UNDERSTANDING INDONESIAN AND INTERNATIONAL MEDICAL STUDENT-PERCEIVED LANGUAGE NEEDS AND CHALLENGES: A CASE STUDY IN AN INDONESIAN UNIVERSITY

A well-established needs analysis is essential for a successful language program. This article reports the results of a questionnaire-based survey conducted to a sample of 44 Indonesian and 16 international students enrolled in an undergraduate medical school in an Indonesian university. The data were compared in terms of the mean, standard deviation and percentage. The results showed both groups perceived reading skills as their most important language skills to acquire, which was followed by speaking, listening and writing consecutively. The needs for improving reading skills were confirmed in the analysis of students’ areas of difficulties, where both groups were in consensus in perceiving reading medical English texts as the most challenging task. The phenomena abovementioned highlight the importance of reinforcing the teaching of English for Specific Purposes (ESP), specifically English for Medical Purposes (EMP) in higher education institutions. Considering the importance of equipping students with English skills, Indonesian medical education institutions require students to take this course as one of compulsory requirements of study completion, although ESP/EMP actually holds a status of local content in Indonesian higher educations. EMP itself commonly account for two credits and is usually offered in the first year. and attitudes, personal reasons for learning, learning styles, resources and time available.


INTRODUCTION
The globalization and economic co-operations, such as ASEAN Economic Community (AEC) have created a number of opportunities and competitions. In health sector, this has been marked, among others, by the inflows and outflows of medical practitioners seeking the most attractive places to carry out their practices. In Indonesia the number of foreign health workforce including medical doctors, nurses, and midwives has increased gradually although mostly concentrated in several places such as Jakarta and Bali (Kompas, 2013). More of this phenomenon are expected as medical-related professions; dentist, medical practitioner, nurse, are stipulated in Mutual Recognition Agreement (MRA) AEC ratified by the ASEAN countries in February 2016 (detik.com, 2016; refer to www.aeccenter.kemendag.go.id for more details), which entails the need of capability of communicating in English.
Despite the importance of being able to communicate in English, the level of English competence of Indonesians is still below those of Malaysia, Philippine and Singapore (EF survey 2018). In the free market such a condition leads to such a serious consequence as generally it is related to the level of competitiveness of human resources. A clear evidence of this is the fact that Indonesian nurses are less popular or less preferred than their Philippine counterparts in International medical labor market due to, one of the main factors, the English proficiency, in addition to the absence of professional certification internationally recognized (detik.com, 2016). This partly makes the Philippines the leading supplier of nurses in Asia, leaving Indonesia in the second (Shun, 2012) with only roughly half of export capacity in 2007 (Short, Hawthorne, Sampford, Marcus & Ransome, 2012) despite the fact the main competencies of Indonesian nurses are believed to be on par with those of the Philippines.
The phenomena abovementioned highlight the importance of reinforcing the teaching of English for Specific Purposes (ESP), specifically English for Medical Purposes (EMP) in higher education institutions. Considering the importance of equipping students with English skills, Indonesian medical education institutions require students to take this course as one of compulsory requirements of study completion, although ESP/EMP actually holds a status of local content in Indonesian higher educations. EMP itself commonly account for two credits and is usually offered in the first year.
EMP refers to a specialized English course for students or for those working in nursing and medical areas (Lee, 1998). EMP may include job-related English skills such as terminology, abbreviations and conversations used in performing daily medical tasks. This definition does not seem to be rigid in Indonesian context as, in my personal observation, a number of EMP courses include other contents such as English proficiency test skills, as one of manifestations of stakeholder needs.
This article is an attempt to investigate the teaching of EMP in a medical faculty in Indonesia. The teaching of EMP in the institution itself is offered to the freshmen in two major contents; (1) EMP or (2) Academic English skills with English medical contents, such as text books and journal articles, writing and speaking and the skills for improving English proficiency test scores. This "hybrid" two-credit course is presented to the medical students with differing language backgrounds, academic cultures as well as generally social cultures. This phenomenon leads to a number of unique challenges as to the classroom managements and the presentations of language of instructions as, although rarely done, switching from a target language to native language is a useful strategy to explain complex concepts, e.g. grammatical and lexical, which is sometimes quite dilemmatic to do in an international class with various linguistic backgrounds of the students.
In this university, the international medical students study in one specific class with their Indonesian counterparts. Despite most of them coming from neighboring countries, in terms of learning expectations, the groups seemed to have a differing targets, priorities and difficulties. Incorporating their voices and considering their perceptions of what EFL or ESP presentation should be is one of important factors in designing a language course program in a university since higher education students are mature enough and commonly aware of their choices and expectations especially when related to English as a lingua franca (Mauranen & Rant, 2009, Ostler 2010as cited in Landolfi, 2014. This present study, therefore, was aimed at finding out the perceptions of the needs of the Indonesian and International medical students studying in Indonesian academic setting of their English for Medical Purpose.

LITERATURE REVIEW
All language courses, particularly the advanced ones, should be relevant-"to be seen to be relevant" --to the specified needs of learners (Long, 2005). This especially applies to English for Specific Purposes (ESP) program, which is commonly tailored based on the needs of learners; therefore, needs analysis is a crucial component of the program as it allows the course to incorporate the needs, wants, expectations, and lacks of the learners, employers and the other stakeholders. A proper needs analysis will result in a useful information for decision makers regarding the curriculum design of a language teaching program (Juan, 2014). Hutchinson and 6(1), June 2019 e-ISSN: 2549-8673, p-ISSN : 2302-884X Waters (1987 noted that NA is a reflection of awareness of the needs which become an answer to the question "why do the learners need to learn English?" In the same vein, Gardner and Winslow (1983) expound that the main purpose of conducting a needs analysis is to produce information which when acted upon makes a course better adapted to students' needs. Thus, needs analysis plays a vital role in the process of designing and implementing a language program (Hamp-Lyons, 2001;Finney, 2002).
Needs Analysis generally refers to activities that are intended to collect information that will serve as the basis for developing a curriculum that will meet the needs of a particular group of students (Iwai et al.,1999;Brown, 1995). A more specific definitions is provided by Richard, Platt, and Webber (as cited in Brown, 2001). According to them (as cited in Juan, 2014) needs analysis is a process that determines the needs of a learner or a group of learners, who requires a language and sequences the needs on the basis of priorities. The needs are specific and can be identified to determine the content of any course (Richard, 2001) A number of different types of need are possible to be identified. Schutz andDerwing (1981, as cited in Richard, 2001) describe a Munby model developed by Munby (1978) to present the information gathered through a needs analysis. They describe the profile of students' communicative needs or Profile of Communicative Needs, such as personal (individual cultural/language background), purpose, setting, interactional variables, medium-mode-channel, dialects, target level, anticipated communicative events, and key (referring to how a communication is carried out). These needs are further classified by a number of experts. Berwick (1989) suggested the concept of felt needs and perceived needs. Brindley (1989) and Robinson (1991) had a similar proposition; subjective needs and objective needs. Hutchinson and Waters (1987) distinguished two differing concepts of needs; target needs and learning needs. Target needs refer to the necessities, lacks and wants of learner to properly competent the target situation, while learning needs are related to motivation and attitudes, interest, personal reasons for learning, learning styles, resources and time available.

RESEARCH METHOD
This descriptive quantitative study involved 44 first year Indonesian and 16 international medical students and registered in the international class at a medical school in Indonesia. All Indonesian students spoke Bahasa Indonesia as their native language, while in the International group, 8 students were Malay native speakers; 5 spoke Tamil; 2 students were Mandarin natives and 1 student reported to speak English as his/her first language. There were 23 male and 37 female students with length of studying English ranging from 6 to 19 years with all of the international students averaging 14 years, 3 more years longer that the Indonesian group accounting for 11 years of studying English. The class was purposefully selected on the ground that this was the only class with the variations investigated. Thus, this study employed a purposive sampling technique.
A questionnaire adapted from (Tasci, 2007) was employed to collect the data. The adaptations included some ideas relevant to the context of teaching-learning of ESP in the institution were obtained from a brainstorming session (Serafini, Lake, & Long, 2015) with a group of medical English instructors at its language laboratory. The modifications included a number of questions, such as the needs of training for proficiency test preparations that have been traditionally 6(1), June 2019 e-ISSN: 2549-8673, p-ISSN : 2302 -884X integrated in the curriculum. 6 items covering questions related to preparatory courses as used in the work of Tasci (2007) were also dropped as they did not exist in the current context of study.
The questions in the questionnaire covered the demography of the participants, the present situation analysis which comprised their perceptions of and attitudes toward the teaching of EMP; such as the materials and instructors. The next part was the items on the language skills; listening, reading, speaking and writing, followed by the perceived language learning difficulties.
The data collection was conducted to freshman of 2016/2017 cohort in December 2016. The obtained data from both groups were analyzed, described quantitatively in terms of means, standard deviation and percentage. The means were interpreted based on the classification employed in Yükselir (2018) as described in the following table.

RESULTS AND DISCUSSION
This study aimed at gathering information concerning the perceived needs, as Berwick (1989) put it, or subjective needs as Brindley (1989) categorized it, and it was a part or a larger project of needs analysis at the institution.

The Teaching of EMP
The questionnaire was projected to tap information regarding students' attitude and opinion on the teaching of EMP, specifically the class management, the materials, the instructor. In regard to the teaching-learning process of English for Medical Purpose, both groups of students, in terms of the program, generally agreed that EMP was important and the class should be divided into smaller classes based on the level of proficiency. This is understandable, since due to some limitations the class size in the institution can be categorized as a big class for a language program, which is a common phenomenon and one of the classic challenges in ESP administrations in most education institutions, especially in Indonesian context.
Relative to the international students (M=2.43), the Indonesian group tended to aspire to have more English classes after the one they took in the first semester, accounting for M=4.50. Both groups also had a dissenting proposition in relation to the grouping in the interactive teachingleaning method (M=4.50 and M=3.86).
As for the standardized test preparation which had been traditionally embedded in the curriculum, both groups were in consensus that this training was important. The tests,

Priority for Language Skills
In terms of perceived importance, both Indonesian and International groups indicated similar tendencies, being reading the most important to study, followed by speaking, listening and writing respectively (figure 1). The reading skills showed almost similar means and close variability values relative to the others', indicating strong agreement between both groups.  Table 3 showed the comparison of the four skills. A lower mean indicates a higher priority (1 was assigned to the most important -4 = the least important). But for the purpose of convenience, the following chart was plotted to visualize the reversed calculations. The chart indicated that international group put more weight on reading skills than their Indonesian counterparts did. This is especially true for reading, speaking and listening, which is not the case for the writing. This result is an alignment with what Chia (1999( , as cited in Hwang 2011 found in the Taiwanese context where both medical students and the EMP instructors ranked reading skills as the most important skills, followed by listening, writing and speaking. In Turkish setting a similar finding was also indicated by Tasci (2007) and Çelik (2018) where reading skills remained the priority of the medical students, although the other three skills were found to be in a different order of importance.

Perception of Reading Skills
For the reading skills, both groups seemed to be aware of the fact that reading is a crucial skill, making them agree that they always needed it. More than 60% of both groups indicated that they always dealt with it, being the international group higher at around 65%. On the flip side, no students (0%) thought that they never needed this skill.

Figure 2. Perceptions of the frequency of the need for English reading skills
The need for better reading skills is, based on the data, required specifically to comprehend textbooks, resource book, medical journal articles (Table 4). Some students also specified in an open-ended section of the questionnaire that reading presentation slides as a necessary variable to consider. This is understandable since most teaching and learning materials are provided in such resources. This, to a certain extent, might also indicate some difficulties in dealing with those kinds of texts, which is their significant source of learning.

Perception of Speaking Skills
Speaking was the second most desired language skill by both groups. Almost half of the Indonesians thought to always need speaking skills while more than half of the international students (53.33%) believed they always use speaking skills. No students from both groups chose "never".

Figure 3. Perceptions of the frequency of the need for English speaking skills
Students needed the speaking skills mainly to talk to foreign patients, which is the highest percentage (Table 5) with the lowest standard deviation. This could stem from a reflection or aspiration that they target an international setting for their future career. A similar result was found by Tasçi (2007) and Çelik (2018) and who reported that in Turkish context "talking to foreign colleagues and patients" was seen to be the most essential skills to learn by 2 nd and 3 rd graders of Turkish medical students.
While the other micro skills varied in their means, a high agreement between both groups were found on the point of "to make presentations at the seminars and conferences". This seemed to be related to the fact that the institution encourages students to have some international exposure, especially during their academic stage of education. This can be seen mostly by the active participation of the its students in international competitions and medical conferences. Finally "to ask questions in class" was found to be the lowest, which is similar to the finding of the previous work by Çelik, reporting (2018) that participating in a classroom discussion was the least needed by the students.

Perception of Listening Skills
As indicated earlier, listening ranked the 3 rd in the overall comparison of the language skills. However, a more detailed analysis on the needs showed some variations. In general, the international medical students showed they always needed the listening skills (66.67%), while only 39.53% of their Indonesian colleagues had the same perception ( Figure 4). Majority of the Indonesia group chose "often" (55.81%).

Figure 4. Perceptions of the frequency of the need for English listening skills
Regarding the purposes of studying listening skills, as the following table shows, mostly all students agreed with the purposes of learning the skills. "to follows spoken instruction form lecturers" was the highest in percentage. The international students consider all of the points important, while the Indonesian students considered listening "to understand podcast and tv programs" and "take notes during the lectures" less necessary (M=3.91 and M=44 respectively).

Perception of Writing Skills
Writing was perceived as the least important to learn by both groups. The pattern was almost identical to that of listening skills. Slightly more than half or 53.33% of the international students reported always needing English writing skills, a similar proportion of Indonesian group reported to often need the skills.

Figure 5. Perceptions of the frequency of the need for English writing skills
As for the purposes of learning writing skills, both groups generally agreed with the points proposed in the questionnaire, although in a different degree. From the following table, it is found that the main objectives of writing for both student groups were writing research paper and the term project, with the former one reaching the highest means with smaller standard deviations (0.97 and 0.35), indicating a stronger consensus. Self-assessment of the perceived problematic language areas revealed both groups reported understanding medical reading materials with complex use of English was the most challenging (M=4.13 and M=4.40), especially when compared to non-medical materials (M=3.78 and M=4.27). They considered poor grammar to be one of the problematic areas, with international students having higher means, indicating they felt that their grammatical ability was lacking (M=4.20, SD=1.01) or less confident with this ability. Another language component where both groups believed to be weak was vocabulary. Interestingly international students felt more the need of improvement (M=4.13) than their Indonesian classmates (M=3.93). In terms of the language skills, such as listening, reading, writing, and speaking were also the areas where they needed to study more.

CONCLUSION
Intended to explore the needs of Indonesian and International medical students this study found that, in spite of a number of variations both groups believed learning English for medical purposes will bring positive impacts on their academic life and professional career. No students reported to never need the four language skills. Reading skills are considered the top priority to develop, followed by speaking, listening and writing skills. Specific investigation toward the frequency of use of individual language skill, however, reveals that both students slightly different in their preference. Although they both agree that reading and listening need to be learned the most because they believe they always deal with them, the International group put more stress on all the four skills by reporting to always need them, which is not the case for the Indonesian group who chose "often" for speaking and writing. The need for prioritizing reading skills was confirmed by the perceived areas of difficulties, where both student groups agree that reading medical materials with complex use of English is the most challenging. Therefore, it is important for EMP instructors to give more emphasis on reading comprehension skills using authentic medical materials. Vocabulary and grammar are also recommended to be presented in an implicit fashion and activities that support the development of communicative competence to build self-confidence of the students in using English.