Whose Needs Are We Serving: How Is The Design Of Curriculum For English For Medical Purposes Decided?
by Melodie Hull, RPN, MSC, BA, TESL, PID(adult ed)
There is no doubt that English for Medical Purposes (EMP) falls within the category of discipline-specific language learning. This paper will offer a brief overview of EMP literature on design and decision, learner outcomes and learner satisfaction. It will answer the questions: how are the actual goals of the curriculum defined and on which premises are the courses written? Whose needs are being served? Understanding who the students are and what motivates them to learn EMP is germane to curriculum development. Failure can lead to misdirection in curriculum design and poor learner outcomes. Imposing a vision of the graduate of an EMP curriculum is an example of a top-down decision-making model that assumes a ‘we know best’ attitude by academics and politicians. It discredits and devalues the students: disregards their goals and motivation. This paper appreciates that students are willing consumers of education that meets their needs. Curriculum and course designers are provided the opportunity to create a learning environment rich in material that is interesting and useful to their target group if they recognize this. The paper provides material for critical reflection by all teachers, course-writers and curriculum designers of EMP considering reformation of current practice.
Key words: English for medical purposes; EMP; learner-focused curriculum, evidence-based practice in ESP
There is no doubt that English for Medical Purposes (EMP) falls within the category of discipline-specific language learning or English for Specific Purposes. This paper will offer a brief overview of international EMP literature on design and decision, learner outcomes and learner satisfaction. It will answer the questions: how are the actual goals of the curriculum defined and on which premises are the courses written? Whose needs are being served? The author will attempt to answer these questions by providing examples and suggestions, only. The paper will illuminate questions related to curriculum construction and critique however it allows the reader to engage in his/her own critique of the material (Tryssenar, 2003). The paper is not prescriptive. The writer makes no judgment about how or why current curricula is designed and delivered, although admits a bias may appear. This is not the intent. This paper intends only to broaden horizons from an academic perspective.
Naersson (1978) defines English for Medical Purposes as a form of English Second Language education that clearly focuses on teaching aspects of medical English based on the needs of the job for writing progress notes and charting, interviewing and assessing patients, and reporting. Naersson identifies EMP students as physicians, nurses, or pharmacists (cited in Horani, 1995). But is this perspective valid? Do others share Naersson’s perspective? Are the EMP curricula widely used today actually based on student needs and student types? Some of the literature reviewed in this article will confirm this while others will not (ie: Svendsen and Krebs,1984). We are left with the question: how is the decision achieved for curriculum design? Is this a top-down model of decision-making wherein academics and policy makers who are far removed from the medical field and awareness of student needs dictate curriculum or is the curriculum a bottom-up response to needs emanating from students, faculty and potential employers? Where is the evidence?
Traditionally, language learning has been taught by methods of listening to a lecturer and taking notes, and occasionally interacting in communicative activities of listening, writing, and speaking. In many countries, this tradition remains constant while in others such as Canada, the USA, the United Kingdom, Australia and many European countries, ESL instruction relies less on rote memorization tasks and regurgitation of form and structure, and much, much more on communicative interactions by students: a method almost in reverse (Harmer, 1991) . Learner-focused curriculum has arisen in post-modern education as the result of research into learner outcomes. It focuses on the learning needs and future goals of the student. It finds meaning from student feedback: student and teacher input. It provides directionality for the curriculum and drives it and forms the basis of post-modern curriculum design. It speaks to student motivation and student success. In adult education it incorporates concepts of andragogy (Knowles, 1980) additionally providing pathways for knowing and knowing how.
Learner-focused curriculum design forms the basis of instruction in many universities and colleges worldwide and is becoming increasingly popular (Province, 2005). The reason for this is that it is based on evidence. Evidence-based practice provides research and rationale to develop and utilize sound teaching practice. Evidence-based practice finds itself at home in health care and medicine where it forms the base of all current practices and is the foundation of curricular design in this field in Canada, USA, Australia, New Zealand, and the United Kingdom (Russworm and Larrabbee, 1993). It is applicable to all post-secondary education including English for Medical Purposes.
Harrison (1999) believes that managerial objectives have characteristics. Applied to decisions made about English for Medical Purposes curriculum design, some of these are: relevance of the objectives; practicality of realizing the end objectives; measurability of objectives, flexibility to change objectives rather than be confined to one course of action; recognition of whether or not the objectives are within the boundaries of the current subject field, and accountability for attaining the objectives. The assumption of being all-knowing on behalf of students: top-down decision making can be constraining in an educational institution yet this omnipotent view has both merits and drawbacks. While it is true that experts and academics may very well know their subject and are well-suited to teach and design curriculum, the question is: how do they rate on Harrison’s criteria? These questions would need to follow: are the decision-makers in sufficient contact with the world in which their students will actually function? Are they in contact with other academics and policy makers, only? Are they in cognizant of the wants and needs of stakeholders in the field into which the graduates will find themselves working? Are they preparing their graduates for the future? It is true in many countries that academics and policy-makers have not worked at the ground level of their graduates for many years and are therefore far removed from ‘real time’ needs of post-secondary students. These are incredibly important questions to be answered before beginning or revising a curriculum. The evidence of the effectiveness of decision-making strategies will appear in the following review of literature on the subject of EMP learner-outcomes and learner satisfaction.
Do learner-outcomes change if the learners completed their education in an imposed curriculum environment versus a learner-focused one? The writer finds evidence positively for the latter (i.e.: Ahmed, 2004; Simmons, 2001; University of LaTrobe, Australia, 2005;) . In Canada for example, graduates of university are commonly followed-up with a ‘leaving’ survey months after their graduation. Some of the questions in those surveys are: (1) how well did your education prepare you for the field in which you are employed? (2) regarding faculty, what were some of the most helpful techniques or strategies they employed from your perspective? The answers are always very similar: graduates feel well-prepared if educated in a student-focused environment and, they appreciated (and differentiated) the faculty who had on-going experiences in the work world. They comment that teachers who are purely academic seem to have less current ideas about what the ‘real’ needs of the career are, and find their strategies, goals and interpretation of the curriculum does not serve current and future student/graduate needs.
At Kwantlen University College, Canada, for example institutional research confirms this. It has led to the firm commitment by the institution to pursue learner-focused outcomes in all new and old curriculum design. This requires that at the end of every academic year, students be surveyed and faculties and their departments must make meaning from the survey results. Subsequent to that, changes in delivery of the curriculum or in its design will be undertaken. It is part of policy and the mission of Kwantlen University College (Kwantlen University College on-line 2006). In this example, decision-making uses a bottom-up process beginning with students, then adding teacher input, then moving the information forward with recommendations to the appropriate transdisciplinary Educational Council for final approval and/or decision-making (Stokols, 2004) .
Highlights of the Literature Review
Brown (2004) from the United States is concerned with the ESL curriculum and its development that is content-based and will lead to academic proficiency. She strongly recommends a move from functional English curricula to a content-rich one that enhances learner-success in academic, content learning. Brown provides a critical needs rational to support this. She points out that the traditional cognitive academic language proficiency based curriculum is context-reduced and does not adequately prepare the learner with language competency is real life circumstances of academic studies or the work world. Brown, like this writer, believes that subject matter (content) needs to be integrated into all language development curricula. By doing so, students find purpose, meaning and authentic opportunities to use the new language. Brown supports the idea of transdisciplinary collaboration to ensure content accuracy and relevance, although she does not use this specific term.
Dovey (2005), Australia asks the question: “What purposes, specifically?” and explores the discipline-specific approaches to English for Academic Purposes. She finds that this approach to language learning overlooks the ability as well as desire of learners to transfer L2 skills into professional context. Her article concerns itself with the need to question the purpose of the pedagogy being used and recommends a greater importance be placed on communicative modes within the context of the career.
Svendsen and Krebs (1984), USA also explore the needs of learners for English on the job. Specifically, they looked at English for the health care occupations. A key point to their research has been that teachers and curricula often make assumptions about the language the employee actually needs. They find that this is not always accurate. It is an assumption made by people removed from the content and context of the career. Svendsen and Krebs provide evidence to support learner-focused curriculum development: a curriculum with relevance and meaning for the learner. Prince (1984) concurs and also discusses the importance of workplace English language training.
Author (2004) asserts that the ability to provide safe, competent practice in English should be a priority of all EMP curricula. To develop this, she suggests that health professionals need to have a much more prominent role in curriculum design and delivery, working conjointly with linguists and other language experts. This strategy is reverse to common practice. Her approach seeks to address context and content issues in an attempt to make students job ready. Author (2006) refers to the needs of learners related to career-specific language acquisition
Beatty and Chan’s (1984) work examined the perceived academic needs of scholars from the People’s Republic of China as they attempt to function in English in foreign universities. In this article, the authors differentiated between what the scholar perceived as a need versus the real life experiences of those Chinese scholars who had been at American Universities for some time. Interestingly, those who had had overseas experience reported different needs and assigned different levels of importance to their English language learning needs than those who had never spent any significant time abroad in an English-speaking country. Beatty and Chan point out the need to take this in to account when developing curriculum that is relevant and real world oriented.
Horani (1995), USA researched one particular aspect of EMP: responding to what she considered to be the true needs of the learner, with a focus on pronunciation. She hypothesized that she would find a significant positive relationship between a non-native English-speaking physician’s pronunciation and a nurse’s perception of his medical competency as measured on three dimensions (superiority, attractiveness, dynamism) . Indeed, she did. Hornani found that the non-native English-speaking physician who possessed the greater amount of communicative competence in all situations involving patients, physicians and other hospital staff was be seen as a ‘better physician’ . She discovered that physicians with poor pronunciation led to negative evaluation by the native-English speaking listener. As a result, Horani identified the need to add more pronunciation and speaking activities to the EMP lesson in a variety of contexts related to the field of medicine. She also found a need for teachers to tell the students that they will be judged differently by the outside world when speaking than they are in a ESL classroom where the teacher is evaluating them on classroom /course work standards.
Horani’s conclusions suggest EMP curricula have not put enough emphasis on pronunciation to the detriment of the graduates. In her review of other literature on this topic, she came found that most non-native speaking English language instructors are not sufficiently aware of their own accents and the effect this has on their students, and are not therefore motivated to change. This is detrimental to successful outcomes for learners who may find themselves blocked by negative appraisals of competency made outside of the classroom. Horani believes heightened teacher training in pronunciation is absolutely required. She also suggests enhancing real life learning in the classroom by giving EMP students opportunities to use the new language in a non-threatening environment of the classroom in role-plays of talking with patients about their illnesses. Finally, Horani concludes that a question arises from her research still to be answered: what is the effect of ability to communicate content well? She is aware that context becomes an issue when the internationally trained physician is unaware of the Western culture of medicine in which the patient is often referred to as a client and is an equal partner with the nurse and himself in the client/patient’s assessment and treatment. Indeed, patients and nurses want and need to feel a sense of confidence and competence in their physicians. Horani is aware that in Western cultures, this is undermined by muttering, stumbling, hesitation, using incorrect words or partial sentences, and incorrect pronouns. Williams (2006) in Japan identifies that communication and vocabulary acquisition strategies in English language classes deserve more attention and offers his perspective.
Albano, Cancade-Pragnell, and MacGarry, (1998) surveyed Medical Faculty at Italian Universities for a needs analysis based on concerns about the English language proficiency level of medical graduates. They discovered that the objectives of EMP were not sufficiently defined, nor were specific minimum skills levels standardized amongst universities. They support more collaboration amongst EMP from all the universities and believe this will improve not only the quality of teaching, but the learner-outcomes as evidenced on the compulsory examination of Medical English upon graduation.
Hayes and Farnill (1993) of Australia are also concerned with how medical training and English language proficiency are related. The article addresses assessment of student language levels prior to admission to the EMP course and explores the significance of accurate assessment in enhancing learner-success. They found significant results from their research to support a number of initiatives to aid students with language disadvantages (those that begin the course with knowledge or skill deficits in L2) and identify the need for graduates to be able to speak effectively to patients as one of the priorities of the curriculum. In a separate article, Hayes, SC; Farnill, D; Sefton, AJ (1993) provide results of research and recommend strategies for improving communicative skills of medical students in advance of their placement in clinical areas.
Smith (1984) was involved in English for Medical Sciences in Kuwait and Oman. She writes about the use of reading medical journal articles as an activity in class. Her concerns is the lack of critical thinking involved and found that students and faculty did not consider the subjective underpinnings of the articles as evidenced by attitudinal markers. Smith points out that some medical journal articles are more subjectively based than objectively based and it behooves the reader/user of the article to reflect on this. She recommends that faculty consider this before choosing the articles to be used in class.
Certainly, the literature reviewed in this article demonstrates a penchant for learner-focused curriculum design that includes a real time/real world focus on content, learner-goals, and learner-outcomes. The importance of learner-focused curriculum can be seen in the study by Zughoul, Raji and Hussein of Jordan (1985). They completed a needs analysis of both students and faculty, separately focusing on the perception of English language needs. They found that both groups were in agreement that listening skills are of primary importance.
Kimball (1998), in Japan debates that the establishment of linguistic goals is what students require and instead, takes a socio-cognitive approach to recommend how EMP curricula might better be developed. Understanding the differences between top-down decision-making wherein students are analyzed for their competency/skill requirements with specific language components, Kimball sees the value in a process-oriented analysis of learner needs that helps the learner to learn within the context of the career. He advocates for a connection between the EMP faculty, the educational institution and the stakeholders: members of the career into which the graduate will proceed. Kimball also appreciates new trends in English of Specific Purposes education that support subsuming linguistic units such as grammar and vocabulary into the context of the career, rather than vice-versa. Chou (2004) agrees, discussing the importance of socio-effective strategies to assist learning.
The literature provided some examples of educational institutions that currently utilize learner-focused education in their ESP programs. These are in discussed in articles by Ahmed (2004) in India , Kwantlen University College (2006) in Canada, , Yang (2005) in the USA, and the Social Service Research Council (2004) of Vietnam.
Improved levels of quality in teacher motivation and satisfaction
There is a good deal of research in the field of education that concludes when teachers are contributors to the curriculum design and decision-making process they are more satisfied with their work, and more motivated to do well at same. Some examples of this are found in the literature reviewed herein.
At the University of LaTrobe, Australia (2005) for example, policies are in place to support and promote teaching excellence. The focus is always the learner and the decision to make this a policy statement was arrived at through the bottom-up decision-making process. Research within the institution, combined with review of international trends in post-secondary education led to the universities declaration of best practices in curriculum design and focus. This research would include student and faculty input.
Suslu (2006) of Turkey explored what motivates the ESL teacher and found that teachers are more motivated , inspired and able to inspire when they themselves feel energized and empowered in their work. He/she understands that when teachers have job satisfaction, they perform better and this is directly correlated to higher levels of learner-outcomes and learner-satisfaction. Suslu explores the importance of psychological reward for the teacher: the ability to function with a degree of autonomy and creativity on the job, familiarity with the subject matter and ability to make changes in same for the student’s benefit as well as increase one’s one professional competency. He/she clearly points how that lack of support and acknowledgement by the educational institution and constraints of an imposed curriculum will greatly effect teacher satisfaction and learner-results. The ability for the teacher to be recognized for his/her contributions within the ESL department and to the institution as a whole is an example of bottom-up communication. In this case, it will lead to empowering teachers to have a voice that will positively affect curriculum design and revision.
Improved levels of quality in learner outcomes and satisfaction
When student feedback is incorporated into the design of curricula, many believe their level of motivation, satisfaction and outcomes will be greatly improved (Berlitz, 2004). They will find meaning and purpose in the course work. Examples of this research come from Simmons (2001), USA and Barrie, Ginns, and Prosser (2003), Australia. In their own published works, the authors identify how learner-focused curricula affect not only students’ own outcomes but improve teaching quality assurance. Simmons, (2001) provides an example of perspectives on learner-focused curriculum as they are now being instituted in American high schools.
Current Trends in Post-Secondary Education
Transdisciplinary collaboration is the post-modern paradigm for educational instruction (Stokols, 2004). In this model, faculty members from one discipline recognize the relevance of consulting with peers in other faculties to ensure delivery of a cohesive, learner-focused curriculum. Rather than working in isolation, disciplines pull together collaboratively and are aware of course content and curriculum goals for each related program. They are not working at cross purposes. For example, in English for Medical Purposes the faculty would meet once a month or so with the Faculty of Medicine to synchronize and solidify the learning experience for students. They would teach similar subjects as context at the same time, but with their own unique disciplinary perspective. Examples in the literature of the transdisciplinary model can be found in the documents of the Social Science Research Council (2004), English Language Training in Vietnam and Kwantlen University College (2006) Graduate Nurse English as a Second Language project in Canada.
The author believes that the premise of transdisciplinary collaboration has significant merit for English for Medical Purposes. The traditional method of linguists and various other English language teachers creating all facets of the EMP curriculum themselves, with only occasional input and collaboration from the experts in the medical field can leave the EMP students less than satisfied. Certainly this was a major theme for medical students in China as presented in the research and discussion at the 2004 International Symposium on English for Medical Purposes held in Xi’an, China.
Recommendations for Curriculum Design Decisions:
How the decision for curriculum design is made is entirely up to the educational institution. However, should one consider revising a curriculum from one that is imposed to one that is learner-focused, this writer offers a few suggestions arising from the literature that could precede any changes:
* review how the current decision-making process for curriculum design and delivery is undertaken and be prepared to make recommendations based on evidence.
* survey current and past students for assessment of how the curriculum met their own perceived goals
* survey current students for learner-goals
* survey current students for desired outcomes from their perspective
* survey current teachers for their expected outcomes related to the curriculum they are currently using
* consider learner-satisfaction: implement post-graduate surveys
* consider teacher-satisfaction: implement post-course surveys to determine where and why instructors are comfortable or uncomfortable with the curriculum
* consider the stakeholders: who will reap the rewards of the EMP program?
-Who exactly will be the recipient of the learning completed in an EMP program?
-Define whether or not the stakeholders are employers, teachers, learners, or the academic institution.
-survey employers of the EMP graduates for employer-satisfaction levels
* identify and evaluate how content and context are being addressed to mirror real world experiences in which the graduate will soon become involved
* identify how quality assurance will be evaluated. Will the criteria of measurement be number of graduates versus quality of graduates?
This paper has provided a literature review of practices in the teaching of English for Medical Purposes. The intent was to identify whose needs are being served by the curricula currently in use in a number of countries worldwide and what the literature and research have to say about the success of these methods. Within the literature are themes of decision-making strategies and their effect on curriculum design, evidence-based practice, and learner satisfaction and learner outcomes. The question posed at the beginning of this paper is answered: who knows better what language skills and competencies to strive for than the students who are specialists in their own disciplines? The Learner knows. Learner-focused and teacher-focused outcomes as well as levels of satisfaction are identified in most of the articles reviewed, as key criteria in evaluating the worth of the curriculum’s design
The literature identifies new trends in decision-making for curriculum design that use feedback from learners and teachers to form a part of a bottom-up decision-making model, rather than the traditional top-down, imposed one. As well, a theme becomes apparent that learners and stakeholders not only want but benefit from more context-related learning with a greater focus on communicative activities that are work-place related. Finally, the post-modern paradigm of transdisciplinary collaboration has implications of curriculum design and delivery for English for Medical Purposes. The paper has provided some recommendations for EMP curriculum assessment and revision.
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