Bridging the language gap for simulation resources

Abstract

With increasing use of open access platforms, simulation-based resources are being shared across geographical borders. There are benefits to designing resources with language and content which is understandable and applicable to learners in different countries. This report aims to assess the differences between scenarios from different groups and explore whether common terms can be used to make internationally relevant simulation resources in future. In collaboration between two groups producing Free Open Access Medical Education simulation resources in the UK and USA, we present observations of terms used in our simulation resources. The content within a series of simulation scenarios from both groups was reviewed, with notable differences in language collected. There are areas of overlap between the terms used in the UK and USA. Semantic, cultural and system differences were found which could prevent scenarios from being transferred between countries. The differences we describe highlight that language choice is important if simulation producers are intent on developing scenarios with international impact. There is work to be done to ensure that resources can be used internationally—embracing linguistics has the potential to aid this process, with the use of simplified language and feedback from local communities being key steps.

Introduction

Many aspects of life have been changed by the rise of digital platforms and social media. Medical education has seen a shift toward the use of accessible online resources, allowing for sharing and discussion across the world. The FOAM (Free Open Access Medical Education) movement has aimed to democratise medical education by encouraging the sharing of resources and removing barriers to access.¹ FOAM resources are varied, including podcasts, blogs, discussions on social media, as well as simulation resources. Two FOAM simulation sites that have gained momentum are EM3 (East Midlands Emergency Medicine Educational Media, UK) and the ACEP SimBox (American College of Emergency Physicians simulation box, USA).

EM3, based in Leicester in the UK, has been providing local and FOAM education and resources since 2014. The most popular scenarios recently published by EM3 are the ‘Resus Drills’, short simulation drills which are run in the emergency department (ED) with a focus on teamwork, leadership and behavioural skills.²

The ACEP SimBox was developed through collaboration of US-based simulationists. Since 2017 the team has developed a series of simulation resources under the ‘SimBox’ and ‘TeleSimBox’ umbrella. These simulations can be run online or in person using a simple manikin with an internet streaming device connected to the website to display the monitor and video of a patient. These simulations cover teamwork and communication around paediatric critical illness presentations.³

While exploring possible collaboration between the two simulation groups, differences in language, systems and approach became apparent. This report aims to explore these differences to examine how these might impact their use internationally. Previous discussions around the USA and UK language in medical literature have highlighted difficulties in exploring such differences.⁴ In their proposal of the use of a ‘Minimal English’, Goddard and Wierzbicka suggest that simplifying our use of the English language is worthwhile to avoid elements of English which are difficult to cross-translate and to reduce Anglocentrism.⁵ As the FOAM community continues to make materials accessible to all, our use of language needs to be considered to ensure usability across an international audience.

Communication and language use within medicine is recognised to be important within good practice. Social studies show how communication practices can influence outcomes of doctor–patient interactions and influence how patients accept and reject medical services.⁶ Linguists have made similar observations about the imperative to consider language and cultural differences when implementing practices across languages. This notion is best summed up in this quote:

It is good to realize, however, that not all languages have a word corresponding exactly to the English word pain, and that other languages may offer somewhat different perspectives on the range of phenomena associated in English with the words pain, hurt, ache, and sore. In that sense, ‘pain’ is not a conceptual universal, even though all people feel, at times, what in English can be thought of as ‘pain’.⁷

We know that not all languages talk about (or even have the same concepts for talking about) concepts that can be important for healthcare, such as emotions, bodily feelings and sickness. As English is often used as lingua franca for doctors accessing medical knowledge and education, we acknowledge the influence of language and the importance of linguistics in the history and in the continued evolution of medicine.^{4 8} Given this, it seems more important than ever to advocate for establishing a formal discipline dealing with these issues that can emerge when medical education and practice is distributed across borders. It is up to the FOAM community to invite and recognise contributions from linguistics to help improve healthcare as language-based material has the potential to reach further than ever before with the increasingly easier sharing of information online.

Methods

Resources from each group were selected for comparison, these being the ACEP TeleSimBox scenarios, and Resus Drills and Time Critical Infusions in Children sessions from EM3. A member of each group reviewed the resources of the other group (AR and ES). Reading through each resource, phrases were highlighted if they were easily understood, and if the reviewer felt they required translation. Areas of the scenarios where clinical practice differed to the reviewer’s local practice were highlighted. Where phrases were incongruent, translations were sought by discussion between reviewers. Differences in particular were reviewed in order to group them into categories, and then highlighted if they could limit understanding in practice.

Results

As expected, there is considerable terminology in common between the scenarios. The area of most interest is where language differs significantly (table 1). Semantic differences were common and have varying potential for preventing understanding. Spelling differences and acronyms are unlikely to cause confusion unless starkly different. Differences in jargon however have potential to prevent use of scenarios across geographical lines—for example, the phrase ‘EMS patch’ or ‘haste call’ in ACEP’s scenarios was entirely unknown to our UK reviewer, with its equivalent being the UK’s ‘red call’, a colloquialism with its origins in the fact that the telephone in most EDs for prealerts is red. These terms both refer to an ambulance notification to hospital that they are en route with an unstable patient.

Table 1.

Example differences in terminology between EM3 and ACEP simulation scenarios

Variation examples	EM3 phrasing	ACEP phrasing
Semantic differences
Spelling	Oesophagus Hypoxaemic Paediatric	Esophagus Hypoxemic Pediatric
Acronyms	ECG	EKG
Jargon	Fitting Red call Bloods Cannula	Seizing EMS patch/haste call Labs IV
Drug names	Paracetamol Salbutamol 5%/10% dextrose	Acetaminophen Albuterol D5/D10
Historical and cultural differences
Use of local brand names	Plaster	Band-aid
Units of measurement	Blood glucose in mmol/L Birth weight in kg	Blood glucose in mg/dL Birth weight in lbs
Medical system differences
Titles of organisations and people	A&E (accident & emergency) Paramedic or technician crew (of ambulance)	ED (emergency department) ALS/BLS crew (of ambulance)
Roles, certifications and expectations	Intravenous access performed predominantly by medical staff Medications from drug cupboard	Intravenous access performed predominantly by nursing staff or technicians Call pharmacy for drugs
Differences in clinical practice	Phenytoin as second line after benzodiazepines in status epilepticus	Levetiracetam as second line after benzodiazepines in status epilepticus

ACEP, American College of Emergency Physicians; EM3, East Midlands Emergency Medicine Educational Media.

Historical differences in naming conventions and units also featured, for example, differing units of measurement and the use of brand names instead of generic terms in the ACEP scenarios. Providing equivalents in scenarios would be a suitable workaround, for example, including the weight of an infant in metric and imperial measurements. Comparison highlighted system differences also, including differences in staff roles and responsibilities, process variations and differences in clinical practice from local guidelines. These differences are potentially more difficult to plan for without an overall awareness of how one’s practice differs compared with other regions.

Discussion

The differences found have a variable potential impact on how easily a scenario could be used in different parts of the world without modification. Small differences in spelling are unlikely to cause confusion. Differences in units could be troublesome—a normal blood sugar of 4.0 mmol/L in an EM3 scenario could be confusing to read for a team familiar with mg/dL, the equivalent level being 72 mg/dL. Having to convert units on-the-fly could be disruptive. Differences in which team members perform which tasks in a given scenario could also cause confusion.

While the USA and the UK broadly speak the same language, differences in jargon are widespread with enough variability that could limit how generalisable these scenarios are. Differences in treatment algorithms, investigations and so on also need to be considered when producing simulation scenarios, and could potentially be a difficult hurdle to overcome—should scenarios suggest referring to local guidance, or provide localised scenarios with different algorithms for different regions? Potential solutions to address these differences include the creation of country-specific scenarios, glossaries, use of simplified terms (avoiding colloquialisms, acronyms and eponyms), pictures and infographics and the inclusion of multiple terms, for example, code cart/crash trolley.

Within this discussion hangs a balance between ensuring scenarios are generalisable, while being mindful of the risks of side-lining country-specific and region-specific practices. For groups producing resources to cater to many learners across the world, an awareness of the language within scenarios and how easily it can be interpreted is likely to be helpful. Simplifying the language has the potential to decrease the cognitive load of facilitators, enabling more focus on participant learning. FOAM producers might consider seeking user feedback on language and cultural differences. We acknowledge that being mindful of language differences is the first step in developing universal content for global use.

If the medical community is sincere about tackling world health issues through global sharing of knowledge and training, it is time that we advocate for a formal medical linguistics discipline that is guided by issues of global healthcare. We know that language, culture and social practices play a focal role in the outcome of both training and when training meets practice.

Furthermore, we recognise that especially simulated scenarios can be problematic and risk reproducing an Anglocentric view of health, disease or symptoms. This is however not limited to simulation scenarios and may be relevant for other areas of FOAM and medicine as a whole. We recognise this, and as a result we propose some initial steps that can help adaptation to local circumstances and avoid misunderstandings:

• Create a range of non-Anglocentric scenarios that can be adopted/included for local needs.

• Create a simplified medical language (based on simplified English).

• Create language-specific material for each language-culture that uses the simulation.

• Include glossaries where language is not amenable to simplification.

• Create an opportunity for different language-communities to share information and discuss the relevance of the simulation for their language-community.

We have discussed steps that can be taken by producers of FOAM materials, but this does not mean that facilitators cannot be mindful of these issues when using existing resources. Preparation for sessions to ensure that scenarios and their supporting materials are appropriate for local use can go some way to remedy this. Feedback from facilitators is likely to play a role in adapting and producing resources, and FOAM’s existence within a social media context means that these conversations can be had easily.

Limitations

These comparisons are between scenarios produced by two groups with their own inherent geographical contexts; what EM3 and ACEP include should not be thought to represent practice for the whole of the UK and USA, respectively. The themes found in these comparisons are perhaps limited by the perspectives of those reviewing the scenarios, and what was felt to be easily understood and what required translation may have varied if different reviewers had been used.

This report has come from the analysis of a limited number of scenarios, and it is clear that what we have found is by no means exhaustive. Additional work can be done, not just comparing the scenarios mentioned, but also including those from other countries in order to reach a wider audience and educate more clinicians and students. Furthermore, it will be important to consider the impact of findings in clinical care outside of simulation as with increasing globalisation there may be other latent errors in communication that have not yet been identified.

Conclusion

We have described differences in language between simulation scenarios from two groups which highlight that careful language choice is important if simulation producers are intent on developing simulation scenarios with an aim of international educational impact. Providing materials for free on the internet is a step in the right direction in the democratisation of medical education but is only one piece of the puzzle.

Data availability statement

Data produced from the comparison outlined is available if requested.

Ethics statements

Patient consent for publication

Not required.