Research article
Open Access

An insight of Malaysian students attending European University toward participation in Malay Language Class

Mohd Ikhwan Marion[1], Cathy Cunningham[1], Joseph Harbison[1], Aileen Patterson[1]

Institution: 1. Trinity College Dublin
Corresponding Author: Dr Mohd Ikhwan Marion ([email protected])
Categories: Educational Strategies, Professionalism/Ethics, Undergraduate/Graduate
Published Date: 20/04/2020

Abstract

Purpose: There is a demand of international students from Malaysia studying medicine in Ireland. Malaysian medical students must develop communication skills in Malay Language as part of their preparation for internship. A Malay Language exam is mandatory before application is made. This study examined an insight of students’ attitudes and awareness toward teaching and participation in a formal Malay Language Class (MLC).

Methods: A descriptive cross-sectional study was undertaken in December 2019 at a medical school in Ireland. This involved the use of an anonymous survey to gain information on career goals, prior learning exposure, perceived area of interest and confidence in an MLC.

Results: A total of 40 students responded to the survey. The analysis described low perceived confidence in communication skills in Malay Language and most respondents demonstrated an interest in participating MLC with different motives.

Conclusions: The study suggests that Irish medical schools should prepare students future career by considering an effective communication skills program contextualised to their need.

Keywords: Communication skills; international students

Introduction

The study reports on data collected as part of an evaluation program to see if there is a need to develop effective communication skills for Malaysian students attending medical school in a European university.

Background

Communication skills
Medical students must develop effective communication skills to prepare for careers in medicine (IMC Guideline 8th Edition, 2019). The skill must be developed and nurtured as early as pre-clinical years so that students can feel confident in clinical practice. Furthermore, the skills are essential to develop competence (Rubin and Martin,1994) and ensure patient safety. Medical schools in European universities adhere to global standards (WFME Global Standards, 2015) by measuring the outcome of communication skills within medicine and medical practice. Students need to be taught about verbal and non-verbal aspects, particularly emphasising empathy by giving them explicit training and feedback.

Challenges faced by Malaysian students attending medical schools in Europe
There is a sustained demand for international students from Malaysia (Groake and Durst, 2019) studying medicine in Ireland. Some of them might go back to Malaysia to practice medicine. A few of them might be concerned about language difficulties and medical communication skills incompatibilities across cultures (Chur-Hansen, 2004). It is a genuine concern for medical schools to acknowledge the communication barrier and to facilitate adequate skills for medical students to stay competent and confident in their practice.  

Malay Language and Malaysia healthcare system
The Malay Language is the common language in Malaysia, particularly in healthcare settings. Doctors are expected to have a basic level of language proficiency to practice safely and effectively towards patients. The Malaysian government mandates all healthcare professionals to pass the Malay Language exam (SPA) before practising medicine in Malaysia. Yet, traditional medical teaching does not emphasise communication skills enough for medical students during undergraduate years.

Patient care and scope of practice
Patients value the ability of the doctor to communicate effectively. In her study, Eng TC (Eng, 2012) mentioned the preferences of Malaysian cancer patients in the communication of bad news. Participants emphasised resonant communication skills. Such skills need to be learnt and nourished to provide good quality care. Furthermore, effective communication skills will lead to less treatment related mistake, and improved health outcome for patients and relatives (Pope, Rodzenn and Spross, 2008). Communication may be utilised as a good quality indicator for healthcare providers (Wanzer, Booth-Butterfield and Gruber, 2004) and patient experience (Clark, 2003). Choy and Ismail mentioned the physicians’ low mastery of interpersonal communication skills (Choy and Ismail, 2017) that diminishes patients’ trust in current practice.

Currently, little is known about the thoughts of Malaysian medical students to effective communication skills in the Malay Language at the undergraduate level. Furthermore, exploring motivations, personal and professional barriers, content and objectives to learn such skills would give a good indication of how to provide a service based on needs assessment. The aim of this study was to evaluate student perceptions of the Malay Language Course. It will give a guide to developing formal effective communication skills in the Malay Language. The study would transmit perceived areas of communication skills deficiency in clinical settings. The study was aimed at a Malay Language Class that conveys the skill competencies required by medical students.

Methods

Participants and setting
Trinity College of Dublin medical school offers a five-year Bachelor in Medicine (M.B.) course, with two pre-clinical years followed by three years in a clinical setting. The questionnaire was offered to all undergraduate Malaysian medical students.

We designed a 22-questionnaire on the Microsoft platform (see Table 1).

Table 1. questionnaire

Question no.

Question

1

Current Medical Year

2

Please mark your intended internship preference

3

Previous formal Malay Language learning exposure

4

Spoken Language(s)

5

Do you intend on speaking Malay Language when treating patients?

6

Are you interested in learning and mastering the Malay Language for better patient care?

7

Motivation factors to participate in a Malay Language Class

8

Confidence in speaking Malay abilities

a

Day to day communication

b

Talking to co-interns

c

Talking to senior medical officers

d

Talking to allied healthcare professionals (AHP)

e

Talking to patients

f

I feel confident in history taking

a

I feel confident in examining patients

b

I feel confident in explaining medical investigations

c

I feel confident in asking for consent

d

I feel confident in breaking bad news

e

I feel confident in handling a distressed patient

9

I would engage in a Malay Language Class during medical school

10

What topics would you include in a class?

11

Any other comments

Students were asked their demographic characteristics: current medical year, spoken language(s) and previous formal Malay Language learning exposure. They were also asked about their career plan and perceived confidence and abilities in speaking Malay. Their speaking abilities were rated on a 5-point Likert scale (‘strongly agree to strongly disagree’). Comment box and topic suggestions to be included in a class were provided at the end of the questionnaire with open-ended input. The questionnaire was designed with two medical education staff and piloted by seven medical students before dissemination.

Recruitment and questionnaire distribution

We recruited participants directly through a gatekeeper who has access to the student database. The gatekeeper contacted participants via email. A brief introduction to the questionnaire, participants’ information leaflet and link to access the form were included in the emails. Our researchers did not contact students directly. The gatekeeper sent these emails to all Malaysian medical students. Before the questionnaire was closed, a reminder email was sent one week before to increase the uptake rate. 40 participants out of 71 students responded to the questionnaire, resulting in a response rate of 56.6%.

Statistical analysis
We analysed data (percentages, weighted mean, student t-test and probability test) using Microsoft Excel and SPSS version 24.

Results/Analysis

We gathered 40 participants from Malaysian medical students at Trinity College of Dublin. Demographics are detailed in Table 2.

Table 2. Demographics of 40 Malaysian student participants

 Current medical year

N

%

Year 1

5

12.5

Year 2

4

10

Year 3

13

32.5

Year 4

8

20

Year 5

10

25

‘Spoken Language(s)'

 

0

   Malay

34

85

   English

38

95

   Chinese

18

45

   Tamil

1

2.5

   Other

2

5

‘Do you have any previous formal Malay Language learning exposure?'

 

   Secondary School

32

80

   Primary school

30

75

   Other

5

12.5

Of the 40 participants, the majority came from Year 3 (32.5%). Most (85%) participants speak English followed by Malay Language (85%). 32 (80%) students had formal Malay Language learning exposure in secondary school.

Table 3. Career plan of 40 Malaysian student participants

Question

N

%

‘Please mark your intended internship preference.’

  

  Malaysia

20

50

  Other

20

50

  Total

40

100

‘Do you intend on speaking the Malay Language when treating patients?'

 

0

  Yes

31

77.5

  No

1

2.5

  Maybe

8

20

  Total

40

100

Half the participants intended to internship in Malaysia, as shown in Table 3. 31 participants (77.5%) intended to speak Malay Language when treating patients. 8 (20%) participants might speak in Malay as 5 (62.5%) did not intend to work in Malaysia (p=0.456), and 2 (25%) participants did not speak Malay (p=0.1214).

As for perceived confidence in speaking Malay abilities, they scored an overall weighted mean 3.30 +- 0.4 P<0.05 (agreed) on 5-point Likert scale. (see Table 4)

Table 4. 5 -item Likert Scale Points

Answer options

Mean and standard deviation

Sum of points

Student test values

Probability level

 

Strongly agree (%)

 

Agree (%)

Neutral (%)

Disagree (%)

Strongly disagree (%)

 

X ± SD

S

t

p

5 points N

 (%)

4 points N

 (%)

3 points N

 (%)

2 points N

 (%)

1 points N

 (%)

Day to day communication

4 ± 0.9

160

56.2

<0.05

15

37.5

12

30

11

27.5

2

5

0

0

Talking to co-interns

3.7 ± 1.0

146

44.7

<0.05

9

22.5

15

37.5

10

25

5

12.5

1

2.5

Talking to senior medical officers

3.6 ± 1.1

142

38.9

<0.05

11

27.5

8

20

14

35

6

15

1

2.5

Talking to allied healthcare professionals (AHP)

3.4 ±1.1

137

36.2

<0.05

8

20

9

22.5

16

40

6

15

1

2.5

Talking to patient

3.5 ± 1.0

128

35.9

<0.05

8

20

9

22.5

17

42.5

5

12.5

1

2.5

I feel confident in history taking

3.2 ± 1.1

138

34.2

<0.05

5

12.5

10

25

16

40

6

15

3

7.5

I feel confident in examining patients

3.4 ± 1.1

131

35.4

<0.05

8

20

8

20

14

35

8

20

1

2.5

I feel confident in explaining medical investigations

2.8 ± 1.2

146

28.2

<0.05

9

22.5

15

37.5

10

25

5

12.5

1

2.5

I feel confident in asking for consent

3.2 ±1.3

142

29.3

<0.05

11

27.5

8

20

14

35

6

15

1

2.5

I feel confident in breaking bad news

2.7 ± 1.2

137

26.3

<0.05

8

20

9

22.5

16

40

6

15

1

2.5

I feel confident in handling distressed patients

2.8 ± 1.2

138

27.4

<0.05

8

20

9

22.5

17

42.5

5

12.5

1

2.5

They felt confident on day-to-day communication (weighted mean 4 ± 0.9) followed by talking to co-interns (3.7 ± 1.0), talking to senior medical officers 3.6 ± 1.1, talking to patients 3.5 ± 1.0, talking to allied healthcare professionals (3.4 ±1.1), examining patients (3.4 ±1.1), history taking (3.2 ± 1.1) and asking for consent (3.2 ±1.3).  They felt less confident in explaining medical investigations 2.8 ± 1.2, handling distressed patients (2.8 ± 1.2) and breaking bad news (2.7 ± 1.2).

Most participants (80%) are interested in learning and mastering the Malay Language for better patient care as shown in Table 5.

Table 5. The Response of 40 Malaysian student participants to the question 'Are you interested in learning and mastering the Malay Language for better patient care?' 

 N%
Yes3280
No820

As for factors to motivate 40 Malaysian student participants to learn the Malay Language, the majority 32 (80%) felt that it was a requirement to work in Malaysia, followed by 30 (75%) who would like to increase their confidence in a clinical setting, 15 (37.5%) with intrinsic interest and 12 (30%) with honour. See Table 6.

Table 6. Factors that motivate 40 Malaysian student participants to learn the Malay Language

Factors

N

%

Requirement to work in Malaysia

32

80

Increase confidence in clinical setting

30

75

Intrinsic interest

15

37.5

Honour

12

30

Other

4

10

Participants were able to select more than one option

Only 72% participants would participate in a Malay Language class during medical school (p=0.3470). See Table 7.

Table 7. The Response of 40 participants to the question, 'I would engage in a Malay Language Class during medical school.'

 N%
Yes2872
No1128

The sub-thematic analysis and comments box demonstrated that participants would prefer a module on the following subjects: effective communication skills in history taking, physical examinations, explaining medical investigations, asking for consent, breaking bad news and handling distressed patients.

Discussion

Our study demonstrates that most participants are interested in, but not prepared for Malay Language communication skills in a healthcare setting. While most students speak Malay and have had formal Malay Language teaching (Table 2), these skills need to be developed and nurtured in clinical settings.

In addition, the study was to determine if students would be interested in engaging in MLC if proposed at their college. (Table 5). Even though half of them intend to work in Malaysia, 72% of participants expressed interest in such class with different motivations. (Table 6).

This is the first research to investigate these themes toward Malaysian medical students studying abroad.

In Denmark, Kling J and colleagues (Kling et al. 2019)  evaluated the doctors’ reactions to ‘internationalization’ in clinical training in a public university hospital. International students rated significantly lower than the local students by the doctors for their communication skills among patients, Danish doctors and hospital staff. Substantial faculty support is required to overcome the language barriers for international students.

Eva King and colleagues (King et al. 2019) argued that International medical students face tasks of learning to interact and interacting to learn during clinical years may outdo cultural/linguistic backgrounds. It draws attention to the complexities of students’ impressions of management processes and proposes that this concept be further explored. The authors believe that MLS is one of the platforms to harmonize the main curriculum with the native language. In order to build the skills required for effective communication, English as a second language students need specific support.

Mong‐Lin Yu et al. 2018  suggests that professional interpersonal skills should be exposed to undergraduate students and to be included into academic education curriculum. It is also to prepare them better for practice education.

Malay Language Class

The authors proposed a Malay Language Class for the next 2020/2021 academic year. It would be a 2-hour session, 6-week module. The theme is based on history taking, physical examination, explaining medical investigations, asking for consent, breaking bad news and handling distressed patients. By the end of the module, students would be assessed by a 5-minute one Objective Structured Clinical Examination (OSCE) station. Students would demonstrate their communication skills in a clinical scenario.

Conclusion

Most participants demonstrated an interest in participating in the MLC with different motives. The study suggests that Irish medical schools should investigate the need for an MLC for Malaysian students in preparing for their future career. A proposed Malay Language Course is being developed for the next academic year to fulfil the demand. Based on our data, sub-thematic analysis would be the subtopic for a curriculum design and emphasizing more on less perceived areas of confidence.

Take Home Messages

  • Effective communication skills are important to be taught at an undergraduate level before learners embarking their career.
  • Effective communication skills programs should be provided formally and contextualised for learners working environment.
  • Besides emphasizing colloquial language and reducing medical jargon, effective communication skills programs for learners should incorporate interpersonal skills, cultural competence and emphatic listening skills.

Notes On Contributors

Mohd Ikhwan Marion is an Assistant Professor in Medical Education Division, Trinity College Dublin, Ireland.

Cathy Cunningham is an Assistant Professor in Medical Education Division, Trinity College Dublin, Ireland.

Joseph Harbison is the Director of Teaching and Learning (undergraduate), School of Medicine, Trinity College Dublin, Ireland.

Aileen Patterson is Associate Director of Undergraduate Teaching and Learning, School of Medicine, Trinity College Dublin, Ireland.

Acknowledgements

The authors of the study would like to thank TCD staff for facilitating the research. The authors of the study would like to also thank the Trinity College Dublin for giving the opportunity to implement the study. 

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Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

This research was approved by the Faculty of Health Sciences Research Ethics Committee Trinity College of Dublin, (Reference Number 20191101).

External Funding

This article has not had any External Funding

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Mohamed Al-Eraky - (19/05/2020) Panel Member Icon
/
The article highlighted a serious concern of students who have been graduated from Western medical schools and return back to homeland to practice medicine. They encounter many challenges including linguistic barriers and other issues related to re/acculturation and professionalism. We wrote a Letter on a similar issue to suggest a comprehensive induction program for ‘doctors on the move’, as in this article: When in Rome (1). It’s imperative to plan language courses, but it would be even more critical to orient newcomers to the expectations of patients in their local contexts (e.g. in Malaysia), which might be far different from the ones they have encountered throughout their undergraduate medical education.

Thank you and good luck.

Al-Eraky, M. M., & Marei, H. F. (2016). Medical professionalism: When in Rome,… Romans should help visitors. Medical Teacher, 38(2), 214–214. https://doi.org/10.3109/0142159X.2015.1074993