Discipline-specific language learning, such as training in medical English, is situated within the long-established EAP practice of delivering what learners need to succeed in their professional careers. Rather than establishing linguistic goals like lexical mastery as reflective of what students require, however, this article examines needs in terms of social and cognitive processes through which learners themselves discover and generate what is necessary to acquire conceptual knowledge and linguistic control. This approach to needs and syllabus design is illustrated by way of describing pedagogic elements comprising the learning environment of second-year Japanese college students, doctors-in-training, who read, discuss and write in response to medical case studies accessed and mediated through the Internet.
Discipline-specific language study has long been linked to an expectation that learners' needs should be analyzed in order to select language components that match what students require to succeed in their academic studies. In this regard, Widdowson's sense of two distinct kinds of needs analysis is germane. One kind, fixed on so-called goal-oriented needs, considers what students will do with their knowledge of L2 as they proceed in their academic and/or professional careers. In contrast, the second kind of analysis, as depicted by Widdowson, is process-oriented and "focuses on presentation of language by reference to the means of learning ... [allowing] the learner [to exercise] the ability he or she has acquired" (Widdowson, 1981, p. 2).
Current developments in ESP and EAP have been responsive to this second, process-oriented analysis of needs. The very elements of analysis have increased in number and variety, and the sometimes-conflicting results of analyses have led to more encompassing, multifaceted views of needs (Johns, 1991; Long & Crookes, 1992). Robust investigation of needs begins, of course, with diagnostic review of students' language achievements as well as of relevant institutional constraints. Beyond learner/learning-institution contexts are the demands placed on L2 learners and their institutions by practitioners and professional organizations in the disciplines connected to students' future careers.
Thus, diagnostic tests of students and polls of students' and teachers' expectations of needs are only preliminary procedures in assessment for syllabus design. Other procedures might include surveys of experts in the discipline in question, review of authentic data gathered from real-world sources, etc. (Ferris & Tagg, 1996).
Moreover, ways language is specified to students' needs have evolved from, first, identifying lexico-grammar features and typified rhetorical actions within a discipline (Miller, 1984) toward additional specifying methods informed by social and cognitive influences on discourse in disciplines. For many EAP teachers, and researchers, specifying language by way of discourse and textual analyses connects to broader concerns like genre analysis, which has been variously defined as inquiry into (a) staged, goal-oriented social process (Martin, Christie & Rothery, 1987); (b) consistency of communicative purpose (Swales, 1990; Bhatia, 1993); (c) socio-cognitive factors involving dynamic change in disciplines, community ownership of discourse, group-negotiated "intertextualities," and so forth (Berkenkotter & Huckin, 1995). Accordingly, there has been a shift in what are viewed as appropriate units of analysis. Regarding syllabus design, primary linguistic units like vocabulary and grammatical features are now frequently contextualized within socio-cognitive frames that better capture the real-world disciplinary practice facing language learners.
1.1 Units of Analysis
With respect to units of analysis, in my own teaching of Japanese college students, second-year doctors-in-training, I choose to concentrate on discipline-relevant concepts and tasks in the form of contextualized problem-sets (which by definition embed vocabulary and grammatical features in chunks of natural language). Tasks of this sort "provide a vehicle for the presentation of appropriate target language samples" and "delivery of comprehension and production opportunities of negotiable difficulty" (Long & Crookes, 1992, p. 43). Teaching principles that underpin such an approach can be described as problem-based and inquiry driven.
First, teachers pose problems of emerging relevance. The nature of the initial problems posed by the teacher influences the depth to which students can search for answers. Posing problems of emerging relevance and searching for windows into the students' thinking create a classroom setting in which the teacher and the student jointly search for new knowledge [...] Teachers structure lessons around important concepts and ideas, not facts and skills. Learning occurs in context. Focusing on discrete information or specific skills makes sense only when the student has a context in which to learn the skills and consider the information. (Kaufman and Grennon-Brooks, 1996, p. 234)
2. Socio-Constructivist Principles
These tenets fall under the general rubric of socio-constructivist pedagogy, which emphasizes learners' figuring out what they need to know and creating (or constructing) pathways to knowledge. Other socio constructivist principles are learner activities that offer multiple perspectives on concepts (Spiro, Feltovitch, Jacobson & Coulson, 1992) and case-based instruction that provides not only multiple perspectives but deeper processing of concepts (Jonassen, Ambruso & Olesen, 1992).
Applying these principles to the Japanese college learning environment for medical English, I supplement conventional emphasis on the memorization of technical terms by introducing frequent occasions for students to engage the lexicon and become familiar with the conceptual constructs to be inferred from the lexicon and related grammar. The classroom setting and principal means for creating these occasions are a well-endowed computer lab (equipped with something like two computers for each of 25 students) and a set of hyperlinked texts and other Internet resources which my students and I have assembled over the course of the last two years. The web site that contains readings and tasks for our classes is "Topics in Medical English" <http://interserver.miyazaki med.ac.jp/~kimball/med/1.htm>.
2.1 Teaching Medical English via the Internet
The outline of "Topics" is as follows. There are preliminary readings and exercises to familiarize students with computing in English, surfing both the "Topics" web site and the Internet beyond, and to introduce general medical subjects for reading, discussion and writing. A second set of readings and exercises focuses on nutrition; a third and fourth set concentrate on sensory, skeletal and orthopedic anatomy; and a final set features heart disease and other pathologies. One advantage to the order of topics, from the second through the fifth set, is that my students and I work in domains that lend themselves to clinical narrative. Course progression on topics such as nutrition and heart disease, for example, can be rendered in ways that easily move from reading texts to conversations about the ideas in texts to conceptual applications of ideas (and recycling of the lexicon and grammar) within diagnostic and counseling scenarios. Internet media, moreover, allow for ideal application of the multiple-perspectives principle: hyperlinked texts scaled in difficulty from introductory to intermediate to advanced levels; raw data compilations for reference; photographs, diagrams, charts, and other graphic representations to supplement readings and discussions; audio visual material. Additionally, E-mail facilitates formal, informal and ad hoc consultation between instructor and learner and among learners at various stages of a topical project.
3. Task-Based Project Stages
Topical projects are designed in three stages. The first stage of each set of readings and tasks is structured to flow from initial key concepts to more descriptive data containing more topical concepts and subsidiary information that, in aggregate, constitute reference material for current and future use. To illustrate, the nutrition set commences with basic readings on "Tips to Healthy Eating," "The Food Pyramid Guide," and information on calcium intake. These readings start off in familiar territory, that is, the relationship between diet and health. Basic readings help students become comfortable with inputting ideas and conversing about nutrition in English. Easily-grasped concepts such as "balanced diet," and "lifestyle choices" lead to more complicated biochemical concepts in associated readings and exercises on vitamins, cholesterol, fat intake, and the like.
The second stage of a topical project calls for more practice in productive skills on the part of students and might include such tasks as summarizing of data, fact-checking and small-group discussion and debate related to implications of data under review. This stage, again, follows essential socio-constructivist principles encouraging deeper processing of concepts and contextualized problem solving. A final stage encompasses in-depth reading and discussion of a case study, leading to multiple drafts of a case analysis composed by each student. Here, for example, is the first section of a case study on cardiovascular disease and hypertension.
Patient Okada (O) is a 47-year-old Kobe business executive who suffered a mild myocardial infarction two months ago while on a hiking trip in Shizuoka. He had been unaware of any CVD problems before his heart attack and, in fact, he visited his doctor only after he returned to Kobe, two days after his attack. His wife insisted that he see a doctor even though Mr. O thought "everything was back to normal, and now I'm feeling fine." Mr. O is not in good health. While he is still relatively young, his blood pressure indicates moderate to high hypertension, 165-105 mm Hg. Mr. O's doctor reports that the results of cholesterol tests are not positive: LDL - 173 mg/dl; HDL -- 26 mg/dl. Furthermore, Mr. O now complains of sharp chest pains that sometimes occur right after his dinner meals, a clear symptom of angina pectoris. And from causal observation it is clear that Mr. O is almost 20 kilos overweight.
This segment illustrates how clinical narrative accommodates the mix of technical terminology ("myocardial infarction," "angina pectoris") with less specialized, natural language and, more important, it demonstrates how medical concepts can be contextualized for L2 learners in a problem set simulating real-world clinical thinking. Effective response to problems posed by a case study like the above obliges students to adopt cognitive strategies that bona fide medical professionals deploy. Students commit themselves to reviewing key and subsidiary concepts, data files, notes, etc. in order to deal with a number of interconnected topics. (In this instance, the topics are risk factors for hypertension, angina, fat intake, cholesterol as a predictor of CVD, the relationship between proper exercise and preventing coronary disease, and the right kind of behavior in the event the patient should have another heart attack.)
Typically, the sortation of these topics entails reaccessing materials online; spontaneous conversations among students, in pairs and small groups; E mailing of texts, questions, and drafts among students and between the instructor and each student -- a range of real-world collaborative inquiry, in other words, that further enforces conceptual fluency and deeper engagement on task. 4. Conclusion My students have profited from such simulations of clinical problem solving. Over the course of the last two years, more than two hundred students have completed analyses in one or more of four discrete topics, and roughly half of them have composed responses that so excel in conceptual thoroughness and linguistic control to warrant online publication. The web site for these texts by L2 learners is titled "Student Case Analyses," accessed at <http://interserver.miyazaki-med.ac.jp/~Kimball/case.html>. A further advantage for my current students and, by extension, for L2 students of medical English worldwide is that these Internet texts function as compelling models for crafting analyses on other topics, compelling in that these are models provided by near-peers.
It almost goes without saying that an approach to syllabus design such as I describe here reflects the cognitive and linguistic demands my students face as they continue in their medical studies. While most of their course work outside their English classes is conducted in Japanese, in some instances, concepts about innovative treatments and new findings in research are introduced in English and, in other instances, textbooks for selective course work are written entirely in English. Regardless of the language used in other courses, students reapply many of the collaborative, inquiry-driven strategies I emphasize in my classes as they continue toward their M.D. degree. For those who plan on conducting original research after they receive their degree, there is the likelihood that many will find these strategies of value and that many will continue to read and write in English. Finally, given the rapid pace and wide reach of change in medical education today, the syllabus I outline draws on a variety of authentic sources, a result of the combined expertise of practitioners from Japan and elsewhere as well as the good counsel of medical professionals and students at my college.