For many years, non-European doctors who wished to register with the GMC (General Medical Council) had to prove their competence in English by first obtaining a band 7 or 7.5 in the IELTS exam. This initial hurdle was often the most difficult and time-consuming, sometimes involving repeated attempts at the exam over periods of two or three years. But then in February 2018, the situation changed. The GMC announced that it would be accepting a grade B in the Occupational English Test as an alternative to IELTS 7.5. The NMC (Nursing and Midwifery Council) had already made the move. Many of the doctors that I was teaching at the time treated the news with something like joy, feeling that now they would be playing on home ground with a medical English exam. Teachers and trainers were rightly more cautious. The fact is, however, that nearly two years later, the overwhelming majority of doctors now choose to prepare for OET rather than IELTS and, although the exam is still challenging, most of them seem to pass it within a noticeably shorter time.
So what skills does this new exam require and what blocks does it perhaps remove? As with IELTS, the section that students need most help and guidance with is often the writing paper. This consists of a set of case notes which provide the input for a letter writing task, most typically a referral letter. Superficially, this looks easier or at least puts the candidate under less pressure than the IELTS writing exam as there is only one task of 180–200 words in 40 minutes (plus 5 minutes reading time). It does, however, require careful sifting and grouping of the information. It is of course also daunting for the non-medical EFL teacher, who will be faced with acronyms and short forms s/he may not be familiar with and references to test results and drug prescriptions that s/he may not understand.
“Instilling the idea that the content and organisation came first, and that the language was there as a means of expressing their ideas in the clearest and most convincing way, was often an uphill struggle.”
Selection of information
In the OET writing, unlike IELTS, there is no generation of ideas involved. This perhaps removes one of the biggest barriers to success, as doctors would often struggle with unfamiliar topics in the IELTS task 2 writing paper. Here, all of the input for the task is provided by the case notes. The first instruction on the rubric tells the candidate to ‘Expand the relevant notes into complete sentences.’ The word ‘relevant’ is key, as the notes contain many more facts than can or should be included in the letter. It is here that the non-medical teacher will probably feel most disadvantaged. Acronyms can be Googled, purposes of drugs quickly checked online if necessary, but as a layperson, I am not always in a position to judge whether a particular fact is relevant to the patient’s current situation. Trainers will need to check their perceptions against the students’ knowledge here, but can still provide tasks where they are asked to rank or classify information according to its relevance. ‘Relevance’, of course, is a spectrum rather than a yes/no dichotomy; most of the information provided might become relevant in a particular scenario, so the question is about what is most immediately relevant. As part of this, the principle of keeping the intended recipient in mind and considering what they will already know, what they will not know and what they need to know (a very familiar one to the general teacher of writing skills) is very important for making the right judgments.
Grouping of information
As in IELTS, there is no one fixed template which can be used to organise the information in the writing task; rather, two or three different possibilities which may be adjusted slightly according to what needs to be communicated. A common communication model used in many health care organisations is known as SBAR (situation, background, assessment, recommendation). This can be easily adapted to form the basis of paragraphing for most letters, with some of the categories possibly split up into two paragraphs or one or two extra sections added as necessary. The kind of activities traditionally used to develop writing skills such as deciding on paragraph order or inserting pieces of information into the correct paragraphs are useful here. Students can also be given paragraph headings based on the SBAR model and asked to pick out information from the case notes that they think should be included in each one.
Transforming the notes
Once the planning stage is done, then students can move on to the actual writing. The task here is to transform the case notes into full sentences. This is familiar territory for the general EFL/ EAP teacher. It is also a skill which is not required in IELTS and one where students will often need a fair amount of practice and support. After discussing what words are typically left out in notes (articles, pronouns, small grammar words), small sections of case notes can be given for students to transform into sentences or paragraphs. This will probably throw up a number of issues related to sentence structure, grammar or punctuation, which can either be dealt with at the time, or in a subsequent session. Traditional gap-fill exercises focusing on the types of words that will need to be supplied, such as ‘insert a/an, the or no article into the gaps’, or ‘mistakes’ correction exercises can all be helpful here.
‘But it’s a language exam!’ was one of the most frequent objections I heard during my years of preparing doctors for IELTS. Students would often approach the exam convinced that the way to pass was to use (or, as it often turned out, misuse) obscure items of vocabulary or complex, wordy expressions and grammatical structures. Some even tried to work to a kind of checklist (at least one ‘although’ sentence, at least one inverted conditional …). Instilling the idea that the content and organisation came first, and that the language was there as a means of expressing their ideas in the clearest and most convincing way, was often an uphill struggle.
In the OET exam, this issue has certainly not gone away. In one sense it is more acute than ever, as the writing task requires the relevant information to be compressed into a letter of just 180 to 200 words. This means that there must not only be strict criteria of relevance, but the content must be expressed very concisely. On the other hand, students are better able to appreciate that busy doctors will want to be given the necessary information as quickly and clearly as possible and not be bothered with obscure words or flowery language. To this end, they can be given guidance in how to include a number of pieces of information in one summarising sentence. For example, in the case of test results, a list of normal results can be summarised and the one or two abnormal ones highlighted with a sentence such as Examination of the cardiovascular system revealed no significant abnormalities except for a mid-diastolic murmur. Language work on elision and using parallel structures is also helpful here, as is work on word types, so that words from different grammatical categories can be manipulated and slotted into different structures, rather than requiring a new sentence.
Practising doctors of course have to be acutely aware of different registers so that they can switch from simple or colloquial language when talking with patients to the more technical terms they will use with colleagues. This is not much of an issue in the OET writing exam, as they will normally be writing to another health professional. The level of formality of the letter, however, does have to be carefully judged so that it does not come over as over-deferent or inappropriately authoritarian. Again, keeping the recipient in mind here is the key: what does s/he as a health professional know, what does s/he not know about this particular case and who is going to make the decisions and take responsibility for aspects of the patient’s care?
It is clear that the subskills tested in IELTS and OET are significantly different. There is no creative thought or generation of ideas required in OET and the planning and organisation comes in the form of deciphering and reformulating notes rather than as a response to visual information, as in IELTS task 1. Other aspects of the writing skill, which are only in the background in IELTS, such as awareness of the audience, are here very much to the fore. Yet for all that, there is much that can be transferred over, and the differences are perhaps not quite enough to explain the greater rates of success among doctors taking OET, compared with the older exam.
There are, I believe, a number of studies by cognitive psychologists which suggest that context can play a key role in determining whether certain skills are activated or not. Children or adults may perform poorly on tests of cognitive ability or skills development when they are presented in an abstract or unfamiliar way, yet do much better when these same tests are dressed up with situations or equipment drawn from their own culture. Perhaps in future, comparative studies of the pass rates in the IELTS and OET exams may provide us with a further example of how empowering a familiar context can be when it comes to the development of seemingly unrelated linguistic skills.
Norman Whitby has an MA in TEFL from the University of Reading and since 2001 has worked largely with refugee health professionals in the UK. He has authored books on Business English and co-authored a number of publications for IELTS. His most recent publication, co-authored with a GP, is Dear Doctor, a book to develop writing skills for the OET exam, now available on Amazon.