LANGUAGE IN INDIA

PROBLEMS OF MEDICAL TRANSCRIPTION IN INDIA
A Brief Linguistic Overview
M. S. Thirumalai, Ph.D.

1. BLUNDERS IN MEDICAL TRANSCRIPTIONS ARE COMMON, BUT MANAGEABLE

A sensational report was published recently in the Daily Telegraph of London, England, on the errors or blunders committed in medical transcriptions done through outsourcing. It looked as if such errors are committed only by the Indian medical transcriptionists. But the fact of the matter is that errors or blunders are committed every day in all the medical transcriptions, whether done in native English-speaking countries by the native speakers of English or not. Unfortunately, the Press Trust of India (PTI) that carried this news item did not mention the fact that errors and blunders are commonly committed, but with alert supervision and diligence, on the part of the transcriptionists and their supervisers, these are rectified without much damage. Now read the report as sent by the PTI.

Confusion in Indian medical transcription: report.
London, Aug 19. (PTI): The outsourcing of medical notes to Indian call centres to save money and speed up work at the National Health Service in Britain is leading to cases of confusion, a London daily claimed today.

While some "lost in translation" mistakes are hilarious, trained medical secretaries warn that the consequences could be serious if drug quantities are wrongly heard, The Daily Telegraph reported.

A drug for stomach ulcers called Lansoprazole was transcribed as the much more familiar holiday destination of Lanzarote.

Information about a patient's "phlebitis" (vein inflammation) left leg" was typed out as "flea bite his left leg".

A "below knee amputation" was transcribed as "baloney amputation" and "Eustachian tube (in the ear) malfunction" was given as "Euston station tube malfunction".

Eight London hospitals are using or negotiating to use the services of Omni-medical which employs a pool of secretaries in India to transcribe letters from tapes dictated by consultants.

It is estimated that about 7,000 letters a month, often between consultants and GPs, are dealt with in this way. The association of Medical Secretaries has been keeping a log of some of the most glaring mistakes.

2. WHAT IS MEDICAL TRANSCRIPTION?

Contrary to common belief among young people in India, medical transcription has been done for many years, long before the advent of the computer age. Medical doctors and other health care professionals in large hospitals and small clinics, mostly in the western nations, maintained a record of their observations using tape recorders, and their dictated observations on magnetic tape were transcribed into medical records in writing.

Such observations presented the state of the medical condition or the health condition of their patients so that such records could help the same medical doctor or some other doctor to understand the effect of the treatment suggested and undergone by their patients. Doctors used their own notations, abbreviations, technical terms, and abbreviated or elliptical sentences commonly used in their profession while dictating such messages. It was the duty of the trancriptionist to faithfully transcribe the message as it was dictated. This description of the process has not changed much. However, there are many interesting factors that have come to impact the profession of medical transcription.

3. THE ENTRY OF NON-NATIVE ENGLISH SPEAKING MEDICAL AND HEALTH PROFESSIONALS

For one thing, since the 1960s, doctors, whose mother tongue is not English, have been employed increasingly by hospitals in the United States, and other western nations. While their competence in the medical profession may not be questioned, their competence of the English language has been a matter for humorous remarks in various publications and among their mother tongue English-speaking colleagues. Their accent differed from one individual to another based on their country of origin.

East European and West European doctors had their own accent, which, perhaps, was easier for the transcriptionist whose mother tongue was English, relatively speaking. Asian accents and African accents, and even the Australian and New Zealander accents posed great problems for the transcriptionist. And yet most of the transcriptionists at that time were, generally speaking, mother tongue speakers of English, and the majority of the doctors were also mother tongue speakers of English.

Elliptical sentences, the nasal twang, vowel reduction, use of peculiar phrases, colloquialisms, etc., were easy for them to imagine and supply, and to hit upon the correct intent of the doctors who dictated these messages.

4. CHANGE OF SITUATIONS

Situations have changed dramatically in the last decade.

While medical transcription as a profession is still pursued by a good number of mother tongue speakers of English, the volume of work is too large for this small group of people to handle and to deliver results as quickly as possible to keep the records up to date. The medical fields and services have burgeoned enormously, along with the influx of a variety of technical terms and expressions. Even in this age of dominance of English, foreign terms have entered the medical profession, because surgical procedures are continually being updated and developed in Europe, Japan, etc., and these foreign terms are Greek and Latin to this small group of people.

5. THE MEDICAL TRANSCRIPTION PERSONNEL IN THE WESTERN NATIONS

Another dimension is that an undergraduate college degree in the United States and many other western nations is still valuable in terms of its potential to earn high wages, without doing this back-breaking transcription work. As a result, the medical transcription profession largely attracts two-year Associate Degree graduates. Their knowledge of the technical terms needs to be continually updated, even when they continue to have an edge and advantage over the medical transcriptionists from nations like India. The tuition fees to take a three level medical transcription courses to become qualified medical transcriptionists are rather enormous, in the vicinity of at least 10,000 dollars. Well, we can go on listing the special problems faced by the medical transcription profession in the western nations.

6. THE PROBLEMS OF MEDICAL TRANSCRIPTION IN INDIA

The problems faced by the budding medical transcriptionists in India are somewhat of a different nature. It is too early to say that many of these young people employed as medical transcriptionists by enterprising contractors in India would dedicate themselves to this profession as their life-long career. Most of these young people have under graduate and post-graduate degrees, especially in science, and they really do not have to pay anything to train themselves to be medical transcriptionists. Often they learn the trade on the job, and their original investment is "good" English competence and some science background. We realize that this characterization of the situation does not really do justice to the situation. But it is, in our assessment, largely true.

7. CORRECT DECIPHERING OF DICTATED MESSAGES

The major problem these young people face relates to the correct deciphering of the dictated messages. Their exposure to native English is minimal, mostly through the Hollywood movies, and the BBC broadcasts. We all know that the Bollywood movies are more popular than the Hollywood movies in India!

Listening to the news through the CNN channel has been popular, but not any more. Indian news channels attract their attention because the politics in India is closer home than the politics most of the time telecast in channels like the CNN and others.

They do communicate with each other and with their parents and relatives (if they are from major metropolitan cities, and if they belong to families with English education) via English, but then their English style is typically Indian. Idiomatic expressions are characteristically Indian, with a good sprinkling of idioms from the Victorian age, etc. They are very good in written expressions, even though such expressions may be rather involved, and may follow the syntactic patterns of olden days.

Their English language textbooks have been heavily impacted by their cultural elements, with stories from their own mythologies. Their knowledge of current spoken English and current simple and plain written English is rather not outstanding.

They are willing to work long hours, and are eager to improve their lot in this world. Their science textbooks have been good, but their pronunciation of the terms used in such textbooks is not much closer to the native English pronunciation of the same terms and phrases.

They have internalized a phonological pattern of English that is not identical to that of the native English speakers. Their phonological pattern of English gives them keys to pronunciation, following its own rules. The native speakers have a slightly different pattern, with several special features such as stress, stress reduction, vowel reduction, etc. And the mother tongue users can intuitively apply such patterns to the new word they come across. On the other hand, our Indian young people have their own phonological patterns which they use to interpret and reproduce a new word they come across in the dictated passages.

8. ERRORS AND BLUNDERS IN MEDICAL TRANSCRIPTION

Generally speaking, medical transcription should tolerate zero error, because the wellness of patients depends on the correct transcription of the records of diagnosis and procedures. And yet even the English mother tongue transcriptionists do still commit errors. There is some freedom to make corrections in the transcribed material for grammar, as well as for some clarity. Devices such as parentheses to present the amplification may be used. Although the physicians and other health care professionals whose dictations are transcribed will have the chance to validate the transcribed material, the professionals will certainly get mad if they have to make extensive corrections in the transcribed material to set the record correct, so to say.

George Heymont, who is Managing Partner of San Francisco's Alert & Oriented MedicaL Transcription Services, lists many interesting episodes in his insightful articles on the subject. Consider some of the following comments on the peculiar speech habits of some of the medical and other health care professionals he came across (Read his insightful articles in http://www.wwma.com/alert.html):

• Wet dictation (the tendency to dictate with a mouthful of saliva). This garbles some sounds and also gives transcriptionists the impression that the dictator is spitting into their ears. Transcriptionists do not like this kind of sound. Indeed, it can cause them to scream and curse at a dictator on a regular basis.
• Acceleration/deceleration. A tendency to speed up dictation on items which may not interest the doctor (usually segments of the physical examination or the patient's list of medications), but which the transcriptionist needs to hear clearly.
• A tendency to transpose "L" and "R" sounds. Is the doctor talking about a 24-hour urine collection or a 24-hour urine correction? How much second guessing must a transcriptionist do in order to cut through a physician's impaired speech habits?
• Neglecting to carefully spell the names of patients and doctors (especially those with Asian names).

9. PROBLEMS OF SECOND LANGUAGE USERS OF ENGLISH

Making the statements grammatically correct may be done with ease, suggesting amplification requires greater acquaintance with the language, diction, usage, punctuation, and technical terms, apart from a deeper sensitivity to the content and the style, structure, and the form of medical records.

In this, young people in India, drawn by the socio-economic circumstances into the field of medical transcription, certainly are in a disadvantageous position. There are greater demands made on their skill in understanding a variety of native English dialects or styles, and they have to accomplish this sensitivity over and above the heavy impact of their own Indian English and speech styles. Not only this demand, they are also required to understand the varieties of English a Hispanic or African American, or a Cambodian or a Chinese doctor, or a recent immigrant professional from any one of the corners of this world would be using.

The problems of the second language user of English as a medical transcriptionist are indeed different from those of the first language speakers of English. George Heymont remarks, "The influences of rap and Ebonics have taken a terrifying toll on the common use of the English language. When combined with such cross-cultural phenomena as "Engrish" and "Spanglish," one cannot ignore the tragic results of dumbing down America's education system. What Shaw saw as a verbal class distinction has become visible in electronic format all over the Internet. In email messages and bulletin board postings, one sees medical transcriptionists using the most atrocious grammar. Computer slang runs rampant. Homonyms appear everywhere."

Develping better speech and listening habits even in Indian English is thus an important prerequisite for our young medical transcriptionists. Their youthful indulgence in SMS lingo, and many other expressions should be kept under check, in order to better grasp the complexities of spoken native English. Suitable training programs are needed in this area, and the companies or contractors, who profit from outsourcing, owe it to their own profession and employees to set up really sound training programs.

Poor medical transcriptionists in India need to be aware of these things, and prepare themselves to meet this challenge, if India is to continue to attract more clients in this area."

10. HELP FROM CONTRASTIVE LINGUISTICS

In late 1960s and during 1970s, university departments of English and Linguistics in India did some intensive contrastive linguistic studies between Indian languages and English, and between various Indian languages. It will be a good thing to look into such studies again, and seek to identify the problems that confront the young Indian medical transcriptionists.

For example, the auditory and productive skills relating to contrasts such as r and l, s, sh, and S, between f and ph, even between p and b, between w and v, etc., need to be strengthened. A sensitivity to the syllabification process in English, related problems of spelling, placement or avoidance or reduction of stress on words, ability to hear unstressed syllables, recognize the patter of vowel reduction, the distinction between the voiceless and voiced inter-dental fricatives, the pluralization processes of English, specific gender distinctions normally adopted in native English, morphological processes that have a bearing on the phonological usage, etc. need to be revisited and drilled. Auditory comprehension holds the key, but auditory comprehension is related also to the other language skills.

11. A WORD OF ENCOURAGEMENT AND CAUTION

It is not easy to compete with the medical transcription professionals in the western nations. They have all the advantage, but still, outsourcing or not, Indian boys and girls can develop a professional attitude to the career they have adopted and contribute to the field, with the help of linguistics scholars, something original even as they overcome the handicaps of being the second language users of English, and consequent backbiting, and campaigns against the Indian professionals that will crop up in the newspapers now and then. But, ultimately, honest work, truthfulness, and diligence will win the day.

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