English for Doctors : An ESP Approach to Needs Analysis and Course Design For Medical Students

English is considered a language of communication as well as language of fashion and status in Pakistan. For last some decades, it is being taught in different institutions to meet specified academic and professional needs of learners. As far as medical profession is concerned, doctors need English language during their academic studies as well as in their professional settings. The study investigated the communicative needs of doctors at academic and professional level in survey based research. The data was collected, analyzed and interpreted quantitatively by administering questionnaire among medical students and doctors. The findings revealed that there is huge gap between the acquired competencies of doctors with their desired level of English proficiency skills. Majority of the respondents stressed upon the need to introduce English language courses and workshops for medical students and doctors respectively, so that they may fulfill their communicative needs in effective way.


Introduction
Though there are other international languages which thrived around the world, English is still playing a central role in Education all over the World.English language has gained the status of international language and the second official language in Pakistan.It has become the language of science, media and technology.However, in this modern age, learning English language is equal to learning skills of life; it was being learnt according to the needs of a specific field.This sort of learning is called ESP (English for specific purpose).EMP (English for medical purpose) is a sub-type of ESP which is a fundamental part of this study.Pakistan is a country in which all medical literature is published in English.English language in the medical field is essential for students' academic purposes such as in reading textbooks, searching material from the internet, in presentations, taking the examination, doing interaction with teachers and further studies abroad.It is necessary for doctors such as in meetings, conferences and in research publications.
The purpose of this study was to explore the English language needs of medical learners and design a course to meet their specific needs.In order to design a course, it was central to consider the point of view of medical students and doctors.English is the language of medical textbooks and journals so there is a dire need to learn basic skills of English language in medical colleges.Further an ESL course helps students to pass the entrance examination when they go for specialization either in Pakistan or abroad.ESP specified need analysis and course designing strategy was used in this study to determine the communicative needs of doctors and medical professionals.Kang (2004) remarked that learning English is essential for medical professionals because all medical information for medical professionals is available in English language.According to Kurfurst (2004) command over English language is necessary for medical professionals as most of information present in books, articles, documents and journals are in English language.In addition it is necessary for their training and upcoming medical careers.However, English for medical purpose (EMP) became essential.EMP is a kind of ESP which is important for academic and professional needs of medical students.Niazi (2012) remarked that English has got an unquestionable status in medical settings of Pakistan.There are several reasons for medical students to learn medical English as it has gained the status of Lingua Franca.There are many academic and professional settings relying on English as far as Pakistani medical situation is concerned.In Pakistan, the medical students have strong needs to learn EMP (p.3).

Research Questions
1) What are the English language needs of medical students in their academic activities?
2) What are the English language needs of doctors in their professional career?
3) To what extent medical students are proficient in English proficiency skills?
4) What ESL course can be designed based upon the information gathered during the present study?

Research Objectives
1) To find the English communicative needs of doctors in their academic settings.
2) To investigate the English language needs of doctors in their professional career.
3) To examine the existing level of proficiency in English skills among medical students.

4)
To identify what ESL course can be designed based upon the information gathered during the present study.

ESP and Medical Discourse
Ramirez (2015) said, "ESP is defined to meet specific needs of the learners" (p.2).Smoak (2003), "ESP is English instruction based on actual and immediate needs of learners.ESP is needs based and task oriented" (p.27).One clear difference between ESP and EGP was that, ESP courses served a "utilitarian purposes" (Mackay & Mountford, 1978) while, Crystal (1996) said, "EGP aimed at establishing a general level of proficiency".According to Hutchinson and Waters the difference between ESP and General English is "not the existence of need but rather an awareness of the need".The difference is "in theory nothing, in practice a great deal" (Hutchinson & Waters, 1987, p.53).Frinculescu (2009) puts, "English gains the status of Lingua Franca" due to its vast importance and usage across the world.Most of the medical journals are in English and paramount contributions in medicine and science are published in English.Both in American and international journal, English became a vital medium for the transmission of information in recent years.Along with presence of traditional communication system in English, there is also the WWW and computer networking system which operates in English languages.The consequence of this has been the rapid export of English into other language cultures (Frinculescu, 2009).In the last five years the discipline of EMP has lived powerfully in international countries.Its range is from Hong Kong to US. English is used as an instrument across the World (Master, 2005).Now, English became the "Premier research language" among the language of medicine (Swales, 2004).Medical English is highly technical and contextually based.In workplace doctors use technical and academic language, and use jargons and common language.They hardly focus on proper sentence structure.Medical English is the advanced English, thus it cannot be taught as the same method of fundamental English language teaching.Health professionals and students of health department of a university or college are the EMP learners.The aim of EMP learning is not to learn primary grammar and structure but to learn use of language for social and career relations (Niazi, 2012, p.51).
EMP courses like ESP courses should be designed accordingly to learner's needs and purposes, first thinking are that who are the medical learners can be and what are their purposes.English language course should enhance the communicative effectiveness of EMP learners.It is based on instructional methodologies like content-based and problem-based learning.For the purpose of real life communication in classroom, the use of technological equipment is an important aspect of EMP course.Medical terminology are also include in ME course.Traditional methods like grammar translation method and vocabulary teaching method have also been found (Maher, 1986).
Needs analysis had taken the needs of students in terms of EAP and EOP: "which aims to specify as closely as possible what exactly it is that students have to do through the medium of English" (Robinson, 1991).It was "designed to meet specified needs of the learner" (Johns & Dudley-Evans,1991).According to Robinson (1991) needs analysis is the important and crucial factor of ESP.Learners' target needs and learning needs are assessed by using different evaluation techniques.These evaluation strategies are used to determine the communicative needs of learners in specified fields (Brown, 1995).Based upon the information obtained from the need analysis process, new courses are designed or existing courses are modified.

Curriculum Design for Medical English
Niazi (2012) pointed out that, the requirements of Medical English language teaching are a new and modern approach.Teaching medical English should be different from teaching of general English language.Medical students gathered a large amount of medical knowledge and skills in their medical education.The purpose of learning English at this level is for the use of language in their medical studies rather than learning grammar and primary structures.For the help of non-native English speaking, students of medicine learn English jargons, for that reason, information about medical discourse and register should be mutual with pedagogical skills of a language teacher.The curriculum of medical English course should be based on medical English rather than rules and structure of English language.DuGas, Esson and Ronaldson (1999) have given a lesson format.It has followed an 'A'-'B' format.Lesson 'A' has establish its center on vocabulary presentation and acquisition.Lesson 'B' gives chances to apply learning from the preceding lesson into context.Learning exercises in Lesson 'B' can comprise using real hospital forms and charts, use of medical equipment, role playing assessment, open exploration of treatments and interferences related to the key subject.Understanding that, discussions including all students are improved as health professionals try to consult and confer, sometimes conversation about medical-health setting can be practices.They have also stated that Medical English should be taught from the following perspectives of health and medicine care:

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It is necessary to emphasize on grammar, structure and vocabulary acquisition.

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Teachers are mandatory to be language instructors as well as health professionals.
On the other hand, lesson and case studies consist on easy and complex medical practices, anatomy, physiology, pharmacology, pathology and treatment.The aim to get ready the learners for ongoing studies in English, preparing them for exams and for English language proficiency at work that can be specific to career.Applying the EMP approach to teaching medical English can be useful in regard to providing feedback from graduates of the medical faculties.
EMP courses like ESP courses should be designed accordingly to learner's needs and purposes, first thinking are that who are the medical learners can be and what are their purposes.English language course should enhance the communicative effectiveness of EMP learners.It is based on instructional methodologies like content-based and problem-based learning.For the purpose of real life communication in classroom, the use of technological equipment is an important aspect of EMP course.Medical terminology are also include in ME course.
Traditional methods like grammar translation method and vocabulary teaching method have also been found (Maher, 1986).
A course should be designed for health department with the concept of how to improve learners' learning in ESL context.Course started journalistic writing and use of time magazine, next step is reading medical literature.
Finally watching videos about medical issues and performing dramas.According to writer, at the end of the semester students improve English because they found the very useful and authentic learning with this instruction.The communicative skills made great progress through discussions and communication.He concluded that students experienced the pleasure of learning in groups as considering on appealing health issues (Bailey, 2000).
The textbooks for teaching EMP are suitable for doctors, medical students and those who have it in mind to work in a foreign country.The various skills and cross-cultural awareness are adept in the different units.Constant innovation and development are occurs in medical field, the content of the books is modernized in every edition (Holmstrom, 2005).
Shirvan (2008) described, following four reasons for English instructions because medical students have: • to read academic literature in English, • to make discussion with their colleague from English speaking countries or from non-English speaking countries for medical interrelated determination,

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opportunities to study or job in English speaking countries, • to use English widely in their future career as well as it is extensively used by professionals.Shirvan (2008) has more recommended that, the curriculum designer should be keep in mind who are the students, what are their motivations and recognize the viewpoints of the EMP teachers.A sample of the study was conveniently selected from Sheikh Zayed Medical College and Hospital Rahim Yar Khan.200 students of MBBS were selected conveniently from Sheikh Zayed Medical College Rahim Yar Khan for this study to analyze the English language needs in their academic and future career.Furthermore, twenty doctors were selected conveniently from Sheikh Zayed Hopital RYK to analyze the professional linguistics needs.In this study closed ended questionnaire was used for medical students for the purpose of data collection.

Framework of Research
The questionnaire used for doctors consisted closed ended and open ended questions.

Description of Questionnaire for the Students and Doctors
In the process of questionnaire construction the first step was gathered information about academic and professional activities of medical education.For this purpose researchers made informal discussions and interviews with doctors.Further the researchers read relevant literature and the previous researches done in the field of EMP.After gathering information through process on Needs Analysis, the inventory was developed.The questionnaire was made valid and reliable in the pilot testing phase; after which it was made ready to administer among the sample determined for this study.The detailed description of questionnaire for medical students is as follows: No scale was used for this part 2 Importance of English This part was consisted on the importance of English language.In this part eight questions were designed to ask the importance of general and medical English in their educational and professional settings.
Five points Likert scale of importance.
3 Necessities This part was designed to examine the opinions of using and learning the English language skills (listening, speaking, reading and writing).Five points Likert scale of quality.

Data Analysis
Data were gathered from two groups of medical discourse community: medical students and doctors.Questionnaire one was used to gather data from medical students and questionnaire two was used to gather information from doctors.

Data Analysis of Responses Obtained from Medical Students
Questionnaire one has six parts, each part consists of sub items.First part was the demographical information, which deals with students' personal information, part two was the importance of English and next part was the necessities which cover the area of language skills by using sub items.Fourth part was the analytical information which deals with the existing proficiency level of medical students.Next part was about the learning needs that consisted of eleven questions.Lacks and wants was the last part, in this part nine statements was designed.
This part provides quantitative analysis in regard of importance of English language in academic and professional medical settings.For this purpose five point Likert scales was used to determine the opinion of respondents.The data in above table showed that how many students mentioned that English was extremely important and that English was important for them.Whereas, some students reported that English was somewhat important and others believed that English was minimal important and remaining believed that English was not important for academic and professional settings.Data shows that English language is rated as very important at academic level, at professional level and for understanding medical terminologies.Majority of the respondents emphasized upon the need of English language course which could fulfill their academic and professional needs.This part was designed to identify the opinions about using and learning four English language skills.Table 4 presents the frequencies and percentages of responses about using and learning four English language skills.The data in above table showed that how many respondents were strongly agreed, agreed and were not sure about using language skill.Data also indicate that some respondents were disagreed and others were strongly disagreed with regard to use language skills in medical settings.The overall mean value of learners' responses was more than 4, that indicates that vast majority of respondents opined that they use English language in their daily conversations, to discuss medical issues, reading textbooks, journals, medical reports and research papers.This part was designed to identify the opinions of medical students about their lacks and wants regarding English language learning.In the above table the perceptions of medical students are presented quantitatively regarding learning English language.Data divulges that students quite often fail to communicate well about medical reports.They face a lot of problems in developing good understanding about English books, articles, magazines, case histories and lectures.

Summary of the Findings
Students' opinions about the importance of sufficient English proficiency to perform their studies effectively as 87.5% students mentioned that English was important for their studies.Responses about the importance of English in medical profession as 85% students believed that it was important.Respondent's opinion about the importance of English for medical purpose as 75.5 % students believed that it was important.Students' opinions about the importance of language skills 75.5% respondents believed that it was important.Students' perceptions about comprehension of medical terminology as 74% believed that it was important.Students' perceptions about the importance of English for Pakistani medical discourse community as 69% students believed that it was important.
The overall findings of students' perceptions about necessity of listening skill for daily conversations showed that 84% students were agreed that it was used in daily conversations.Student's perceptions about necessity of listening skill to comprehend discussions on medical issues showed that 82% students were agreed.Students' responses about using speaking skill to participate in class discussions showed that 84.5% were agreed that it was needed.Students, responses about using English speaking skill in presenting oral reports showed that 78% respondents were agreed with it.Students' responses about necessity of speaking skill in presentations at medical conferences and seminars showed that 81% respondents were agreed with it.Students' responses about the necessity of reading skill to read textbook showed that 87% respondents were agreed that reading skill was necessary.Students' responses about necessity of reading skill to read medical articles and journals showed that 82.5% respondents were agreed.Students' responses about the necessity of writing skill to write laboratory reports showed that 81% respondents were agreed with it.Students' responses about necessity of writing skill to take notes during lectures showed that 81% respondents were agreed that it was necessary.Students' of responses about using writing skill to write research papers showed that 81.5% respondents were agreed that writing skill was necessary.
About existing proficiency in listening skill 52.5% students perceived that their listening skill was not adequate.About existing proficiency in speaking skill 71% students perceived that their speaking skill was not adequate.
Existing proficiency in language factor of English vocabulary 78.5% respondents perceived it was not excellent.
Existing proficiency in language factor of English grammar 80.5% respondents considered that it was not excellent.Existing proficiency in language factor of English pronunciation 74% students perceived that it was not excellent.Existing proficiency in comprehension of medical terminology 73.5% students perceived that it was not excellent.
Data shows that majority of the students 69.5% suggested that English should be taught as subject in the first professional year of medical students.Similarly, majority of the students further opined that English taught to them should be relevant to their medical fields and medical profession.They also agreed that medical students don't have sufficient knowledge about English used in medical profession and medical discourse.
Students' responses about that they are not able to communicate perfectly about medical related topics in English showed that 53.5% students were agreed that they are not able to communicate perfectly.Students, responses about that they are not able to comprehend easily medical books, articles, and magazines which are published in second language showed that 53.0% respondents was agreed that they had difficulties.Students' responses about that they should be able to understand medical related instructions and lectures showed that 58.5% respondents were agreed.
Doctors' perception about the importance of sufficient English proficiency to perform professional activities showed that 70% respondents reported that it was important.Doctors' perception about the importance of English for medical purposes as 65% respondents reported that it was important.Doctors' perception about the importance of English language skills for medical studies showed that 60% respondents reported that it was important.Doctors' perception about the importance of comprehension of medical terminology showed that 70% respondents mentioned that it was important.Doctors' perception about the importance of English for Pakistani medical discourse community showed that 55% respondents believed that it was important.
Doctors' responses about using English in seminars showed that 55% respondents were agreed that it was used.Doctors' responses about the English needs in order to read medical literature showed that 75% respondents were agreed that it was used.Doctors' responses about the needs of English to understand the manuals of medical equipment showed that 85% respondents were agreed that it was used.Doctors' responses about the needs of English to communicate with foreign patients showed that 85% respondents were agreed that it was used.Doctors' of responses about the needs of English to write professional purpose letters showed that 80% respondents were agreed that English was used.Doctors' responses about the using of English during meetings showed that 80% respondents were agreed that it was used.

Interpretation of Research Questions
The findings related to each research question are presented as follows: 5.2.1 What Are the English Language Needs of Medical Students in Their Academic Activities?
In response to the findings related to first research question the opinions of majority of respondents that English was important for medical students.They believed that EMP was important for Pakistani medical discourse community.The overall findings of students' perceptions about necessity of English language skills indicated that English was used in different academic activities like to follow lecture instructions, discussion on medical issues, in seminars and conferences, in presentations, to read articles and journals, to comprehend graphs and charts, to write laboratory reports, assays and research papers.Students' responses about instructions for medical English should start from first year of medical classes 70% respondents were agreed.EMP can be taught for academic purpose to medical students.It was taught in work and pre-work situations, for example to practicing doctors.So, it was very important to distinguish between the different needs of the group.The needs of medical students were to read articles and textbooks, write clinical reports and short essays (Dudley-Evans & St. John, 1998).

What
Are the English Language Needs of Doctors in Their Professional Career?
In response to the findings related to the second research question the opinions of the majority of doctors that English was important for medical students.Responses showed that English language was important for Pakistani medical discourse community.Respondents mentioned that all language skills are important in medical profession.The overall findings of the doctors' responses showed that the English language was used in various professional activities like to participate in seminars, to read medical literature that was published in English language, to understand the manuals of medical equipment, to communicate with foreign patients, doctors and other health professionals, to write medical purpose letters and medical prescriptions and taking case histories.The official language is English for medical representative in Pakistan.They have needed to interact and communicate in English with educated class.They are required to perform their occupational needs like meetings, presentations and briefings in English.English for this purpose is more useful than any other language.Medical representatives are required to interact in English with professional trainers, chemists, officers, colleagues and medical organizations.English has gained the status of international language, so, it is important that medical representatives of Pakistan should be competent in use of English for their professional activities (Khan, Awan, & Afzal, 2016, p. 45).EMP was a type of ESP.Medical doctors and learners had different reasons for learning medical English.One of the reasons was that they had needed to read books and journals in medical genres.Doctors and nurses also need to speak with colleagues, to make use of important database available on the internet, to contribute in international conferences, to write research papers for journal publications, to take postgraduate courses in the U.K or in U.S, and work effectively in hospitals where English was used as a first language (Kawagoe, 2009).

5.2.3
What Is the Existing Level of Proficiency in English Skills Among Medical Students?
In response to the findings related to third research question the perspectives of students related to existing proficiency in listening skills 52.5% students reported that it was not adequate, in speaking skill 71% students perceived that their speaking skill was not adequate, in reading skill 60% students perceived that their reading skill was not adequate and in writing skill 60.5% learners perceived that their writing skill was not adequate.
Existing proficiency in language factor of English vocabulary 78.5% respondents perceived it was not excellent, in language factor of English grammar 80.5% respondents considered that it was not excellent Existing proficiency in comprehension of medical terminology 73.5% students perceived that it was not excellent.
According to respondents difficulties are encountered to speak English efficiently at seminars and conferences.
Students had different level of English proficiency, therefore; extra English language classes should start for those students.English has gained the unquestionable status in Pakistani professional and occupational settings.
In Pakistan the medical representatives have strong needs and motivation to acquire English for different job-related activities.At this time, for the purpose of enhance the medical representative's English language competence there is no English courses are present (Khan, Awan, & Afzal, 2016, p.44).

What ESL Course Can Be Designed Based Upon the Information Gathered During the Present Study?
The findings related to fourth research question, respondents mentioned that EMP should start in medical colleges.They recommended problem based learning.The course content should be key vocabulary, terminology of medicine and communication skills.Niazi (2012) pointed out that, the requirements of Medical English language teaching were a new and modern approach.Teaching medical English should be different from teaching of general English language.Medical students gathered a large amount of medical knowledge and skills in their medical education.The purpose of learning English at this level was used of language in their medical studies rather than learning grammar and primary structures.For the help of non-native English speakers, students of medicine were learning English jargons for that reason; information about medical discourse and register should be mutual with pedagogical skills of a language teacher.

Conclusion
The conclusion of the study was made according to the findings obtained from the data given by medical students and doctors.The main point of the study was to identify the language needs of medical students and doctors.They had several reasons to learn English for medical purpose.In their academic setting they had different needs to cope a variety of tasks such as reading books, journals and magazine, to understand lectures.Similarly, in professional settings, doctors had different needs of to perform their tasks effectively such as to participate in seminars, to communicate natives and to read medical texts.English has gained the status of lingua Franca in an international community of medicine.A large number of Pakistani students and doctors go abroad for their higher education and job settings, where medium of communication is English language, therefore; the strong need of EMP was existed in this situation.In Pakistani medical colleges, English is taught as non-credit course to medical students during their entire academic career.They are not trained well to develop effective communication skills.However, it is integral to impart effective English proficiency skills among doctors as they face a lot of problems in their academic and professional areas due to their poor language proficiency skills.

Recommendations
There are several recommendations concerning to recommend a course of English for medical purposes: 1) The research recommends that medical learners were not satisfied with their existing proficiency of English language as the amount of English instructions given to them was not sufficient.There is a need to EMP course that should address the academic and professional needs of medical discourse community.
2) The learners come from different linguistics, regional and cultural backgrounds, so the need of English course in medical colleges can play a vital role for creating mutual understanding.
3) Both general and medical English should start in the first year of medical college.EMP course should be designed specifically as medical students should adapt it easily.
4) Needs analysis process should be conducted to explore other areas of language needs.It can be conducted on a larger scale where ESP practitioners can be involved.
5) A further study should be conducted at different level of medical education.The course of English should be designed and divided according to preclinical and clinical needs.Similarly, various fields of medical profession like nursing, operation theatre, medicine, and medical discourse can be included.
6) English language refresher courses and workshops should be introduced for continuous professional development of doctors.
of this part was to analyze the medical students' existing level of proficiency in linguistics skills and factors.Thirteen items were used for this purpose.

Table 1 .
Design of research is the set and framework of procedures and methods used in collecting and analyzing the specified variables and research problem.It defines the type of study, data collection methods and statistical plan.The nature of this research was descriptive.Descriptive research describes the characteristics of population and it usually precedes the explanatory research.It aims to describe the characteristics and data what have been studied.It involves frequencies, averages and statistical calculations.It involves gathering data that explain events and after it organizes, tabulates, depicts, and describes the collected data.It frequently uses visual aids like tables, charts and graphs to help the reader in understanding the data distribution.The researchers have selected the mixed method approach for conducting this research keeping in view different consideration.It includes the mixing of quantitative and qualitative methods.Population of this study was doctors and enrolled students of MBBS in all medical colleges of Southern Punjab.In Southern Punjab, Medical colleges are in three districts: RYK, BWP and Multan.Figures of medical colleges taken from the website of PMDC

Table 2 .
Description of data collection inventory

Table 3 .
Importance of English

Table 4 .
Using language skills

Table 5 .
Skills and factors

Table 5
was designed to identify the existing proficiency level of medical students in different language skills and factors.The presented frequencies of students show their existing proficiencies in different skills and factors of language.Data shows that mean value of listening proficiency was highest i.e. 3.55 rated as good.On the other hand, mean score of speaking proficiency was 2.79, vocabulary 2.65, grammar 2.49, pronunciation 2.77 and medical discourse proficiency was rated as 2.94.It relates that majority of the medical students rated their language proficiency at "average" level.

Table 6 .
Lacks and wants