The CSA: Cultural and Linguistic Issues

Celia RobertsDepartment of Education and Professional Studies

King’s College London

Celia.roberts@kcl.ac.uk

Outline of the session

1.Cause for concern: the ‘under performance’ of minority ethnic candidates, particularly those who graduated overseas.

2. Can social theory help us understand these complex factors?

3. Simulations4. Linguistic capital : Examples of problems5. Evaluation of failed candidates6. The interpretation of generic indicators: a short activity 7. Conclusions: ‘You’ve failed. How does that make you

feel?’

Cause for Concern-1• Persistent gaps between white British and all BMEs and even wider

gaps between UK grads and overseas grads, over a range of undergraduate and postgraduate assessments ( McMannus et al 1996, Wakeford et al 1992, Roberts et al 2000, Wass et al 2003, Haq et al 2005, Dewhurst et al 2007).

• The causes of these gaps is multifactorial.

• Good news is that the oral exam which shows the widest gap of all 4 components has now been discontinued i.e.

UK OverseasGraduates Fails Graduates Fails• Oral exam: 7.7% 35.9%• Consulting skills 12.8% 26.8%(2006 RCGP annual report)

Causes for Concern - 2

However persistent gap in the nMRCGP (2008 interim unpublished report)

CSAFails by place of graduation: Fails by ethnicityUK 8.4% White 6.7% Europe 28% All minorities 32.3%Non-Europe 46%

NB Not for comparison as somewhat different groups

Are these the right categories?

• The gap cannot be readily or totally explained in terms of where graduated or ‘command of English’ although these are significant contributory factors.

• HE success overwhelmingly in terms of class rather than ethnicity (Reay 2005). It may not be appropriate to talk of a white-ethnic minority divide (Modood and Shiner 1994).

• Many students in UK undergraduate programmes have received most of their education outside the UK.

• Self-reporting of first language use is surprisingly low compared with the numbers of BME candidates overall.

• ‘Command and control of English’ is under-defined and over-simplified. Everyone is on a continuum.

Can social theory help us here?• Pierre Bourdieu - good for thinking with• • ‘Habitus’ – ways of standing, speaking, walking and so feeling and

thinking (including values, ideologies, assumptions, perspectives etc) (Bourdieu 1990). A system of dispositions (notoriously vague and indeterminate) but habitus positions you within the social structure.

• These dispositions are products of early opportunities and constraints, particularly early socialisation within the family.

• Habitus functions within a market place where certain capital (cultural, social and linguistic) sits along side economic capital.

• Those in power have the most of this ‘symbolic capital’ and people are judged (and judge themselves) in relation to it. It gives ‘a feel for the game’ according to the particular circumstances. e.g. playing snooker in a working man’s club demands a different habitus from the CSA for the MRCGP.

Linguistic capital• The capacity to produce language appropriate to a particular market.

(so ‘command and control of English’ takes on a specific meaning).

• Linguistic capital is gradually acquired over time within the family, through education and the opportunities offered and sought during professional training.

• Much medical linguistic capital is in the mode of every day conversation e.g. ‘pairing phenomenon’ when the gloomy news is given first and is followed up with a sunnier turn as in ‘This is potentially serious but there is a very good recovery rate’.

• These everyday modes of conversation blend easily with the informal professional talk of the consultation. So those who hear more of this kind of talk until it becomes part of them (embodied) will find it easier to produce in CSA exam.

Acquiring Linguistic Capital

• Those who graduated overseas are the least likely to have acquired it. And those who came to Britain to do their undergraduate training may also have trouble being socialised into this new form of capital.

• But also British working class and ethnic minority groups are less likely to be socialised into this form of linguistic capital. Dissonance between home and school/university for these groups. Middle class ethnic minority students from private and grammar schools more likely to learn the necessary cultural capital at home and at school/university.

• Those whose habitus has prevented them from acquiring the dominant linguistic capital will have ‘less feel for the game’. Its harder to be ‘a fish in water’.

‘Double Consciousness’

Du Bois’ notion of ‘Double Consciousness’ among minority ethnic professionals: compartmentalisation , maintaining distinct cultural spheres in which the personal, private and affective (closely related to ethnic/cultural consciousness) is kept separate (Bell 1990).

(Impact of this on the challenge of consulting with simulated patients)

Conclusions from social theory

• Those who were trained or educated overseas have to develop at least some aspects of a new habitus if they are to acquire the linguistic capital required to meet the criteria of the CSA.

• But any working class student may have some learning to do and many working class BME students will have the fewest opportunities to be socialised into this habitus and acquire the appropriate capital.

• Candidates are on a continuum of class and language/cultural socialisation. No easy categories and so need more nuanced data collection.

Simulations - 1• Despite many thoughtful studies on simulation (Hawthorne et al

2006, Denney et al 2006) most studies of the use of simulated patients are only concerned with ‘successful mimicry’ of real situations (Seale et al 2007).

• However, candidates’ inner psychological experience (anxiety about being assessed and self-monitoring) may be at odds with their expected performance (being empathic). Just as actors’ performance on stage may not correlate with their inner experience (wondering how the performance is going) (Konijn 1997).

• Seale et al argue that managing simulations i.e. both the inner and the outer experience may well be related to a general facility in language in interaction i.e. managing frame ambiguity/multi-tasking.

• And those with a ‘feel for the game’ will have the capacity to be ‘hyper –real’ in order to play to the examiner.

Simulations - 2

• So, this puts additional pressure (i) on those who have relatively less ‘linguistic capital’ and so less ‘feel for the game’ (ii) the double consciousness of BME candidates – where have a double simulation: the activity itself, the compartmentalisation of self, particularly in those areas of sensitivity and empathy which are crucial to being successful in the CSA.

• It is possible that the CSA puts more pressure on non middle class BME candidates and those who graduated abroad than the old style consulting skills exam of real consultations.

Examples of lack of linguistic capital

• Over-modelling• Result of required ideological shifts (e.g. towards a more

‘patient centred’ approach) and lack of support in developing appropriate linguistic resources (changes in habitus).

• So gap between knowing the model and how to realise it in practice.

• Recipe like, formulaic both in terms of relating to the patient and in managing the consultation. The bones of the consultation stick out through the flesh

• Overall driven by a model of the consultation

1 Managing elicitation: data gathering/ exploring Examples

• Over direct and/or formulaic, very little mitigation or hedging

• D: Did you know why we did the X-ray? Too much direct questioning to elicit expectations• Eliciting concerns e.g. • D: Is there anything particularly worrying you ? (When

the patient has already expressed her worries)• P: Ive had heart problems and I was told to come in to-

day D: Just going through your medical records, you have

been hypertensive for some time.• (re. taking Warfarin) P: I’d rather not.. Im not keen D: Is it mainly because you forget taking that?

2. Managing the management plan. Examples

• Being pedagogic in an advisory role

D: Lets summarise - could you summarise what you’ve got from this

D: Tell me what you have understood by this consultation

D: Can you just repeat what you’ve got from the consultation

3. Rapport/involvement/sharedness/ picking up on cues

1.Imagining how the patient may be feeling and the problem of trained empathy. Interrogating rather than building on patients’ talk

e.g.. A patient is given bad news about abnormality in the lungs (possible asbestosis)

D: ‘How does that make you feel?’ (before giving the bad news) D: ‘Are you on your own?’ ‘Where’s

your wife?’ (which elicits the answer that he and his wife live together).

Later: P: This uncertainty is very difficult – not knowing D: it could be another two weeks P: Yeah D: OK so now, going back to the same question (i.e. if wants to go

straight to hospital)

Rapport etc (continued)• 2. Finding common ground• Picking up or not on the patients’ language

e.g. overly categorical: D: we don’t treat blood tests we treat patients – so sets up a rhetorical debate

between the patient and the doctor re. how to treat patient’s concerns re. prostate cancer.

• (Later) D: it’s a good idea to have the test because you worry about it. Not checking or mitigating before labelling

• e.g. candidates talk about patient in terms of ‘your obesity’

• e.g. D: this is a high risk pregnancy without mitigating the bad news – (no sunny pairing) or appropriate used of auxiliary modal verbs i.e. verbs such as ‘may, should, might etc.’ used inappropriately: ‘She should be upset’ (Instead of ‘she must be upset’) ; ‘You will be having a lot of questions’

Explanations

Empathy/Clarity mix

• Doesn’t explain nebuliser

• Doesn’t explain ECG tests

• Wrong register – medicalised ‘

• D: There are intermittent phases where your heart beat is irregular – ineffective fibrilation.

Interactional smoothness

• Problems of rapid topic change rather than topic glide

• Lack of metacommunication : D: Now the question is what can you do about it D: I just wanted to explain, we need to make a

management plan• The way the interaction is managed e.g.

candidate speaks in long speaker turns; interrupt the patient

Feedback - 1 (from the 2008 interim report)

Most frequent comments made of failed candidates, with non –UK graduates more likely to under-perform in these areas:

1. Does not develop appropriate management plan. (Unsurprising since the development of management plan draws on the whole consultation)

2. Does not develop shared management plan3. Does not identify patients’ agenda/preferences or make use of cues4. Does not recognise the challenge5. Too Dr-centered6. Does not use relevant and understandable explanations7. Disorganised and unsystematic gathering of information

2 - 5 Sharedness, communicative sensitivity, patient-oriented6 - 7 Clarity and organisation of communication

Feedback - 2

• All of them require a sensitivity to the detail of speaking and listening in interaction which depends upon developing the linguistic capital required of the CSA.

• Frequent comments about the evidence of weak candidates’ interpersonal skills:

• Eye contact• Didn’t ask open questions• But neither of these in isolation account for the way the

whole interaction is going. They are often proxies for more subtle features and their placement at particular moments in the consultation.

Generic IndicatorsInterpersonal skills - 1

• Positive indicators: Negative indicators:• Explores (agenda) Does not inquire• Appears alert to (cues) Pays insufficient attention to • Explores (the impact) • Works in partnership Instructs the patient• Enhances (patient autonomy)• Responds( to needs) Shows little interest (no

warmth)• Backs (own judgement • appropriately) Inappropriately influences• Acts (in an open manner) Appears patronising• Is co-operative and inclusive

Generic IndicatorsInterpersonal skills - 2

• Positive indicators more open to interpretation than negative ones

• So, easier for the candidates who are ‘fish in water’ who share the same interpretive processes as the examiners and so have more leeway in the consultation. They have a feel for the game and so can bend the rules a little as examiners feel comfortable with them.

• Easier for examiners who know intuitively how these verbs should be realised

• Problematic for candidates who are given feedback but no linguistic resources to deal with identified failings.

Activity: From ‘Doing the Lambeth Talk’

Activity: Developing an analytic language to talk about how to realise these generic indicators for use in assessment and on preparation and re-sit courses.

Dr P with Latin American patient who has an on-going

problem with high cholesterol.

Assess his interpersonal skills according to these generic indicators or any other criteria which seem useful for the task. Describe the detail of his mode of consulting in as complete a way as you can.

Conclusions• Step back from the exam and think about ways of helping students

to develop an appropriate habitus and linguistic capital at the undergraduate and training levels. Language socialisation is a long process. Many students/ trainees may not recognise this.

• Develop an analytic language and ways of supporting those on preparation and re-sit courses by working on the detailed ways of realising the positive generic indicators.

• Background the models/ communication techniques and foreground listening, relating and a more organic mode of interacting

• Acknowledge the challenges of the double simulation for many minority ethnic group candidates and provide opportunities for plenty of practice.

• No easy categories for collecting data: need a more nuanced approach which takes account of when candidates came to the UK, when they first learnt English and more research on the undergraduate/trainee socialisation process.