OET vs IELTS: FINDING THE MOST APPROPRIATE WAY TO TEST LANGUAGE SKILLS FOR MEDICINE

The question of whether someone is ‘proficient’ in a language or not can be difficult to measure. The problems that surround language testing are well researched and the suitability of tests such as the International English Language Testing System (IELTS) has been studied extensively. How well studying for tests such as IELTS equips learners with language needed for the world of work is, however, less researched. This paper focusses on the suitability of two tests, the Occupational English Test (OET) and IELTS, for the evaluation of language competency in people who wish to access employment and register in a medical profession, where the need to communicate effectively is essential for professionals such as nurses and doctors to be safe at work. Rather than looking at the tests themselves to ascertain their suitability, this paper explores the views of the test-taker and investigates their experiences of preparing for the two tests and their opinions of the test content. The findings show that candidates overwhelmingly prefer the OET, rating it more achievable, more relevant and more motivational than the IELTS.


INTRODUCTION
Language proficiency can be difficult to measure. In language assessment research, questions that relate to the kind of English we are testing, what is meant by standard English and, in an increasingly globalised world, questions that relate to the suitability of approaches to testing are areas of debate (Bachman & Purpura, 2008;Hall, 2014;Pennychook, 2007;Pilcher & Richards, 2017). The validity of specific language tests such as the International English Language Testing System (IELTS) has also been investigated (Bayliss & Ingram, 2006;Dooey & Oliver, 2002) as has the question of whether the English learnt when studying for an exam will equip that student with the language needed to succeed academically (Pilcher & Richards, 2017), or whether this English will enable a student to cope in the outside world beyond the language classroom (Badwan, 2017).
Language tests are increasingly used by employers and professional bodies who wish to determine the language proficiency of an overseas professional. In healthcare, communicating effectively is paramount to patient safety. Hull (2015) emphasises the possible risks for patients should there be a breakdown in communication and highlights "the potential to positively or negatively affect patient outcomes" (2015: 158). Hull distinguishes between 'medical language' and 'standard language' and states that "neither command nor fluency of a standard language guarantees success in specific contexts such as medicine and healthcare" (2015: 159). Bachman and Purpura (2008: 460) agree: "those who achieve the grade required by their profession are assumed to be prepared to function successfully in their relevant professional context". The barrier between the testtaker and their goal is often language based, however, even when the grade required has been reached, the 'assumed' outcome mentioned above, has not always been achieved.
The medical professional's communicative task is challenging and includes balancing the use of medical terminology (or jargon) with language known by the patient along with carefully selecting empathetic language, which is essential for a task such as breaking bad news. Hull (2015) called for a more contextualised test which prepares a learner more appropriately with language they need for the workplace. This paper considers whether the OET is better able than IELTS to do this for healthcare workers.

BACKGROUND
Currently the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) accept two tests for doctors and nurses to evidence their language 1 Evidence of language proficiency forms only part of the requirements needed for registration purposes with the NMC and the GMC. For example, the GMC also ask qualified doctors to demonstrate their "knowledge and skills necessary to practise medicine in the UK" by passing further exams: Professional Linguistic Assessment Board (PLAB) 1 and PLAB 2, before they can gain registration.

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Vol. 9(1)(2021): 89-106 while a nurse may be asked to talk to a carer about a patient's aftercare following an operation.
For registration with the GMC, doctors are required to achieve a grade 'B' in each of the four skills in one sitting. Each sub-test is marked out of 500 and scores between 350 and 440 equate to a 'B'. For nurses, the NMC require 'B's in all skills except in writing, where they accept a C+. Furthermore, the NMC will accept the required scores being achieved over two separate sittings of the exam. According to OET (2019) a grade 'B' is equivalent to a band 7.0-7.5 in IELTS. At the time of writing, there are other healthcare professional bodies which do not yet recognise the OET, such as the General Dental Council (GDC) and the General Pharmaceutical Council (GPC), both of whom continue to accept only IELTS.
While extensive research has been carried out to establish the suitability of IELTS, its suitability for professional registration purposes has been significantly less researched. A study by Merrifield (2009) looked at the rationale behind the decision of regulatory boards to use IELTS for registration purposes. One of the key aims was an evaluation of "the appropriateness of the test for the purpose of association membership or registration" (Merrifield, 2009: 6). However, only 14 of the 24 associations Merrifield approached agreed to participate, with a possible explanation being that "they were reluctant to be interviewed, even in an informal manner, on a subject about which they had limited knowledge " (2009: 8). This may demonstrate that professional bodies feel that their knowledge of English language testing is 'limited'. In her study, Merrifield (2009: 5) comments on the increase of those using IELTS and states that "the growing trend for IELTS to be adopted by users outside of academia, [….] may constitute a risk for the test owners if the assessment system cannot be validated for the purposes for which it is being used." She states what is needed as the 'growing trend' continues: [The] development of a body of knowledge of what is happening in the professional world is an important aspect of risk management for the managing partners. The IELTS partners need to understand the non-expert's perception of how good the "fit" is, the means by which entry level band scores are established, how often minimum levels are revisited and what support might be needed from the IELTS administration. (Merrifield, 2009: 5) OET is relatively new to the UK and Europe, so literature around the suitability of the test is scarce. Soon after the GMC's announcement, Ceri Butler was interviewed for the British Medical Journal (BMJ) and stated that "my gut instinct is that having a test like the OET, which is based on a clinical setting, is better as a measure of a doctor's ability. The OET gives us the opportunity to approach language in a way that is appropriate for a healthcare setting" (Rimmer, 2018: 298). She also commented on how IELTS is used for testing how someone speaks or writes at an academic level and points to the question of the 'appropriateness' of using IELTS to test doctors, unless they are wishing to do a PhD or a Masters (Rimmer, 2018: 298).

HIGH STAKES TESTS
Research undertaken by Saville (2009), which demonstrates the impact language testing can have on both society and individuals, has been considered in this study. High stakes tests, along with high band requirements to access a qualification, or even requalification with a professional body, can indeed have a high impact, and not only on the nurse who is desperate to return to her profession, but also on a society where there is a great shortage of such skills, yet where the need for effective communication is pivotal for patient safety. One could argue that the 'impact' on the individual is significantly increased in migrant workers and in refugees and asylum seekers. For this research, data has been collected from members of the organisation where I work. The organisation is called Reache North West. 2 At this organisation, refugee and asylum-seeking doctors and nurses are prepared with the skills they need to requalify in the UK. Before transitioning to OET in April 2018, members of this organisation studied IELTS. By considering the experiences and opinions of those who prepared for IELTS and/or OET within this organisation, a comparative analysis of the two high stakes tests was undertaken.

AIMS
The aim of this study was to evaluate the content of two English language tests: the International English Language Testing System (IELTS) and the Occupational English Test (OET); and through the investigation of student opinions and their experiences of preparing for the two tests, this study also aims to ascertain the suitability of each test, by evaluating how effectively each prepares the students for their career.

METHODS
This study used quantitative data collected from 50 doctors and nurses, over two periods of time. The first period was in April 2018, and the second was in January 2019. Fifty participants took part: 47 doctors and 3 nurses. All were aged between 28 and 55. Twenty-one participants had already obtained the required IELTS exam 2 Reache North West defines its organisation as being "an education centre that supports refugee health professionals to gain the necessary skills and qualifications to re-enter their profession and become safe and effective practitioners in the UK National Health Service. We are funded by NHS Health Education England and operate as part of Salford Royal NHS Foundation Trust. We run English language classes and clinical teaching programmes with a particular emphasis on practice in the context of British culture and the NHS" (2019).

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Vol. 9(1)(2021): [89][90][91][92][93][94][95][96][97][98][99][100][101][102][103][104][105][106] result for professional registration. The remaining 29 participants had not yet passed their English exam and were studying towards OET. Data was also collected qualitatively through interviews with six of the participants at the latter stage of the data collection process. Ethical approval was sought and approved at both stages and before any data was collected. Participants were ensured full anonymity and confidentiality throughout the process, and the careful saving, handling and deleting of any data was also explained and carried out.
When the GMC announced in February 2018 that they would accept OET as an alternative test to IELTS, many members of Reache North West and myself included, were shocked and somewhat apprehensive. The news had not been anticipated, and many members had already invested a considerable amount of time, money and energy into IELTS.
Along with preparing the pilot group to take the OET test, it was important to also establish how the members felt about transitioning from IELTS to OET before any decisions to do so could be made. At this stage, the participants were therefore asked to complete a short questionnaire (Appendix A) and were also asked to write a reflective piece on their experience of the most recent IELTS exam they had taken. I chose to begin at this point and in this way in order to get a sense of how the members of Reache felt about their studies for IELTS thus far, their approach, and how effective they felt it had been, before they moved over to study for a different exam. I also wanted to discover what they thought about the language they had learnt so far in terms of its suitability. This was not asked explicitly, though I wondered if it would be mentioned in their comments.
In January 2019, the second stage of the data collection process began, and an online questionnaire was distributed to the entire Reache North West membership. Of the 50 participants, the average length of time indivduals had been members of Reache North West was 2 years. Twenty-one had passed their English exam and there were 29 who had not yet passed it. Of the former group, 18 had passed OET and 3 had passed IELTS. It should be mentioned that the 3 who passed IELTS had never studied towards OET, and of the group that had passed OET, 7 had never studied for IELTS, meaning that 40 of the 50 participants had the experience of studying towards and/or taking both tests.
The questionnaire consisted of 29 questions and was semi-structured, containing a combination of open and closed questions. Some of the Likert scale ranked questions were followed by an open-ended question where participants could explain their response. This was done in the hope that a more in-depth insight into the experiences of the learners, and how they felt about both tests, could be captured. The questions were framed positively to avoid bias.
The objectives of this study remained a point of reference for each of the 17 questions written for the interviews. While some of the questions were semistructured, all were indirect, as the aim was to gain the participants' opinion throughout.

ANALYSIS TOOLS
For the first stage, the comments made by individuals regarding the transition from one test to another and which felt they would need to improve the most moving from IELTS to OET were examined. The reflective pieces were analysed to gauge how the leaners felt about studying for IELTS and the progress they thought they had made. Comments made by the healthcare professionals when asked about the appropriateness of the OET test in contrast to IELTS were also considered. For the second stage, the results from the online questionnaire were also analysed, and from the data collected at the two stages, themes began to emerge. I then analysed the transcribed interviews and looked for any continuation of the themes identified in the questionnaires. As well as identifying a continuation of themes, additional emerging themes were also recognised. Eventually, five themes were established and a colour was assigned to each theme. I then reviewed the questionnaire responses with the themes in mind, and colour-coded words or phrases thematically.

First stage findings
The findings at this stage in the research were that students held views that were generally negative. Many participants expressed a significant amount of frustration and felt that they had not progressed satisfactorily considering the amount of time they had spent studying towards their IELTS exams. Only two of the thirty participants who wrote the reflective pieces said that they were 'happy' with the progress they had made in their studies. Others used words such as 'depressed', 'devastated', 'struggling' and 'stressed' to express how they felt about their most recent IELTS test and/or their results. Dr AH said 'I feel sometimes that this is an impossible test and I cannot ever achieve the marks that I need to pass the exam'.
A number of participants wrote about their many attempts to pass the IELTS exam, three mentioned that they had made at least five attempts. 3 Some said they obtained the required mark in three of the four areas tested, but failed in one. Then in another attempt, the individual passed in the area they had failed in previously, but failed in a different area. For example, Dr F said 'in the first exam, I scored 7 overall, with a 7.5 in writing and a 6.5 in reading. However, as I took the next two ANDREA CARR Vol. 9(1)(2021): 89-106 exams, I improved my reading and passed, but I got 6.5 in writing both times.' She also wrote 'scoring 6.5 in writing twice, in subsequent exams, shattered me and I lost my confidence. ' When asked (in question 6) for their initial thoughts on the news of the GMC accepting OET, the comments reflected a more optimistic outlook. Dr W said 'I am very optimistic. I think being more relevant to medical topics will make it easier to pass OET because we are familiar with these topics'. The word 'optimistic' featured quite frequently in the answers to this question. Another member, Dr H, stated 'I am very optimistic about taking the OET exam as a proof of my English ability as I believe the language that I'll be tested on is more relevant to what I was and will be practicing and easier in my opinion.' (Carr, 2018).

Second stage findings
When asked whether participants thought that IELTS had been beneficial in the improvement of their English language skills, a total of 68% either agreed or strongly agreed, and only around 10% disagreed or strongly disagreed. Reading seemed to be the skill that many considered as being developed the most, and when asked why, 11 explanations included words or phrases such as: 'reading quickly', 'skimming and scanning', 'speed reading'. Those who mentioned writing indicated that 'grammatical structures', 'sentence structure', and 'structuring an essay' were aspects they had 'specifically improved'. 'Learning new vocabulary' was also given as a reason. When asked whether participants thought that OET had been beneficial in the improvement of their English language skills, a total of 75% either agreed or strongly agreed, and only around 6% disagreed or strongly disagreed. In the responses to the question which asked what specifically had improved in their choice of skill, many commented that their writing of a referral letter had improved. One said that this was 'very important for doctors'.
'Communication' was one word which reoccurred frequently in the responses and one participant said 'I learnt how to avoid jargons, also the style of language that [is] used with patients'. Another who indicated that they were being more suitably prepared by studying towards this exam said 'I learnt to speak naturally, not like a robot'.
When asked which part of studying OET had been most beneficial, many answered 'all' or 'most of them'. One person wrote: 'I'm pretty sure almost all the topics I studied in OET were relevant to my profession.' The word 'relevant' appeared numerous times and one person said 'everything, something related to my career and I need it in everyday practise.' When asked how interested they were in the topics studied for OET, 96% chose either strongly agree or agree. Some of the reasons why were that the topics are 'familiar', or they said they were 'interested' in them. One respondent said the Vol. 9(1)(2021): [89][90][91][92][93][94][95][96][97][98][99][100][101][102][103][104][105][106] topics 'put me on the right track for my career and help me improve in both sides, English and practically for medicine. ' Interestingly, some of the responses indicated that the level of engagement was increased as they enjoyed or understood the topics. One participant wrote: 'because the topics are familiar, I understand very well' and another said 'because when I studied English with my favourite topics, I found my English burst up'.
When asked if the topics in OET related to their future career, one person stated: Studying for OET helped me to get my confidence back to study and prepare for my future career. Studying for OET played a major role in improving my speaking and writing skills. Because we are learning how to explain medical language in a language that can be understood by the patients.
As well as the more positive tone detected in the responses, the relevance of the content also seemed to be of significant importance to the participants. One person reflected on the relevance of studying for OET: 'that is what I need and what I will use in the future. Otherwise, in IELTS, I have to know everything, spades, dinosaurs, oceans.' The percentage of those studying for OET, who considered the topics relevant to their future career, was significantly high with 83% in strong agreement. This was in contrast to the percentage of those who considered the topics studied for the IELTS exam to be relevant. The response was significantly lower, as only 14% either agreed or strongly agreed with this. When asked why they had responded to this question in such a way, the most common words or phrases used in the responses were 'irrelevant' (topics) or 'not related to' or 'close to' (medical field/my career/my field/future career). Words such as 'boring' and 'uninterested' also appeared. One person said: 'I'm not interested in reading talking about insects or animals', and another stated 'it was like having a branch from each tree in the jungle. History, environmental issues and building a dam.' The issue of time was also mentioned in relation to the IELTS preparation: 'it takes us away from our profession and let us forget most of our career information because of lack of enough time to keep updated in medical knowledge'. Themes of time, relevancy and engagement were emerging, but it was clear that for further explanations, quantitative data would need to be collected.
The overall rating given to the experience of studying towards the two tests was significantly different. For OET, 44 of the participants rated it good or excellent, whereas for IELTS, just 3 rated it as excellent.

Interviews
Of the six participants invited for interview, all were doctors, four of whom were male and two were female. The ages ranged between 30 and 45 years, and apart 97 ANDREA CARR Vol. 9(1)(2021): 89-106 from one (Dr T), they had all studied at Reache North West for an average of two years. All of those interviewed had experienced preparing for and taking both tests, apart from Dr A, who had never sat an IELTS exam because he 'saw friends struggling to get results so [he] never attempted it'. The remaining doctors had studied IELTS for an average of one and a half years. Dr T had, however, been attempting to pass IELTS for four years. Whilst most of the interviewees had studied IELTS for a similar length of time, the time each had spent studying for OET differed.
The average overall IELTS band score of the participants at the point of transitioning to OET was between 6 and 7. However, Dr H's and Dr T's (who both passed in April 2018) overall band scores were 7.5/8, and both reported that writing had been the issue, as they could only reach 6.5 in that skill each time they sat the exam. Dr T said 'I would get 8, 8.5, even 9 in listening and/or reading, but every time I would get 6.5 or even 6 in writing. It was very frustrating.' When asked about their experience of studying IELTS, the general response was fairly negative. Dr S stated 'it was all just a bit vague, I mean, you didn't know what to study. It's a general language exam [...] it was just a long tunnel, neverending. And my colleagues -no one was passing'. Dr M stated that 'the content wasn't very appealing. We were doing topics which weren't related to my career so I wasn't motivated at all. I wasn't really engaged. You just think it's going to take a really long time.' In contrast, when asked about their experience of studying towards OET, the comments were quite different. Dr M, for example, said 'OET felt like this is what I need. I was more engaged, so I did more homework and studied more, wrote a load of referral letters and I remembered the language from medical school so could still use the language I had learnt [there]. ' In terms of the development of the participants' English skills, when asked which skill they thought had improved the most, each of the four skills were mentioned. Furthermore, when asked whether studying for IELTS or studying for OET had helped the most to improve this skill, the answers were mixed. However, Dr F gave an interesting response. She said that OET had helped her to develop her strongest skills (writing and reading) the most, because she had been able to 'focus more on the language rather than the topic.' This comment prompted consideration of the idea of having the space to focus on the language when the topic is familiar. This had also been mentioned in the questionnaires.
When asked what advice they would give to a healthcare professional who is trying to decide whether to study for and sit IELTS or OET for registration purposes, the responses were unanimous. All six of the interviewees expressed the view that they would encourage the person to work toward OET. Dr A said: 'OET is achievable and feasible and will help a healthcare professional in his future career and with his communication skills.' Dr M gave the following response: OET is the best exam for healthcare professionals in general, because it has a direct relationship with your profession and this is not just about passing the test, it's about learning the language that you will need in the world or you will need to deal with patients, so its very helpful for healthcare professionals to study OET.
The final question asked for their opinions on the suitability of each test for testing the English skills of a healthcare professional. Dr F stated: OET is a strong test, it's not easy, but it's more useful. IELTS is useful for general English. Both are good, but with IELTS, I would struggle preparing for PLAB 1 and 2 and also working in the UK as I've been exposed to medical topics and the healthcare system here as I learnt some of that whilst preparing for the test.
The idea that IELTS is 'unachievable' has been a constant theme throughout both stages of the research. First it was mentioned by participants of the pilot study, and then this idea was reflected on again, during the interviews in the second stage. Dr H said 'in the 3 exams I took I passed the modules except writing, I always got 6.5.' Table 1 shows the figures which have been taken from the database at Reache North West, and whilst they are not a statistic, they can act as a guide as to how the members of Reache North West have fared in their English exams over the last five years.  members of Reache North West as they witnessed significant numbers of their colleagues pass through the part of their journey which had previously been considered almost unachievable. Through considering the comments and written responses of the Reache members who participated in this study, it would seem that, generally speaking, the members felt that passing the IELTS exam with an overall band of 7.5 (with a minimum of 7 in any skill) was an extremely daunting prospect. According to the feedback of many of the participants, it seems (overall) that despite the amount of time spent trying to study for and pass the exam, the variety of resources used to study, the mode of study and the long lengths of time spent studying, the exam was very difficult to achieve. The suitability of the style of writing being tested was also questioned by many, as was the appropriateness of learning language to deal with an extension range of non-medically related topics.
The participants interviewed expressed a preference for being tested on language which was 'career-related' and that they can 'do' something with. Dr A said he had 'learnt how to speak like a robot for IELTS, but for OET, it felt like a real conversation, with a patient or a person, so it's the real English that we need in our career and in this country.' Dr A said when talking about preparation for OET: 'I felt more motivated, it seemed like something feasible, achievable, and related to my future career. I studied and worked harder as I knew all the vocabulary and information I would learn in that period would be used in my future career.' Time and how it was considered 'wasted' was also an emerging theme particularly in stage one of the data collection process. Many students had spent a long time attempting to pass IELTS.
I would like to conclude this section by offering some insight into my own experience of teaching both OET and IELTS. The resources and materials used to deliver English for OET are, of course, more medical and therefore relate to the learner's career. However, what this has also allowed, is a greater opportunity for me and my colleagues to expose the learners to topics that are culturally different yet extremely important for healthcare professionals to be aware of before taking up work in countries such as the UK. The cultural perspective, which is intrinsic in a globalised world (Jiang, 2013), is given more time and space as the language needed for this test can be found, studied and practised within topics which lend themselves to the exploration of culturally relevant, but sometimes very culturally different themes.
Topics such as Safeguarding, Palliative Care and Discharge Planning are all processes which can differ significantly in a clinical setting in different countries. Noun phrases such as 'care home' or 'home carer' are words which often do not translate, as in the home countries of many of my learners, these places and roles do not exist. Challenging or controversial topics such as euthanasia and abortion can be stressful and problematic for the learner and often require a great deal of sensitivity in the approach. However, it would be fair to say that exposure to such topics is vital when international healthcare professionals enter the world of work as they will undoubtedly work with others and treat patients who may have very different attitudes or views to their own. Most of my students are Arabic learners from Muslim countries, so topics such as alcohol and drug abuse can be problematic in that the existing knowledge is often very limited. For example, defining what constitutes a 'heavy' or a 'social' drinker could be very different from one person to the next, particularly if one person is from a country where alcohol is prohibited and is of a religion that forbids its consumption. The narrowed scope of topics in OET can be useful in that a greater exploration of topics, which are vital for healthcare professionals to be aware of if they are going to practice within a UK context, can be accessed and explored. In contrast, for IELTS, the focus of the lesson would need to be on topics which would be expected or anticipated to be seen in the exam. Topics such as global warming and space exploration would often leave no room for topics which are related to the healthcare professional's career.

CONCLUSION
This research has highlighted some of the key issues surrounding the use of a language test such as IELTS for purposes for which it was not designed. The issues around language tests which assess a person's competence in a 'standard' form of a language have been questioned as has the suitability of using one test for so many different functions. Beyond university, there is the English needed for the globalised world as well as the English needed for the world of work. 'Messy communication' is how out-of-class communication has been described (Badwan, 2017) but there is also the 'highly evolved, career specific, technical and culturalbound' language (Hull, 2015), which is needed by healthcare professionals at work. Having a test such as OET which deals specifically with the language needed in the occupation of a group of people can perhaps form the backdrop for us to see just how unsuitable a test such as IELTS is for some learners, and it may also provide a model for other specific purposes English tests. There was a need for formal evidence to prove that OET is a more suitable test for the healthcare industry than IELTS, and this study shows how the OET can enhance language proficiency in candidates in a more effective way. The GMC and NMC have acknowledged this, as they now accept OET as an alternative to IELTS for registration purposes. It is hoped that this research can provide some evidence for other healthcare regulatory bodies and for other countries employing Englishspeaking healthcare professionals to consider accepting the OET as evidence of language competency.
OET is a test which is relatively new to the UK. The data for this study was collected from participants who had had a maximum of 11 months of experience of the exam. It may therefore be beneficial for further research at a later stage, when the experience of individuals who started to study towards the exam with a lower