Multilingual Interactions in Clinical Dental Education: a Focus on Mediated Interpreting Susan M

Multilingual interactions in clinical dental education: A focus on mediated interpreting Susan M. Bridges, Cynthia K. Y. Yiu and Colman P. McGrath The University of Hong Kong, Hong Kong and SAR China

Abstract There are few places in the world where the delivery of health care takes place in mono-cultural contexts. Thus the ‘teaching’ of cultural diversity, development In clinical dental consultations in multilingual con- of cultural ‘awareness’ or gaining of cultural ‘safety’ texts, medical interpreting is often performed by the is a ubiquitous priority in medical education. Yet it supporting staff as part of routine triadic formula- has not been adequately addressed. tions. As academic dentistry becomes increasingly This was reinforced by a following, general call for internationalized, issues of language and culture add a ‘communicative mentality’ in healthcare (Sarangi to the interactional complexity of clinical communi- 2004). The particular need to address the cultural cation and education. A multivariate approach was and linguistic complexities of healthcare interactions adopted to investigate one case of multilingualism in remains a pressing focus for research and education. dentistry in Asia. Collection of both survey (n=86) Indeed, one may argue that, given both the continued and interactional data provided empirical evidence diasporic movement of populations in need as well regarding language use and language demands as heighted global interactions, both physically and across integrated Polyclinics. Descriptive statistics of virtually, across languages and cultures, issues related Dental Surgery Assistant (DSA) perception data and to developing cultural awareness and intercultural conversation analysis (CA) of mediated interpreta- competence are now core to medical communication indicate that, as members of the oral healthcare tion and education (Qureshi 2011). While a growing team, DSAs in Hong Kong are an essential resource field, the majority of research in cross-cultural and in their role of intercultural mediators between pa- intercultural medical communication has taken place tients and clinicians, both staff and students. Discus- in English-dominant or European linguacultures. A sion of sociolinguistic notions of place-as-location recent special issue in the Journal of Asian Pacific and place-as-meaning supports a wider conceptu- Communication (Kang and Zayts 2010) on medical alization of the role of support staff as interpreters communication in Asia has worked to contribute to in clinical settings. Implications are drawn for policy, a widening of the contextual focus of such studies. curriculum and staff development. However, there remains much to be done globally to understand multilingual healthcare environ- Keywords: multilingualism; clinical interaction; med- ments at both the macro and micro levels so that ical interpreting; dental professional education; inter- we can better understand the unique qualities of cultural communication each doctor-patient encounter (Stewart 2001). In seeking to better understand individual encoun- ters, sociological, sociolinguistic and sociocultural 1. Introduction approaches can do much to support contextualized understandings of clinical interactions. The aim of this study, therefore, is to examine multilingualism in In the editorial to a special issue of Medical Educa- one specific Asian context and to better understand tion on the topic of cultural identity and represent- how communication in such an environment is sup- ing culture in medicine, Prideaux (2001: 186) noted ported and mediated. that 198 Susan M. Bridges, Cynthia K. Y. Yiu and Colman P. McGrath

The small-scale study of a dental teaching hospital 2. Language, culture and healthcare as a multilingual workplace and educational institution presented in this paper draws on sociolinguistic The inherent tension and ongoing debate between and conversation analytic traditions to examine monolingual cosmopolitanism and linguistic diversity how languages are used and mediated in one par- (Ives 2006) is not the focus of this paper. However, the ticular healthcare context. In considering context, rapid establishment of English as the lingua franca Johnstone’s (2004) interpretation of a theoretical re- where multilingual speakers adopt it to achieve orientation from linguistic anthropological notions communicative goals (Seidlhofer 2004) remains a of ‘place’ as location to more recent post-structuralist fact of the working lives of health care providers in perspectives of ‘place’ as meaning holds salience multilingual contexts. This growth in English as the for analysis and discussion. The site of investiga- lingua franca of science and medicine is linked to tion is indeed geographically fixed. As such ‘place’ the language’s strong relationship between global is location. Globally, the location is Asia and at the economic and scientific development; its widespread regional level, it is Hong Kong with its strong tradi- usage amongst increasingly diverse communities tion of multilingualism defined in national policy of speakers; and its place within multilingual and educational practice. Additionally, location is communities (Sano 2002; Seidlhofer 2004). While it the site of the study: two clinics in the same dental may be given that English is considered the lingua teaching hospital. However, as analysis will reveal, franca of the medical community, concerns have been ‘place’ also holds import for ‘meaning’ as mediated raised that ‘Almost all communication skills research through language use. To be explored in the ensuing in medicine has a western setting, and it is not known analysis and discussion is how ‘place’ as negotiated whether conclusions based on this research are and formulated meaning impacts upon the language generalizable’ (Skelton et al 2001: 258). As noted in choices made within one location. the introduction to this paper, research in medical This study therefore seeks to provide an evidence communication to date, while grappling more base for commonly shared, long-standing institu- recently with issues of multilingual communities, tional practices and beliefs regarding workplace has worked from a somewhat etic perspective, languages in clinical dental education in Hong Kong. problematizing issues of communication and The approach is ‘bottom-up’ as our intention is to interpretation in English-dominant (McClure 2010; gather empirical evidence on current languages-in- O’Neill 2011) and European countries. Research from use in order to inform language policy, curriculum this perspective includes studies on international design and staff development. Using mixed method- students in medical programmes in English- ology, our aim is to gather baseline descriptive data dominant countries (see, for example, Treloar et al. of the phenomenon at hand whilst also examining 2000) as well as survey and discourse-based studies real-time interactional data on clinical languages- on the impact of cultural and linguistic diversity in in-use. medical communication (Roberts et al. 2005). Work Issues of workplace languages in a multilingual on medical interpreting in Europe (see, for example, community are inextricably bound to the physical Bolden 2000) and the US (see, for example, Tang et and social context in which they are found. If one al. 2011) has investigated issues regarding healthcare is to take the policy approach that language aware- for immigrant populations. The focus of this paper ness is about ‘a person’s sensitivity to and conscious differs in its interest in language use and awareness awareness of the nature of language and its role in within a multilingual cultural context in Asia. Recent human life’ (Svalberg 2007), then, logically, a focus on discourse-based work on triadic interactions in sensitivity and conscious awareness of how language geriatric care and health education in Taiwan (Tsai impacts upon working lives is critical at an institu- 2007, 2010), prenatal genetic counselling in Hong tional level. Gaining understandings of how such Kong (Kang and Zayts 2010; Zhang 2010), medical sensitivity is enacted through mapping workplace phone-in consultations in China (Yu 2010), midwifery language demands should perforce hold implications in Japan (Kawashima 2010), and undergraduate for education. Before examining this local study of medical and dental education in Hong Kong (Lau et clinical languages-in-use in Asia in detail, however, it al. 2001; Bridges et al. 2010) is contributing to the is appropriate to situate dentistry within the broader, literature in Asian healthcare settings but this is in global literature on the relationship between lan- its infancy. guage, culture and healthcare as well as related studies theoretical orientations to the relationship in clinical education. between culture and language hold import for this Multilingual interactions in clinical dental education 199 research. Broadly two paradigms have emerged over communities. Roberts et al.’s (2007) large-scale the last few decades and these can be separated into survey amongst healthcare professionals in a bilingual the cross-cultural and interculturalist traditions. context examined Welsh language awareness in Within the cross-cultural paradigm, the approach Wales, UK. Despite limited levels of Welsh language to sojourner adjustment and cross-cultural man- proficiency within the cohort, they found that ‘those agement is for trainers to ‘help people from diverse with modest proficiency endeavour to use the lan- cultures work together effectively’ (Tjosvold and guage with patients and clients, particularly within Leung 2003: 2). The theoretical foundations for this an informal context’ and recommended increased approach are grounded in Hofstede’s (1983) work language awareness training for minority languages on dimensions of cultural variability and it has led (Roberts et al. 2007: 1183). to development of various intercultural training Clinical education in English medium-of- packages. Such tools, lists and kits have proven valu- instruction universities in Asia has received limited able to the international business or foreign affairs attention. The larger body of published research sojourner. However, such an approach has been concerned with broader cultural and linguistic issues criticized for its focus on homogenizing cultural has focused on issues related to the importation groups rather than on individuals in social interac- to Asian schools of problem-based learning as a tion (Scollon and Scollon 2001). pedagogy originating from the US and Europe While both paradigms are aimed at supporting (Walker et al. 1996; Khoo 2003 ; Bridges et al. 2012). professional communication across linguacultures, In terms of clinical communication education, Lau some interculturalists have critiqued the cross- et al. (2001) examined first-year medical students’ cultural management paradigm as the ‘culture as perceptions of skills acquisition in Hong Kong after practices’ approach arguing that a) it leaves the role playing either ‘interpreter’ or ‘observer’ roles in learner as an observer firmly situated in their own a communication skills workshop. In dental educa- culture; b) it divorces language from culture, and c) tion, Bridges et al. (2010) examined novice and expert it portrays culture as ‘relatively static and homogene- clinician’s communication skills in Hong Kong and ous’ (Lo Bianco et al. 1999: 9). Bennett, Bennett and found that empathy was identified as one area of Allen’s (2003) conceptual framework for the growth further development for third-year undergraduate of intercultural sensitivity charts an evolutionary dental students. Internationally, the role of mediators pathway from ‘ethnocentric’ to ‘ethnorelative’ stages in the clinical communication process has been of characterized by a movement from acceptance to recent interest with an identified need for ‘further adaptation to integration of difference. Following education and support for patients, clinicians and this model, Lange (2003: 277–278) argued that, in interpreters to ensure effective communication across language education, the final goal of integration of language barriers’ (Fernandez and Schenker 2010). difference is evident when ‘individuals find them- Bolden’s (2000) definition of ‘mediated interpreting’ selves in the process of creating an adaptable identity, holds salience for this study as it situates the inter- not based on any one culture, which allows them to preter as one who is called upon to do both normative evaluate situations from multiple perspectives and interpretation as in the style of ‘machine translation’ communicate constructively with the other’. When and also to coordinate communication. considering mediated interpretations in healthcare, In dentistry, community health studies taking a adaptability becomes a key issue. psychometric approach to issues of diversity and oral In what follows, we briefly explore language health are more commonly found internationally. research to date in clinical communication and Adair et al.’s (2004) large-scale study investigated clinical education, specifically with regard to dental parental attitudes and their relationship to children’s education. oral health with findings recognizing the need to understand cultural and linguistic diversity as an issue in health care provision. Issues of cultural 3. Language use, awareness and clinical and linguistic diversity have been raised in English- education dominant countries recently, due, in part, to two phenomena. The first is the pressure caused by Despite the accepted nature of the phenomenon of changing demographics of dental clinics as an effect English as the lingua franca of medicine and science, of globalization and global movement. The second is less empirical research has been conducted in the the increase in ‘outreach’ services to communities that area of languages-in-use, particularly in multilingual have difficulties accessing oral health care services. 200 Susan M. Bridges, Cynthia K. Y. Yiu and Colman P. McGrath

These twin influences mean that practising dentists postgraduate dentists. In the study reported here, we in these countries are currently reflecting upon issues focused particularly on examining the languages-in- related to cultures and languages and service delivery use in Polyclinics as the majority of undergraduate with an ensuing increase in research related to these. clinical education occur in these multidisciplinary Two recent studies in the US and Australia have clinics. explored the key role of interpreters in multilingual For undergraduate student dentists, supervised clinical dental consultations and found implications clinical practice occurs in small groups. In the in terms of clarity of roles and dentist communication Polyclinics, individual students treat their patients skills (Goldsmith et al. 2005; Rowland 2008). under supervision and across a variety of conditions Globally, sociolinguistic and ethnomethodological depending upon the approved diagnosis and research related to clinical dental education is scarce. treatment plan. As part of their Polyclinic learning, Candlin et al.’s (1983) sociolinguistic study in the dental students treat patients in an ongoing capacity UK compared and contrasted novice and expert and establish positive, longer-term professional talk in dental education hospitals. More recently, relationships. ethnomethodological research has begun in this field There are multiple interactants in the Polyclinic in both Hong Kong (Bridges et al. 2010) and the UK setting (including patients; Dental Surgery Assistants (Hindmarsh et al. 2011) (DSAs); dental hygienists; undergraduate students; This study therefore attempts to address identified postgraduate students; part-time and full-time gaps in the literature on clinical communication. academic staff/clinicians). The DSAs were selected First, we focus on one particular place-as-location of as survey respondents for two key reasons. First, they language use in Asia, the multilingual Polyclinic for are permanently stationed in the Polyclinics. It is the dental education. Analysis of survey data presented site of their work and all other interactants move in below provides useful evidence as to which languages and out of the clinics depending upon consultations are reportedly in use and with whom these languages and the wider curriculum (see Chung et al. 2007). are used. Analysis of a small excerpt of recorded Second, in addition to their technical dental support clinical talk provides some further insights into how role, if required, the DSAs will be called on to act as mediated interpreting is enacted in real-time. Finally, interpreters between the various interlocutors. data analysis is used to further explore the notion of While, originally, Hong Kong universities may have ‘place’ in relation to language use. placed greater emphasis on internationalizing their academic staff, recent initiatives are similar to those of Australia in internationalizing the student body. 4. Context Motivations differ, however, with Hong Kong’s interests orienting to global citizenship and interculturality The site of the study reported in this section is the rather than being necessarily more pecuniary in nature only dental teaching hospital in Hong Kong. The as in other countries in the regions (Bridges and Barlett Faculty of Dentistry at The University of Hong Kong 2007). The policy focus on internationalizing the Hong has recognized the multilingual context of clinical Kong student body has resulted in an increase in inter- work and has made a clear stance to indicate a national undergraduate and postgraduate students pragmatic approach to language policy: as well as international staff. Indeed, defining who is ‘international’ or what constitutes ‘international’ The medium of instruction for, inter alia, PBL tutori- becomes a slippery task when one considers the als, briefing and debriefing discussions during clinical global experiences and educational backgrounds of sessions, practical classes, laboratory sessions and 1 many of the staff and students in a large research-led resource sessions of the BDS curriculum, other than chair-side teaching, is in English. university. These globalized lifeworlds combined with Board of Faculty of Dentistry, 2008 institutional initiatives to internationalize contribute to varied language use in this specific environment. While recognized anecdotally and in policy, to date, empirical evidence of actual language demand is limited. This paper reports on part of a larger investigation into language practices at the point of 5. Methods contact – clinical dental education. Clinical work requires the accomplishment of service provision to As noted in the introduction, the purpose of this patients who have knowingly registered as teaching small-scale study was to provide empirical evidence cases for the education of undergraduate and to document and better understand the dimensions Multilingual interactions in clinical dental education 201 of workplace language demands in clinical dental The questionnaire aimed to capture information education. In what follows, we examine both spoken on the languages used and with whom they were used language backgrounds and workplace language and was therefore designed into three sections: demands. The key research question addressed was: what language demands do DSAs experience in 1. Personal profile (age, gender, place of birth, Polyclinics? place/s of education); 2. Personal language profile (education, social); and 5.1. Participants 3. Work-based language profile (clinical speak Dental Surgery Assistants (DSAs) from two different ing, reading, writing; interpretation of spoken dental Polyclinics in the same hospital were and written language). originally surveyed on two separate days over a two- With the exception of some personal data and week period in 2008. The study occurred during the reporting on interpretations, a 10cm Visual teaching semester so that routine clinical teaching Analogue Scale (VAS) was adopted. The end activity would be reported. Demographic data descriptors on the scale indicated a range from indicated the DSA participants were all female and ‘not at all’ to ‘all the time’. For the majority of items, all were locally trained. Eighty per cent were born respondents could choose to indicate their language in Hong Kong and the majority (58%) were aged use across all three official languages of the Hong between 31–40 years. Kong Special Administrative Region (HKSAR): Cantonese, English and Putonghua. Additional 5.2. Data collection and analysis work-based language options under ‘Others’ were To achieve the study’s aims, a multivariate approach included after the trial. to data collection and analysis was adopted (Heritage Following the daily journal approach, a daily and Maynard 2006; Bridges et al. 2010). First, a language use log in the form of a questionnaire language use survey was conducted with Polyclinic was distributed for each of the data collection days. DSAs using a logbook approach to provide self-report Questionnaires were distributed to consenting data on language use in clinics. In addition, three participants just prior to the start of the morning consenting dentists, DSAs and their patients were clinical sessions. These were then collected at the audio recorded during routine clinical interactions. end of each day. After completing the background While the questionnaire items asked the DSAs to information on personal language profiles (Day One), report activity across speaking, reading and writing participants were asked to record their daily work- skills, the data and analysis presented in this paper based language activities. Originally, respondents focuses on reported language use regarding spoken were asked to record information over two days across languages in dental clinics. A more detailed focus a two-week period. These days had been nominated on spoken languages drawing on conversation by the Senior DSAs as ‘high usage’ days with near- analysis (CA) explores one sample of a multilingual capacity use of clinical bays in both morning and consultation as it occurred in situ. afternoon sessions. As each clinical session is three hours, this was seen as sufficient to provide baseline 5.2.1. Questionnaire data on language use. A third day of data collection A new questionnaire was designed for this study. was included at the request of some of the DSAs Some items related to language use in social settings who self-nominated an additional ‘interpretation- were adapted from the Welsh Language Survey intensive’ day in the clinic. The total return rate of (Welsh Language Board 2006). The remaining questionnaires across the two clinics was as follows: items were devised, trialled and redrafted by the Day One: n=41; Day Two: n=42 and Day Three: n=3. project team (including clinical teaching staff). The Therefore, across the total of 42 participants, 86 penultimate version of the questionnaire was then questionnaires recording daily language use across tested with two key senior DSAs responsible for 18 hours of clinical teaching activity were completed supervising daily operations in the two Polyclinics. and analysed. Day One data (n=41) was analysed Based on their feedback, further refinements were for DSA background information while work-based made, specifically in relation to inclusion of minority language data is based on the total number of daily dialects. Data for each day was recorded as mutually questionnaire returns (n=86). Data for all VAS exclusive as no trace identifiers were given to the items was measured to the nearest decimal point anonymous survey returns. and entered into SPSS. Additional information on 202 Susan M. Bridges, Cynthia K. Y. Yiu and Colman P. McGrath spoken interpretation was recorded as frequencies. 6. Questionnaire results Descriptive frequencies using mean scores for 6.1. Personal language profile: spoken continuous variables (i.e. VAS scores) and raw numbers (i.e. for categorical variables) are presented The majority of the participating Dental Surgery in section 6. Assistants (DSAs) reported using Cantonese as their spoken medium during both their primary 5.2.2. Institutional talk and secondary education; however, there was a We adopt Conversation Analysis (CA) as an analytic marked shift from Cantonese to English in secondary tool to examine how a multilingual and multicultural schooling. Socially, the DSAs also used Cantonese context may affect the sequential organization of as the dominant spoken medium across the three institutional talk (Drew et al. 2001; Pomerantz and listed social contexts of speaking (see Figure 1), i.e., Rintel 2004; Heritage et al. 2007). Specifically, in daily activities such as shopping etc., talking with this paper we present a sample of triadic clinical relatives, and talking with friends. Of the other talk data that draws on support staff for medical two official languages of Hong Kong, on average, interpreting (Cantonese/English). Analysis focuses English was used more frequently than Putonghua on turn-taking patterns during an extended clini- in communicating during social daily activities as cal interaction. Data collection and transcription is well as in speaking to friends (Figure 1). On the guided by Liddicoat’s (2007) advice on multilingual other hand, on average, Putonghua was spoken more transcription whilst following basic Jeffersonian frequently than English in communicating with transcription techniques. In managing multilingual relatives (Figure 1). texts, audio files were transcribed into the original Chinese (spoken Cantonese) script and then veri- 6.2. Work-based language profile: spoken fied by two Cantonese L1 research assistants, one interpreting of whom was a bilingual hygienist. Translation software2 was used to translate Chinese script into Across the three days of data collection, Cantonese Cantonese pinyin. Next, translation was made into was reported by the Polyclinic DSAs as the dominant English gloss with the English and Chinese-English medium in most clinical interactions. Spoken speaking members of the research team then interactions in Cantonese were predominantly with verifying selected transcriptions and translations. their peers and patients. English was the next most Analysis has been made based on the English gloss frequently spoken language and this was used in and Cantonese pinyin. spoken interactions with students, patients and clinicians. Putonghua was reported as the least spoken

Figure 1. Spoken languages: social activities Multilingual interactions in clinical dental education 203 language and in instances where this occurred, it was As Cantonese-English interpretations were with patients and isolated students and staff. most frequent, Figure 3 presents data on the two areas of daily spoken communication in function and purpose of these interpretations. The the Polyclinics were explored in greater depth most frequently reported purpose for mediated in the questionnaire. These were clinical spoken interpretations between Cantonese and English language and clinical interpretations. DSAs were was in the area of chair side clinical procedures asked to identify first, the various interactants (as opening phase explaining the purpose of the and the languages used with them and second, follow-up of an ongoing case) and patient treatment details of interpretations undertaken. Specifically, (as performance of surgical techniques) (see Figure they were asked to identify: a) the languages of 3). Less frequently, DSAs were asked to interpret for interpretation; b) the purpose of the interpretation appointment making and taking patient histories. task; c) who the interpretations were between; and This is unsurprising given that the former often d) the approximate time spent on interpretation occurs with receptionists and that the latter is brief activities. These data are examined in greater detail given that the majority of Polyclinics patients have below. already been reviewed and are returning for ongoing Of the original 86 responses, one interpretation treatment. response (Day Three) was excluded as an incomplete From the data presented thus far, it is given that and invalid record. Therefore raw numbers (i.e. for the Cantonese-English bilingual DSA is a constant in categorical variables) indicated in Figures 2-5 are the mediated interactions in the triadic exchanges. based on 85 responses. As multiple entries were By further disaggregating the mean results on permitted, higher frequencies are indicated. Of the Cantonese-English interpretation demands with 85 responses, DSAs reported acting as interpreters regard to the roles of the other two interlocutors, it for a total of 20 instances (see Figure 2) with is evident in Figure 4 that the DSAs were required interpretation between the two languages of English to interpret predominantly between clinical staff and Cantonese predominating (18) and 1 each for and patients than between students and patients. English-Putonghua. While the category ‘others’ The next highest frequency for interpretation was was provided as an alternative to the three official between clinical staff and carers (Figure 4). languages, no other languages were reported for Further, with regard to length of time spent interpretation during data collection. on spoken interpretations between Cantonese

Figure 2. Languages of spoken interpretations 204 Susan M. Bridges, Cynthia K. Y. Yiu and Colman P. McGrath

Figure 3. Purpose of interpretation: Cantonese-English/ English-Cantonese

Figure 4. Work-based language of spoken interpretation (Cantonese-English/ English/Cantonese) Multilingual interactions in clinical dental education 205

Figure 5. Time spent on interpretations (Cantonese-English)

and English, the average reported time spent was Excerpt 1: ‘Temporary filling’ generally under 15 minutes (see Figure 5). DSAs The male dentist (Dr) is an experienced clinician and across the three days and 18 working hours reported uses English exclusively in the interaction. The patient four instances when they undertook extended (P) is a middle-aged woman and she communicates ex- interpretation work of more than 60 minutes. clusively in Cantonese throughout the consultation. The From the data on daily self-reported language use female dental surgery assistant (DSA) uses both English as presented in Figures 1-5 above, it is evident that and Cantonese during the consultation. This consulta- while predominantly communicating with hospital tion is a follow-up of previous endodontic treatment. staff, clinicians, students, patients and their carers in Cantonese, DSAs provided spoken interpretation, 19 Dr: =is she having pain with the tooth or is it just the filling has come out? particularly between Cantonese and English across 嗱醫生就問你宜家你嗰問題係就 the data collection period. 10 DSA: (.) (.) (.) 11 係嗰牙粉甩咗呀? 定係有任何痛噤呀? naa (.) ji sang zau man nei (.) ji gaa nei go 7. Mediated interpreting man tai hai (.) zau hai go ngaa fan lat zo aa? ding hai jau jam ho tung gam aa? In the following excerpt of DSA interpreted talk, Well (.) the dentist asks you (.) what is your we find an example of how the act of interpreting current problem? becomes a socially co-constructed, mediated event Has the filling come out? Or any pain with rather than one where the interpreter takes a neutral the tooth? 成舊甩咗 stance such as in the direct interpreting model, 12 Pt: er (.) otherwise referred to as the ‘machine translation’ er (.) sing gau lat zo er (.) the whole piece fell out (Bolden 2000). In what follows, we provide one 成嗰就係牙粉甩咗姐 sample of a mediated interpretation sequence that 13 DSA: (.) sing go (.) zau hai ngaa fan lat zo ze illustrates a self-initiated insertion in the form of whole piece (.) means the filling only topic continuer. The excerpt occurs at the beginning 吓 of a follow-up consultation during the early problem 14 Pt: Haa presentation phase of a dental consultation (Theaker Yes et al. 2000). 206 Susan M. Bridges, Cynthia K. Y. Yiu and Colman P. McGrath

15 DSA: the filling come out a distinction between place-as-location and place- 16 Dr: Yeah as-meaning (Johnstone 2004). Certainly, one must acknowledge that physical location influences 17 DSA: 有冇痛呀? jau mou tung aa? languages-in-use. Sociolinguistic work in this Any pain? vein has taken an anthropological approach to map regional dialects in fixed geographic spaces. Initially, in lines 9 and 10, the DSA orients to a more Alternatively, sociolinguists interested in post- direct interpreting role, focussing on the dentist’s structuralist approaches informed by notions of two key topics of pain and a lost filling. At line 12, humanist geography have come to explore ‘place’, the patient orients to the question, zau hai go ngaa especially the space at the borderlines, as socially fan lat zo aa?// Has the filling come out? She does constructed meaning unable to be restricted to not respond to the topic of pain. After directly clear-cut physical boundaries. This small-scale interpreting the problem presentation of a lost filling study has provided information on both of these in line 15, the DSA then self-initiates an inquiry perspectives. At the level of place-as-location, the about pain at line 17, jau mou tung aa? // Any Polyclinics operate within a defined geographic pain? This self-initiated topic continuer reflects the and physical space – Hong Kong SAR – with its co-constructive nature of mediated communication stipulated language policies, clear demographics whereby the experienced dental nurse as interpreter and associated dominant language. Also, the study takes agency to contribute to a successful history is physically bound to two clinics within the only taking. We argue that such interpreter-initiated dental teaching hospital in Hong Kong. talk by an experienced dental surgery assistant is the impact of ‘place’ is seen in the personal not only diagnostically relevant (Bolden 2000) but background data. As indicated in the results, place- also orients to the institutional task at hand. In this as-location means that the DSAs’ educational brief example, the DSA’s institutional task at hand backgrounds reflect local language policies for is to clearly communicate the patient’s problem trilingualism, while their language of social use reflects presentation to the clinician. More detailed analysis the dominance of Cantonese for everyday spoken of the spoken corpus is further investigating the communication within the territory. The majority of formulation of mediated interpreting. the Dental Surgery Assistants (DSAs) were born and educated in Hong Kong. While there was an even distribution between spoken English and Cantonese 8. Discussion in primary schooling, a marked shift was noticeable in the transition from primary to secondary education Across the three days of the survey, Dental with English spoken more frequently in secondary Surgery Assistants (DSAs) reported that, of the education, reflecting local policies and practices. three languages officially spoken in Hong Kong, Putonghua ranked lowest as the spoken language of Cantonese was predominantly spoken as their education. workplace language, particularly amongst peers. For social use, however, Cantonese was pre When English was spoken in the Polyclinics, it dominantly spoken in all areas. This strong mother- was mostly used with clinical staff and students. tongue background is indicated in government Putonghua was used the least in the Polyclinics; census data that indicates that over 90% of the however, the dominant group in these instances was region’s population considered Cantonese to be their patients. In reporting on language use, Hong Kong ‘usual language’ (Census and Statistics Department participants displayed a high level of metalinguistic 2007). However, this also means that for one in ten, awareness in discriminating between languages- Cantonese is not their usual language. in-use and various contexts. This supports Wang In examining data on spoken language use in and Ladegaard’s (2008: 71) sociolinguistic study clinics, one can see that the dominant language of of the relative use of Cantonese and Putonghua in the local population (Cantonese) combined with the Guangzhou community as a bidialectal speech strong social use of Cantonese, means that DSAs community. This also supports interculturalist speak Cantonese most frequently in clinics. This perspectives on the centrality of language in com- high usage of Cantonese as reported by DSAs in their municating across cultures. interactions with DSA peers in clinical work could be As noted in the introduction, two distinguish seen as a logical flow-on effect from social use and able notions of ‘place’ have been identified. This is interactions with predominantly Cantonese-speaking Multilingual interactions in clinical dental education 207 patients. Indeed, the demographic fact of ‘place’ in non-Cantonese speaking clinician (student or staff) terms of identified usual language of the population to ensure effective communication and the delivery means that DSAs predominantly care for screened of patient-centred care. teaching patients from the local, Cantonese-speaking Finally, educational policy combined with the population. phenomenon of globalization shifts the focus of However, one can also identify how place-as- clinical interactions from ‘place’ as geographic, meaning has affected language use within this physical location to ‘place’ as formulated and socially location and this is where the binary between constructed ‘meaning’. One result of globalization language-as-location and language-as-meaning processes is that students can access information on becomes fuzzy. There are three identifiable factors universities and programmes more freely, rapidly at play if one is to consider the data from the per- and in greater critical detail than ever before. spective of ‘place’ as socially constructed meaning. Students have become savvy ‘shoppers’ critically First, if we hold the premise that English is the lingua evaluating and comparing data on university franca of medicine and science as true, we can see rankings, programmes, research profiles, facilities evidence of this in the reported Polyclinic interac- and fee structures before applying. The phenomenon tions. The DSAs work with a variety of interlocutors, of internationalization in higher education is a more many of whom speak first-languages other than specific subset of the globalization phenomenon. Cantonese or English. For instrumental purposes, Universities globally have responded through clinical work is therefore conducted in English initiatives under the banner of internationalization between DSAs and multiple first-language speakers. but motivated by different local impetuses (see, This is evident most strongly amongst the interna- for example, Knight 2004) to market themselves tional clinical staff and students. This then follows to attract high-performing students and, in some the point that in any given place, interactants may cases, to support income. With local university be more global in orientation than local (Johnstone targets being set for increased internationalization 2004). In the study reported here, the presence of of the undergraduate student body, the Polyclinic non-Cantonese speaking staff and students moves may become a site of even further stress regarding the DSAs into global thinking, especially as they language demand. work as linguistic and cultural mediators through their role as interpreters. If one considers ‘place’ as ‘meaning’, then in this context, the DSA interpreter must think globally and may need to mediate inter- 9. Conclusion and implications culturally as well as linguistically. Under these two conditions, ‘place’ becomes negotiated and formu- Polyclinics are linguistically complex dental educa- lated ‘meaning’ impacts upon the language choices tion and working environments and can be seen made within the one location. Additional analysis as contested ‘places’ of language use. As evident in of a small sample of talk data supports the notion of this study, Dental Surgery Assistants (DSAs) in the place as meaning as the DSA co-constructs the inter- Polyclinic are key interactants negotiating meaning action with both interlocutors in order to achieve in clinical dental education between non-Cantonese the common goal of providing effective patient care. speaking staff and students and their Cantonese- A second force impacting upon place as ‘meaning’ speaking patients. Their work often requires them is institutional language policy. The University is to perform the dual functions of supporting both the an English medium-of-instruction institution. As hands on and the communicative aspects of clinical such, formal teaching is to be conducted in English. work. Their self-reported language use indicates that However, tensions exist for Polyclinics. Patient- forces of ‘place’ may drive their linguistic choices, in centred approaches to healthcare delivery encourage part, be it as location or meaning. These choices are patient participation within the decision-making also evident in the micro formulations within the process (Heritage and Maynard 2006; Ramseier et turn-taking structures. al. 2008). With a predominantly Cantonese patient this small-scale investigation indicates some pool, one should, therefore, in a patient-centred implications for policy, curriculum design and staff paradigm communicate in the preferred language development. The language of undergraduate and of the patient. This is recognized in the Faculty postgraduate education follows the official university language policy indicated above. The DSA therefore language policy. The tension between this policy and stands at the crux of this dilemma and performs a professional faculties is recognized in the Faculty of distinctive role in mediating between the patient and Dentistry policy cited above. At issue here is how 208 Susan M. Bridges, Cynthia K. Y. Yiu and Colman P. McGrath one resolves supporting students in developing clini- References cal communication skills with Cantonese-speaking patients while maintaining the university language Adair, P. M., Pine, C. M., Burnside, G., Nicoll, A. D., policy and supporting the development of clinical Gillett, A., Anwar, S., et al. (2004). Familial and cultural communication skills in English. Also at issue is perceptions and beliefs of oral hygiene and dietary how the faculty can support non-Cantonese speak- practices among ethnically and socio-economically ing staff and students. Dental support staff curricula diverse groups. Community Dental Health 21: 102– may also need to consider how best to support the 111. 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Wolfson and E. Judd (eds) Sociolinguistics and The Institutional Review Board of The University Language Acquisition 56–81. Rowley, Massachusetts: of Hong Kong/ Hospital Authority, Hong Kong Newbury House Publishers, Inc. West Cluster (No: UW 08-026). The authors would Census and Statistics Department (2007). 2006 Popula like to express their thanks to the Polyclinic staff, tion By-census. Retrieved 25 June 2008, from Census clinicians and patients for their co-operation and and Statistics Department, HKSAR. Chung , M. Y., Leung, J. L. K. and Hui, K. K. H. (2007). participation in the study and to Ms Brenda Cheng Dental Surgery Assistants in Hong Kong: History of Siu Shan for her research assistance. The authors training. Hong Kong Dental Journal 4: 67–70. also wish to thank the anonymous referees for Drew, P., Chatwin, J. and Collins, S. (2001). 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Svalberg, A. M.-L. (2007). Language awareness and lan- the Asia Context Vol. 20: 226–242. Amsterdam: John guage learning. Language Teaching 40: 287–308. http:// Benjamins Publishing Company. dx.doi.org/10.1017/S0261444807004491 Zhang, W. (2010). Patient participation: Questions asked Tang, G., Lanza, O., Rodriguez, F. M. and Chang, A. (2011). by Cantonese- and English- speaking patients in a pre- The Kaiser Permanente Clinician Cultural and Linguis- natal genetic counselling clinic in Hong Kong. In M. A. tic Assessment Initiative: Research and development Kang and O. Zayts (eds) Medical Communication in the in patient-provider language concordance. American Asia Context 20: 260–278. Amsterdam: John Benjamins Journal of Public Health 101(2): 205–208. http://dx.doi. Publishing Company. org/10.2105/AJPH.2009.177055 Theaker, E. D., Kay, E. J. and Gill, S. (2000). Development and preliminary evaluation of an instrument designed Susan Bridges received her BA, DipEd from The Uni- to assess dental students’ communication skills. Brit- versity of Queensland and her MA (AppLing), EdD from ish Dental Journal 188 (1): 40–44. http://dx.doi.org/ Griffith University. She is currently Assistant Dean in 10.1038/sj.bdj.4800382a Undergraduate Education at the Faculty of Dentistry, Tjosvold, D. and Leung, K. (2003). Cross-cultural Manage- The University of Hong Kong. Her research focuses on ment: Foundations and Future. Hampshire: Ashgate pedagogy, interaction and learning, diversity and educa- Publishing Limited. tion. She employs multi-method approaches to research Treloar, C., McCall, N., Rolfe, I., Pearson, S., Garvey, G. design and has a particular interest in interactional analy- and Heathcote, A. (2000). Factors affecting progress of sis. She has received international awards for publication Australian and international students in a problem- excellence and is a member of the editorial board of the based learning medical course. Medical Education 34 European Journal of Dental Education and the interna- (9): 708–715. http://dx.doi.org/10.1046/j.1365-2923. tional advisory board of the Journal of Diversity. Address 2000.00625.x for correspondence: Faculty of Dentistry, The University Tsai, M. H. (2007). Who gets to talk? An alternative frame- of Hong Kong, 34 Hospital Road, Sai Ying Pun, Hong work evaluating companion effects in geriatric triads. Kong. Email: [email protected] Community Medicine 4 (1): 37–49. Tsai, M. H. (2010). Presenting medical knowledge in multi- Cynthia Yiu received her BDS degree from the University of lingual context: Southern Min, Mandarin and English in London, MDS (Paediatric Dentistry) and PhD degree from healthcare talks inTaiwan. Journal of Asian Pacific Com- The University of Hong Kong. She is currently Associate munication 20 (2): 297–302. http://dx.doi.org/10.1075/ Dean in Undergraduate Education and Clinical Associate japc.20.2.10tsa Professor in Paediatric Dentistry at the Faculty of Dentistry, Tsui, A. B. M. and Andrews, S. (2002). Setting standards the University of Hong Kong. Her research interests include and language variation: A dilemma for language edu- dentin bonding, durability of resin-dentin bond, oral health cation. Journal of Asian Pacific Communication 12 (1): of special needs children and dental education. Address for 1–11. http://dx.doi.org/10.1075/japc.12.1.02tsu correspondence: Paediatric Dentistry, The Prince Philip Walker, A., Bridges, E. and Chan, B. (1996). Wisdom gained, Dental Hospital, 34 Hospital Road, Hong Kong. Email: wisdom given: Instituting PBL in a Chinese culture. Jour- [email protected] nal of Educational Administration 34 (5): 12–31. http:// dx.doi.org/10.1108/09578239610148250 Colman McGrath graduated from the Dental School Wang, L. and Ladegaard, H. J. (2008). Language attitudes from Trinity College Dublin and received his PhD in and gender in China: Perceptions and reported use of oral health-related quality of life from University College Putonghua and Cantonese in the Southern Province of London. He is currently Clinical Professor at the Faculty Guangdong. Language Awareness 17 (1): 57–77. http:// of Dentistry, The University of Hong Kong. His research dx.doi.org/10.2167/la425.0 interests include social impact of oral health: patients’ Welsh Language Board (2006). 2004 Welsh Language Use and public perceptions. He has published more than 100 Survey. Cardiff: Welsh Language Board. peer review ISI journal articles. Address for correspond- Yu, G. (2010). Establishing solidarity in radio phone-in ence: Faculty of Dentistry, The University of Hong Kong, medical consultation in China: A case study. In M. A. 34 Hospital Road, Sai Ying Pun, Hong Kong SAR, China. Kang and O. Zayts (eds) Medical Communication in Email: [email protected]