011). The impact from our research has,
therefore, depended as much on persuading medical practitioners of the legitimacy of our
methods as on the uptake of our research findings.
The research has explored the institutional practices that unwittingly disadvantage these
groups and identified the language/cultural resources required to manage such institutional
encounters successfully. The research has broken new ground, collecting the first and only
substantive video data sets of selection interviews and clinical skills assessments and of
consultations with linguistically diverse patient populations. It has been funded by the King’s
Fund (1999- 2000), the NHS (through the National Clinical Assessment Authority 2003-4 and
the London Post-Graduate Deanery 2003-5), the Royal College of General Practitioners
(RCGP) (1996-7, 2012 - 13), the Academy of Royal Medical Colleges (2011- 13), Sir
Siegmund Warburg Trust (2001 – 3) and the Technology Strategy Board (2011 – 13, as a
Knowledge Transfer Project) The latter project will lead to significant changes to the licensing
examination for all UK GPs as well as to RCGP disseminated e-learning materials. The
research has been disseminated through peer reviewed articles, reports, book chapters and
briefings and has identified and documented:
 The disadvantages experienced by overseas trained doctors in membership and
licensing exams of the RCGP (1).
 The routine misunderstandings in consultations with patients with limited English and
the communication skills required of GPs (2, 3).
 The linguistic demands of, and knowing ‘how to play the game’ in practice based
assessments of ‘failing doctors’ (4)
 The linguistic and cultural processes of the GP selection interview process which
emphasised interview talk over consultation talk (5)
 The linguistic and performance factors in Objective Structured Clinical Examinations
(OSCEs) in undergraduate medical education (6)
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References to the research
1. Roberts,C., Sarangi, S., Southgate. L., Wakeford, R. and Wass,V. 2000 Oral
examinations – equal opportunities, ethnicity and fairness in the MRCGP British
Medical Journal 320, pp.370-374
2. Roberts,C.,Moss, B., Wass, V., Sarangi, S., and Jones, R. 2005 ‘Misunderstandings: a
qualitative study of primary care consultations in multilingual settings, and educational
implications’ Medical Education 39, pp.465- 475
3. Roberts,C., Sarangi,S. and Moss,B 2004 ‘Presentation of self and symptoms in primary
care consultations involving patients from non-English speaking backgrounds’
Communication and Medicine Vol1/2, pp.159-170
4. Roberts, C and Moss, B 2004 ‘Issues of Language, Culture and Ethnicity in the NCAA
Assessment of underperforming doctors: A discourse analytic study of the Practice
Based Discussion’. NHS National Clinical Assessment Authority
5. Roberts, C. and Atwell, A 2006 ‘GP vocational training selection interviews: a
discourse analysis to assess their potential for discrimination on the grounds of
ethnicity or language’ (2006). NHS London Post-graduate Deanery: General Practice
section.
6. Roberts, C V. Wass, R. Jones, S. Sarangi & A. Gillert ‘A discourse analysis of “good” and
“poor” communication in an OSCE: a proposed new framework for teaching students’
(2003)Medical Education 37, pp.192-201
4. Details of the impact
The research has had an impact on GP assessment policy and on training for doctors from
overseas and for British doctors with linguistically diverse patient populations. This has been
achieved through a mix of interventions: uptake of policy recommendations and consultancy
reports and the production of multi-media teaching materials, based on engaging stake-holders
in the close analysis of interactional data. Our long-standing relationship (over 15 years) with
the RCGP (Roberts et al 2000) has allowed us to address some of the persistent concerns
about the underperformance of overseas trained doctors and international medical graduates.
Building on the earlier changes to the RCGP’s oral membership exam to which our research
contributed and Roberts’ advice to the College on new work-based assessment procedures,
the current Knowledge Transfer Project (KTP), in partnership with the RCGP (2011 – 13) will
contribute to changes in the membership examination and to preparation for it This project has
also led to the design and production of materials, using the video-recordings of the RCGP
clinical skills assessment, available on the RCGP e-learning website for all candidates
preparing for the exam. Part of the participatory design has already included ‘impact readiness’
presentations at GP training days at 8 regional Deaneries (2008-10, reaching over 700 GP
trainers and IMG candidates).
Research on GP-patient communications in highly diverse settings (2,3) led to the production
of two research/data based DVDs funded by the London NHS Post-Graduate for Deanery (i)
doctors and registrars with multi-lingual patient populations, Doing the Lambeth Talk : (ii)
doctors from overseas new to the NHS, Words in Action. Regular training sessions using these
materials has been given at London primary care trusts (2008 – 2010).
All the research cited has been designed as collaborative action orientated research, involving
dialogue with medical practitioners from the start. Joint participation and problematisation has
taken many forms including: early identification of problems with large groups of stake-holders,
observation and participant observation in selection interviewing and examiner training, joint
analysis of data, training for all examiners, sitting on the National Clinical Assessment Authority
Ethnicity and Diversity Advisory Group, co-writing key with decision makers in medical journals
and providing on-going advice to the GMC and the RCGP on issues of language and ethnicity.
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