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Вестник Томского государственного университета. 2022. № 480. С. 236-243 Vestnik Tomskogo gosudarstvennogo universiteta - Tomsk State University Journal. 2022. 480. рр. 236-243
Научная статья УДК 378:37.034 doi: 10.17223/15617793/480/26
Development of professional tolerance in medical students through professionally-oriented
foreign language training
Olga Yu. Makarova1,3, Ulyana A. Kazakova2,4, Daria V. Gorbunova1, 5
1 Kazan Medical University, Kazan, Russian Federation 2 Kazan National Research Technical University, Kazan, Russian Federation
3 mrs.makarova@yandex.ru
4 kazakova-ulyana@mail.ru 5 darya.gorda@yandex.ru
Abstract. Global sociocultural transformations in the modern world are associated with expansive digitalisation and its impact on human life. Given the advantages of digital technology development, a number of significant problems arise, in particular, social differentiation, commercialisation of socionomic professions, information consumerism, emotional estrangement due to the virtualisation of communication, a shift in value orientations, replacement of traditional moral norms with their destructive simulacra. There is a clear need for intensification of educational activities in higher education focused on the humanisation of public consciousness, the promotion of social cohesion and the development of the moral backbone of an individual. Hence, it is necessary to refer to the theoretical and methodological foundations of tolerance development in students. The aim of this article is to clarify the concept of professional tolerance of a doctor and describe the strategy of its development in students in the process of foreign language training. Considering the issue of professional education of future doctors, the authors note that the vector of students' spiritual and moral development is determined by the values, attitudes, and norms of medical ethics and deontology. Herewith, the principle of tolerance is of the basic ones since professional medical practice is based on regular interpersonal interaction. The authors define the concept of a doctor's professional tolerance as the willingness to provide patients with high-quality medical care regardless of the heterogeneity of socio-cultural factors and subjective personal aspects. This concept assumes the doctor's tact, empathy, psychological flexibility and poise. The proposed strategy for the development of professional medical tolerance in students via professionally-oriented foreign language training involves the holistic formation of its cognitive, affective and conative components through the educational content and the parity in subject-subject interaction. In the development of the cognitive component, considerable importance is ascribed to supplementing the basic educational materials by authentic content of social and professional orientation. The connecting link of the development of cognitive and affective components is the identification and levelling of stereotypes and prejudices regarding socially significant diseases. The basis for the development of the affective component is pedagogical tolerance, a favourable educational environment, interactive activities at classes, and the facilitation of students' reflection. The development of the conative component of tolerance is directly tied to the development of professional communicative competence of future doctors: the study and development of various speech clichés in the format of interaction with patients; revision of politeness formulas; practicing non-verbal communication means in playing out quasi-professional situations; mastering the speech norms "plain language" and "people-first language".
Keywords: vocational education, medical education, professional tolerance of a doctor, professionally-oriented foreign language training, communicative aspects of professional tolerance
For citation: Makarova, O.Yu., Kazakova, U.A. & Gorbunova, D.V. (2022) Development of professional tolerance in medical students through professionally-oriented foreign language training. Vestnik Tomskogo gosudarstvennogo universiteta - Tomsk State University Journal. 480. рр. 236-243. doi: 10.17223/15617793/480/26
Introduction: The challenges to society and education in modern era
Modern society is experiencing a moral crisis on a global scale. The rapid commercialisation of all spheres of social and cultural life and oniomania cultivated by the media and social networks determine the prevalence of material values over spiritual ones, selfishness over altruism. The information overload and its uncritical acceptance lead to superficiality and shallow-mindedness making an individual unable to assess the enveloping realities objectively. Falsification of the facts and demagoguery contribute to the implantation of the misconceptions into public consciousness. The tendency to replace traditional morality with pseudo-tolerant ideas
and attitudes triggers the distortion of social code and limits. The uncontrolled distribution of materials illustrating deviant, socially unjust, morally condemnable behaviours on social networks serves as a mechanism of demoralisation. Thus, we are witnessing the desacralisation of socio-cultural reality.
Alongside, rapid digital transformations, carrying certain socio-economic benefits and being the inherent factor of the development of information-and-technology society, nevertheless contribute to social distancing, social differentiation, and exclusion. The global addiction to communication technologies and social networks becomes increasingly obvious. The psychological load on the personality is intensified by the scarcity of direct
© Makarova O.Yu., Kazakova U.A., Gorbunova D.V., 2022
socialisation and constructive recreational and cultural activities. Scholars note the negative impact of digitalisation on the personal and intellectual development of students: decrease in creative activities, insufficiency in systemic and critical thinking, escalating illiteracy, limited communication skills, distortion in emotional development and psychological wellbeing [1-3].
Thus it makes contingent that modern social sciences can no longer be limited only to explaining social reality but must participate in its construction [4]. In the current context, educational methodology and practice require high-quality modernisation with the focus to develop humanistic potential and adaptability of the personality and strengthen the moral backbone of society. Achieving these goals, the pedagogic strategies need to be devised to provide favourable conditions for personality development and the establishment of positive self-conception, unleashing the intellectual potential of the younger generation, building psychological and socio-cultural awareness in various aspects, promoting social cohesion.
Therefore, taking into account modern realities, the relevance and prospects of psychological and pedagogical research into the modernisation of the methodology of vocational education, enculturation and self-identification of student youth, formation of socially and professionally significant personality traits, communication skills, rising the esprit de corps in educational environment is beyond doubt.
Vocational education in medical higher school
Doctor is a socionomic profession (helping, humanistic). The professional activities of a doctor involve constant subject-subject interaction directly addressing terminal values, e.g. mental and physical health, well-being and human rights. Therefore, medical practice leans on the set of moral and ethical principles that have evolved in the course of the historical development and formation of professional medical deontology.
It is well known that the doctor-patient relationship is the cornerstone of medical practice, having a direct impact on the diagnostic and therapeutic process. The establishment of mutual respect and trust-based relationship in this dyad contributes to the accuracy in history taking, diagnostics and devising a treatment plan, as well as to the formation of a positive attitude of the patient towards recovery, decrease in the likelihood of relapse, increase in adherence to treatment, and the development of effective strategies of coping behaviours [5, 6]. Such trustworthiness and affinity in the doctor-patient relationship is not an inherent element, but one which should be attained, carefully developed and nurtured. This, besides the profound professional knowledge and skills, sets the requirements for the doctor's personality and moral rectitude.
However, the above-mentioned challenges of modern era cannot but cause general concern about the state of the moral ground in socionomic (helping) professions. As an example, some clinicians, analysing the problem from within, note dehumanisation and a crisis of patient
confidence in the doctor, blaming the imperfections in motivation for consistent self-education and self-actualisation among some of their colleagues [7. P. 33]. Another scholar regrets that "Medicine-commercialising mindset compromises and defeats its professional principles and purpose, which hold well-founded humanistic values" [8. P. 480]. Indeed, even in the linguistic dimension, we observe the proliferation of the word "client" rather than "patient", and "medical service" rather than "medical care".
At present, the profession of a doctor is in the limelight due to the pandemic, which pushed society to rethink and appraise the importance of the role of doctors and medical personnel. Modern realities only emphasise the need for a new generation of humane, altruistic and caring doctors who will be ready to cope with the emerging challenges of the modern world and provide high-quality medical care to any individual.
Consequently, the framework of vocational education in a medical higher school should be guided by the humanistic ideals of medicine and implemented by the complex and consistent formation of worldview, spiritual, moral and ideological attitudes, values and value orientations, communicative competence, social awareness and skills, psychological literacy, along with levelling negative attitudes in the student environment [9, 10].
In the light of the above, we argue that the formation of tolerance, which is one of the key social values, professionally significant personality traits, and an integral competence of a doctor, is of paramount importance in medical education.
Professional tolerance of a doctor
The general concept of tolerance is construed as the recognition of the equal rights and worth of each member of society, rejection of stereotypes, prejudice and bias, readiness for constructive parity interpersonal interaction. It is a multidimensional phenomenon representing an adaptive and regulatory mechanism of society, in general, and personality, in particular. [11] Tolerance harmonises interpersonal relations given the differences in cultural and socio-demographic variables. It determines the success of communication and interaction in case of divergence in views, ideals, values, subjective acceptability or unacceptability of behaviour models, etc. (Figure 1). Thus, tolerance is an immanent cross-cultural value.
Figure 1. The pyramid of tolerance
The limits of tolerance are determined by legal and moral norms that exclude connivance and indulgence at illegal, immoral, destructive activities and practices, and a fortiori their normalisation.
Considering the issue of professional tolerance of a doctor, let us mention that medical practice in the framework of the doctor-patient relationship implies high linguistic activity, heterogeneity of the patient contingent, the prevailing negative psychological context of tension, emerging situations of uncertainty and ambiguity. Thus, tolerance internalised into the structure of a doctor's personality is a predictor of
effective interpersonal interaction and a factor of a doctor's emotional defence.
We construe the professional tolerance of a doctor as a willingness to provide patients with high-quality medical care regardless of the heterogeneity of socio-cultural and personal factors, founded on the altruistic and humanistic personality orientation of the doctor, tact, forbearance to undesirable personal qualities and objectively or subjectively condemned behaviour of the others, emotional generosity concerning both psychological, and physical state of the patient, rejection of destructive stereotypes and prejudices (Figure 2).
r
Professional Tolerance of a Doctor
based on:
high moral standards; the priority of the holistic perception of the person in need of medical care; recognition of the value of individual autonomy.
4—►
suggests:
psychological adaptability; good emotional regulation and self-control; lack of inclination to prejudice;
sensitivity to a person.
e
A
4—►
expressed in:
the culture of speech and behaviour;
the ability to establish trust-based relationships in the doctor-patient dyad; the fairness of assessments and judgments.
Figure 2. Professional tolerance of a doctor
Establishing a trust-based relationship in the doctor-patient dyad involves a focus on dialogue, the objectivity of a specialist, and the psychological stability of a doctor to various factors of the communicative situation. Given the psychological stress that accompanies patients due to their worrying for their health and wellbeing, the communicative context presupposes the doctor's patience to patients' emotional lability, ability to hear out, calm down and encourage, express understanding and empathy, readiness to resolve a conflict if required, and ability to cope with emotional overload. Thus, the development of professional tolerance in students is of high priority in vocational medical education.
It should be noted that tolerance, without awareness and sufficient knowledge and skills in social sciences and the humanities, may occur as indifference, which can easily erupt into its destructive form - connivance at any phenomenon, without critical thinking and forming own judgement. The latter, in turn, can lead to the discrediting of traditional moral grounds and values and entail social atomisation, and in the context of medical activities - indifferent and neglectful attitudes towards the patient.
Consequently, the priority in the professional tolerance development in students is in the disciplines of social sciences and the humanities, and this process requires the complex formation of the cognitive, affective and conative components of professional tolerance:
- introduction to and in the ethic-deontological principles in medicine, nature and functions of tolerance in healthcare;
- building of awareness and promotion of critical reflection on the importance of tolerance in everyday and professional spheres of activity, as well as the dangers and unworthiness of the opposite phenomena (such as stigmatisation and discrimination);
- development of internal readiness and the need to follow the principle of tolerance in interpersonal and intercultural interaction;
- formation of a communicative culture and readiness to follow the rules of etiquette.
Theoretical and methodological foundations of foreign language training arise directly from an integral and comprehensive component of the socio-cultural dimension of life - communication, and develop within the anthropocentric paradigm. Learning and mastering a foreign language entail studying and appreciating the foundations and values of other cultures, broadening the horizons, accustoming to and recognising pluralism. Scholars note the correlation between bilingualism (proficiency in two languages), psychological flexibility and tolerance [12].
The discipline "A Foreign Language" belongs to the social sciences and the humanities cycle, and, in a medical university, has a professional orientation.
One of the most important goals of professionally oriented foreign language training is the formation of
communicative foreign language competence in students, which will allow them:
- to use a foreign language in various situations of intercultural interaction in professional, scientific, social contexts;
- to perceive and express various communicative intentions inherent to both a professional and business field of activities, and to sociocultural and interpersonal interaction;
- to practise self-education and self-development, to master additional knowledge and skills and improve their qualifications.
The professional orientation of foreign language training in a medical university contributes to addressing the problems of motivation and the development of interest in learning a foreign language. Therewith, it bears great potential in the development of socially and professionally significant personality traits and competencies in students in parallel with the formation of communicative foreign language competence through the educational content.
Professional tolerance development in students via professionally oriented foreign language training
Since the very beginning of the first year of study, students seem to feel uplifted by the entrance in the medical university and demonstrate their eagerness to master the knowledge and art of medicine, explore a new way of self-development, making their efforts in becoming doctors. Consequently, the main purpose of educators and lecturers at this stage is to ensure the
favourable conditions for sustaining the students' motivation and developing a sense of belonging to the medical community. These are the first steps in introducing them to the humanistic ideals and moral standards of the professional culture.
Pursuing the goal to develop professional tolerance in future doctors it is important to emphasise that tolerance is a multifaceted construct, which cannot be acquired or embedded at once. While the core of the tolerance of a physician is a non-judgmental attitude towards the personality of their patients, whose physical, mental and / or emotional state requires medical attention and care, it is not enough to ply students with the knowledge of norms and requirements of medical deontology and bioethics. To be effective and to ensure the development of positive attitudes towards others, this process requires a favourable socio-educational environment, a positive personal experience of interpersonal interaction in different contexts, understanding and management of one's emotions and behaviour.
Consequently, tolerance development is a complex process driven by equal involvement of the contributing factors (Figure 3). Therewith, the contextual approach, which factually is the framework for teaching a foreign language for special purposes, provides psychological and pedagogical conditions for the formation and development of a professional culture of a person, as well as a relevant knowledge component based on a professional interdisciplinary context.
Figure 3. The basic requirements to the process of tolerance development in students
Cognitive component. The basis of the integration of professionally-oriented foreign language training into the development of students' professional tolerance is a careful selection of educational content, proceeding by the principles of authenticity, professional and value orientation of the educational material, its availability and accessibility, redundancy, situational and thematic focus. The implementation of the educational process implies the synergy of contextual, cultural, personality-oriented and activity-based approaches, focus on problematic, active and interactive teaching methods.
Considering the social focus in medical education, there is a number of topics which need to be covered: ideals and key values of medicine; the social role of the doctor; ethical, psychological and communicative peculiarities of the doctor-patient interaction; medical discourse and body language; effective communication strategies; socially significant diseases and associated stereotypes and prejudices; social determinants of health; obstacles in obtaining medical care in the modern world. The study and analysis of the proposed topics contribute to the development of the cognitive component of tolerance.
It should be noted that identification and levelling the existing stereotypes regarding socially significant diseases contribute to the prevention of stigmatisation in healthcare [13]. As follows, it is an inherent and salient part of professional tolerance development in students. When introducing such a content, it is relevant to reveal the awareness level; this can be done in a form of minitests "Fact or Myth", for example:
- A person can contract HIV by touching someone who is
diagnosed with it. - Fact / Myth;
- AIDS can neither be transmitted from person to person
nor contracted. - Fact / Myth;
- People infected with HIV cannot have healthy children.
- Fact / Myth.
Having the test done, the teacher provides the correct answers and organises the review of the topics covered, drawing on the prearranged authentic materials from credible sources (websites of WHO, CDC, etc.).
Affective component. Undoubtedly, the prerequisite for the formation of any personal quality in students is its presence in the teacher, since a personality can only be brought up by another personality. Consequently, the principal defining factor in the development of students' tolerance is pedagogical tolerance - the priority of respect for the person and recognition of the individuality of each student; tact and restraint; sensitivity and responsiveness in interpersonal interaction; emotional stability; objectivity and fairness.
In turn, the personal qualities of the teacher and his / her desire to self-actualise and master social and pedagogical skills contribute to the creation of a favourable educational environment and a comfortable atmosphere in the classroom. This helps to relieve psychological stress and break the language barrier, foster students' self-confidence and sense of self-worth, and the formation of friendly ties and the esprit de corps.
Nowadays, it is especially important to show students that you do not just provide them with "educational
services", but teach and educate them being ready to provide the psychological and pedagogical support they require. Therefore, the fundamental principles of teacher-students interaction are dialogue and feedback -orientation towards cooperation and open and trust-based communication, taking into account the psychological state, educational needs and personal interest of students.
Since the development of the affective component of tolerance is most comprehensively formed in the process of socialisation (development of emotional intelligence, self-control skills, assertive behaviour, and empathy) and introspection (deepening of knowledge of oneself as a person, development of the desire for self-improvement, psychological stability), it is necessary to fulfil two basic conditions:
- utmost involvement of students in interaction with each other, variety of communicative activities in a foreign language in the classroom;
- promotion of students' self-knowledge (for example, analysis of professionally significant qualities of a doctor's personality with subsequent introspection: "What personality qualities would you like to develop? Which would you like to get rid of? What can help you to achieve this goal?"); provision of assignments that facilitate (re-)comprehending value-based information and develop the ability to reason their own opinions correctly (for example, discussing aphorisms and statements on medical topics).
Conative component. Regarding the manifestation of tolerance in professional activities, it is known that communication between a doctor and a patient should be established "on the basis of humanism and mercy and in compliance with three conditions: acceptance, optimism and enhancement of self-esteem" [14. P. 120]. In professionally-oriented foreign language training in a medical higher school, it is extremely important to introduce communicative clichés of greetings and encouragement to talk, expressions of approval, sympathy and empathy, regret, gratitude and response to gratitude, direct and leading questions, the technique of active listening, etc. It is important to emphasise that in spite of the limited time allotted for an appointment, politeness and culture of speech must not be neglected.
Since the first meeting of the doctor and the patient is critical to the formation of the first impression and, therefore, the success and effectiveness of communication, the establishment of a therapeutic alliance, a polite, respectful greeting and correct self-presentation are of paramount importance.
Since the main task in learning a foreign language is not just the development of passive vocabulary, but readiness for its active use in real communicative situations, along with practising these clichés, it is necessary to emphasise the importance of the nonverbal dimension of communication - to highlight the way one can express interest and care to an interlocutor. Consequently, when practising phrases in the form of a dialogue or a role-playing game, it is important to avoid the monotonous reading of lines, master the intonation skills, and stimulate the use of body language.
As an example, consider the communicative clichés offered for making the first acquaintance at the appointment and their subsequent practice:
- Greeting: Good morning / afternoon / evening, Mr / Ms / Mrs + surname (in an English-speaking environment) / name and patronymic (in a Russian-speaking environment ); body language - a benevolent countenance, a slight nod of the head, a smile, an outstretched hand for a handshake (if appropriate);
- Please come (on) in and do sit down; body language - pointing to a chair / examination couch hand gesture;
- How can I help you today? / What would you like me to help you with today? - In the second version of the phrase, the focus shifts from "I" to "you" - from the doctor to the patient, emphasising his / her worth and encouraging him/her to feel more comfortable and confident; body language - a direct look at the patient, turning the body toward him / her, diversion from objects (computer,
documents, pen, etc.) when talking to the patient, lack of signs of superiority or hierarchy in the posture (for example, looking over glasses may demonstrate criticism or condemnation and hurt self-esteem).
Such an analysis of communicative clichés together with the body language contributes to a deeper understanding and perception of the peculiarities of the communicative dimension of interpersonal interaction and the gradual internalisation of speech etiquette provided if such analysis is systematically carried out.
As the lexical-grammatical and thematic material becomes more complex, it is important to introduce relevant phrases expressing empathy, attention and understanding, encouragement, consolation, regret, condolence. The studied speech clichés can be organised in the form of a mind map, e.g. on the topic "Bedside Manner", for better clarity and accessibility, so that a student can quickly refer to it if necessary (Figure 4).
Figure 4. Mind map "Bedside Manner" (created by the authors using web site: https://app.mindmup.com/map/new/)
Analysis of authentic video films also contributes to a more effective emotional and sensory involvement in comprehending and mastering the nuances of communication. For example, the training video "Say this, not that: Patient Experience" by East Idaho Regional Medical Center [15], illustrates and compares two opposing ways of communicating in different communicative situations in a hospital: (1) indifferent,
neglectful, tactless and (2) respectful, empathic, tolerant. These examples are very illustrative and convincing, contributing to the understanding of the psychological and ethical aspects of communication. Moreover, authentic speech is an effective resource for training listening skills, the colloquial phrases and medical terminology are significant in expanding the vocabulary of students.
An important aspect in the development of the conative component of professional tolerance is studying the people-first language. The people-first language refers to an individual first rather than to a disability or a disorder and then the person, e.g. a person with disability vs a disabled person, wheelchair-bound person vs a person using the wheelchair. It is the prescriptive norm of both written and spoken medical discourse aimed at minimising stereotypes and biases, emphasising the priority of the personality and separating the physical factor from it [16].
Regardless of the use of a native or foreign language, an integral part of the communicative competence of a doctor is the ability to express thoughts clearly and plainly, avoiding the use of complex professional terminology or jargon that sounds to most patients as gobbledygook and thus forms "a barrier to effective medical communication, especially when health literacy is limited or the topic is complicated" [17]. Therefore, when studying anatomical and physiological terminology, vocabulary related to diseases and symptoms, etc. it is important to introduce plain-language equivalents, e.g. aneurysm - a swelling in an artery, clavicle - collarbone, perspire - sweat, etc. Plain language communication refers to the clear, succinct and accurate manner of delivering information, enhancing the interaction between doctors and patients, and promoting health literacy, When teaching medical vocabulary, it might be useful to refer to "Plain Language Thesaurus for Health Communications" [18] and to assign students adding such equivalents in their personal dictionaries.
The presented examples are not limiting but intended to show the strategy for the formation of the conative component of tolerance primarily manifested in the professional conduct, manners and communicative culture of the doctor, the style of speech, attentiveness and care for the interlocutor, constructive behaviour in the divergence of views preventing the emergence of conflicts.
Conclusion
Summing up, we emphasise that, in modern socio-cultural reality, the urgent tasks of the vocational education in higher medical schools is to provide conditions for the development of a competent specialist, a mature personality and a person of good morals that is ready for creative social performance, capable of adapting to changes in surrounding realities and resisting the emerging asocial and deviant phenomena. To achieve this goal, it is vital to leverage the educational potential of all disciplines studied and to turn to traditional professional and social moral norms and values.
Since the profession of a doctor presupposes regular interpersonal interaction, tolerance is one of the key professionally significant personality traits. The content and means of professionally-oriented foreign language training in a medical university ensure embodying the development of professional tolerance in the educational process.
The core in the organisation and implementation of the educational process are the following aspects: pedagogical tolerance; favourable educational environment; psychological and pedagogical support; raising of awareness in socially and professionally significant themes; psychological education; promotion of the knowledge of the self by introspection and reflective tasks; organisation of situations of interpersonal interaction and cooperation; development of the speech and behaviour culture; mastering of the etiquette rules of everyday and professional discourse.
Thus, the motto of professionally-oriented foreign language training, recalling one of the key principles in medicine "Treat a person, not a disease", can be formulated as "Teach communication, not just terminology".
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Информация об авторах:
Макарова О.Ю. - д-р пед. наук, зав. кафедрой иностранных языков Казанского государственного медицинского университета (Казань, Россия). E-mail: mrs.makarova@yandex.ru
Казакова У.А. - д-р пед. наук, канд. психол. наук, доцент кафедры методологии инженерной деятельности Казанского национального исследовательского технологического университета (Казань, Россия). E-mail: kazakova-ulyana@mail.ru Горбунова Д.В. - старший преподаватель кафедры иностранных языков Казанского государственного медицинского университета (Казань, Россия). E-mail: darya.gorda@yandex.ru
Авторы заявляют об отсутствии конфликта интересов.
Information about the authors:
O.Yu. Makarova, Kazan Medical University (Kazan, Russian Federation). E-mail: mrs.makarova@yandex.ru
U.A. Kazakova, Kazan National Research Technical University (Kazan, Russian Federation). E-mail: kazakova-ulyana@mail.ru
D.V. Gorbunova, Kazan Medical University (Kazan, Russian Federation). E-mail: darya.gorda@yandex.ru
The authors declare no conflicts of interests.
Статья поступила в редакцию 27.10.2021; одобрена после рецензирования 04.07.2022; принята к публикации 28.07.2022.
The article was submitted 27.10.2021; approved after reviewing 04.07.2022; accepted for publication 28.07.2022.
