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Sectional­ Survey of Staff Physicians, Residents and Medical Students

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Sectional­ Survey of Staff Physicians, Residents and Medical Students Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-044240 on 26 March 2021. Downloaded from Influence of language skills on the choice of terms used to describe lung sounds in a language other than English: a cross-sectional survey of staff physicians, residents and medical students Abraham Bohadana , Hava Azulai, Amir Jarjoui, George Kalak, Ariel Rokach, Gabriel Izbicki To cite: Bohadana A, Azulai H, ABSTRACT Strengths and limitations of this study Jarjoui A, et al. Influence of Introduction The value of chest auscultation would be language skills on the choice enhanced by the use of a standardised terminology. To ► To our knowledge, this is the first study to examine of terms used to describe lung that end, the recommended English terminology must sounds in a language other than the transfer to language other than English of the be transferred to a language other than English (LOTE) English: a cross-sectional survey recommended lung sound terminology in English. without distortion. of staff physicians, residents and ► True sound classification was validated by computer- Objective To examine the transfer to Hebrew—taken as medical students. BMJ Open based sound analysis. 2021;11:e044240. doi:10.1136/ a model of LOTE—of the recommended terminology in ► Participants were from the same hospital—which English. bmjopen-2020-044240 tends to limit the study generalisability—but had Design/setting Cross- sectional study; university- based Prepublication history and different clinical and educational background. ► hospital. supplemental material for this ► Use of more complex sounds (eg, rhonchus and Participants 143 caregivers, including 31 staff paper is available online. To squawk) might have further hampered the observ- physicians, 65 residents and 47 medical students. view these files, please visit ers’ ability to classify the sounds. the journal online (http:// dx. doi. Methods Observers provided uninstructed descriptions http://bmjopen.bmj.com/ org/ 10. 1136/ bmjopen- 2020- in Hebrew and English of audio recordings of five common 044240). sounds, namely, normal breath sound (NBS), wheezes, INTRODUCTION crackles, stridor and pleural friction rub (PFR). Received 29 August 2020 Outcomes (a) Rates of correct/incorrect classification; Lung auscultation has been a traditional part Revised 04 March 2021 (b) correspondence between Hebrew and recommended of the chest examination since the invention Accepted 09 March 2021 1 English terms; c) language and auscultation skills, of the stethoscope. While no other method assessed by crossing the responses in the two languages equals auscultation in providing quick, cost- with each other and with the classification of the audio effective and easily obtained relevant infor- recordings validated by computer analysis. mation about the respiratory system, its value on September 27, 2021 by guest. Protected copyright. Results Range (%) of correct rating was as follows: is limited by the confused terminology.2 Even NBS=11.3–20, wheezes=79.7–87.2, crackles=58.6–69.8, though recommendations on terminology stridor=67.4–96.3 and PFR=2.7–28.6. Of 60 Hebrew have been developed,3–5 significant variation terms, 11 were correct, and 5 matched the recommended in the terms used to describe the sounds English terms. Many Hebrew terms were adaptations persists among health professionals.6–11 or transliterations of inadequate English terms. Of 687 © Author(s) (or their evaluations, good dual- language and single- language To examine this variation, we invited staff employer(s)) 2021. Re- use skills were found in 586 (85.3%) and 41 (6%), respectively. physicians (SPs), residents (R) and medical permitted under CC BY-NC. No However, in 325 (47.3%) evaluations, good language skills students (MS) working in a university- based commercial re- use. See rights and permissions. Published by were associated with poor auscultation skills. hospital in Israel to spontaneously classify BMJ. Conclusion Poor auscultation skills surpassed poor a set of common lung sounds presented to Department of Medicine, language skills as a factor hampering the transfer to them in audio recordings. They were asked to Pulmonary Institute, Shaare Hebrew (LOTE) of the recommended English terminology. classify the sounds successively in English and Zedek Medical Center, Improved education in auscultation emerged as the main Hebrew, taken as a model of a language other Jerusalem, Israel factor to promote the use of standardised lung sound than English (LOTE). Different aspects of the terminology. Using our data, a strategy was devised to survey were highlighted in two companion Correspondence to encourage the use of standardised terminology in non- papers. The first, published recently, found Dr Abraham Bohadana; native English- speaking countries. abraham. bohadana@ gmail. com that poor auscultation skills were the main Bohadana A, et al. BMJ Open 2021;11:e044240. doi:10.1136/bmjopen-2020-044240 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-044240 on 26 March 2021. Downloaded from factor influencing the choice of English terminology.11 midclavicular line and the second intercostal space; (3) The second, reported herein, examined the influence of inspiratory crackles: right posterior basal region at the language skills on the transfer to a LOTE (ie, Hebrew) intersection of the scapular line and a point situated 3 cm of the terminology recommended currently by scientific below the angle of scapula; (4) stridor: over the trachea, societies.3–5 This aspect has practical importance. First, 2 cm above the suprasternal notch; and (5) pleural fric- between- language differences hamper communication tion rub: left axillary region at the intersection of the in teaching and in meaningful exchanges of ausculta- midaxillary line and the fifth intercostal space. tion findings between clinicians and researchers from 10 different countries. Moreover, they can cause divergent Correct versus incorrect sound classification interpretations of the same sound even by caregivers The ability to correctly identify the sounds was determined from the same country. This study aimed to compare the for each sound file by comparing the observers’ response Hebrew terms used by our observers with those recom- with the true classification, that is, clinical classification 3–5 mended currently and with the English terms they used validated by computer analysis.2 In this process, an expert 11 to classify the same sounds previously. selected a segment of the recorded normal sounds that was free of artefacts. A rating was considered correct if a recommended term or an accepted synonym was used MATERIALS AND METHODS to describe the sound (term use ascribed to preference). Recruitment of the raters The use of any incorrect term was ascribed to lack of skills From February 2017 to March 2018, we recruited 143 on chest auscultation. caregivers, including 31 SPs, 65 R and 47 MS working at Shaare Zedek Medical Center, affiliated with the Hebrew Language and auscultation skills 11 University of Jerusalem. Participants were informed The ability to correctly classify the sounds depends about the study by word of mouth. on both language skills and auscultation skills. For each observer, we crossed the sound classification in Questionnaire Hebrew with the corresponding classification in English, On arrival, participants were invited to complete an performed previously by the same observers.11 Four anonymous questionnaire on background information, classes of combined skills were identified, as follows: including demographics, medical status, years of prac- (1) dual- language skills and good auscultation skills: tice and specialty. We avoided questions likely to facilitate use of accepted terms in the two languages to correctly clas- participants’ identification. sify a sound (eg, use of the English term ‘wheeze’ and the Hebrew term ‘tziftzufim’ to classify the wheezes of Presentation of the sounds sound sample number 2), (2) dual- language skills and http://bmjopen.bmj.com/ Next, the participants were invited to listen through poor auscultation skills use of accepted, corresponding loudspeakers to the audio files of five common lung terms in the two languages to incorrectly classify a sound sounds stored in a computer placed in a silent room. The (eg, use of the English term ‘pleural friction rub’ and sound files were taken from a set of processed files in the its corresponding Hebrew equivalent ‘shifshuf pleurali’ to movie.mp4 format, which were deemed to be clean and wrongly classify the wheezes of sound sample number 2), devoid of artefacts, as required for an article published (3) single- language skills and good auscultation skills: use previously.2 The following sounds were presented, in the of a correct term in one language and an incorrect (or no) following order: (1) normal breath sound, (2) wheezes, term in the other language to correctly classify a sound on September 27, 2021 by guest. Protected copyright. (3) crackles, (4) stridor and (5) pleural friction rub. (eg, use of the English term wheeze coupled with, say, the incorrect Hebrew term ‘hirhurim’ to classify the wheezes Classification of the sound files of sound sample number 2} and (4) poor language skills The observers were asked to classify the sounds succes- and poor auscultation skills: use of different, incorrect sively in English and Hebrew in the order they were terms in the two languages to classify a sound (eg, use of played (ie, 1–5). No pre- established list of
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