SKDI-Based Needs Analysis for Designing English for Students of Medicine in Indonesia

This longitudinal study aims to seek for solutions concerning the teaching and learning English at the Faculty of Medicine University of Mataram (UNRAM). The first year of the study is emphasized on the outcomes of needs analysis, which encompasses the Present Situation Analysis (PSA), the Target Situation Analysis (TSA), and the Learning Situation Analysis (LSA). Various data were collected form the documents of Standar Kompetensi Dokter Indonesia (SKDI) a.k.a. Competency Standards of Medical Doctors in Indonesia, the Graduates Profile of Faculty of Medicine UNRAM and the documents of student English proficiency levels within the last 5 years. Other sources of data were taken from a number of focused group discussions and in-depth interviews with students, alumni, subject specialists, management of Block, and various techniques. The data were then analyzed descriptively and qualitatively. Findings of the study show that the level of English of students at Medical Faculty was still far from being adequate to meet the SKDI. As such, three learning goals were generated from this study, i.e. the short-tem, mid-term, and long-term goals. The study suggests that to bridge the gap, the Faculty of Medicine needs to develop a number of language programs to prepare these students to achieve competencies that meet the standard of Graduate Profile and SKDI. The results of this study have an implication that the Faculty of Medicine needs to reconsider the policy of English improvement in terms of learning outcomes, materials, and time allocations.


Introduction
experts to focus on different aspects and meanings of needs (Antony, 2018). To mention some, Hutchinson and Waters (2010), for example, translate needs into three postulates, i.e. necessities, lacks, and wants (personal aims); while Dudley-Evans & St. John (1998) interpret needs in more elaborate ways by dividing it into 8 kinds of information.
Of many complex concepts of needs and needs analysis, the activities of course design are directed to formulate there main things, that is, where to go (destination), where to start from (entry behavior), and how to get into destination from starting point (route) (Hutchinson and Waters, 2010). In line to the concepts, the present roles and concepts of NA has been adjusted significantly to match with educational contexts (Poedjiastutie, Akhyar, & Masduki, 2020). Summarizing various concepts from various experts, they focus the NA into three types: Target Situation Analysis (TSA), Present Situation Analysis (PSA), and Learning Situation Analysis (LSA). TSA relates to the analysis of language uses needed in the target situations, while PSA refers to the analysis of learners' current conditions (entry behavior) in wider meanings. The analysis of target situations will determine gaps that need to be filled through teaching and learning process, known as Learning Situation Analysis (LSA) ---the analysis of materials, strategies, and situations needed in order to learn the target language.
As a theoretical framework, the present research will employ these three types of NA to redesign the teaching and learning of English at the Faculty of Medicine, the University of Mataram, Lombok Indonesia. TSA is used to collect the data on the goals of learning English while PSA will provide present information about the learners from many aspects such as current levels of English, experiences of learning English, and so on. These two kinds of information are the basis for designing courses.

Research methods
The first year of this research focused on two things: conducting needs analysis and translating the results of needs analysis into a curriculum and syllabi. Those two targets were achieved by employing a narrative qualitative research design by investigating various aspects of needs, i.e. the target needs (TSA), present needs (PSA) in order to determine learning needs (LSA). The research plan can be summarized in the following diagram: Diagram 1. Framework for conducting Needs Analysis Diagram 1 above describes the process of conducting needs analysis by investigating Target Needs (Target Situation Analysis/TSA) and Present Situation Analysis (PSA) prior to analyzing Learning Needs (Leaning Situation Analysis/LSA).

Context and participants
The three-year study was conducted at the Faculty of Medicine the University of Mataram, Lombok Indonesia, involving 374 students from five-year intakes (for data on students' level of English), all new students (61 students) for filling the questionnaire, and 5 subject specialists and faculty management.

Data collection procedures
The data were collected using various techniques, depending kinds of data needed. For TSA, the data were collected from the SKDI document issued by Indonesian Medical Council (2012), in-depth interviews, and questionnaire. Similarly, to collect the data pertaining to PSA, the researchers used English language test, focus group discussion (FGD), and document checks.

Data analysis.
As regards method of data analysis, the researchers employed content analysis for a number of data obtained from TSA and PSA. Initially, the TSA data were tabulated, sorted out and then classified into a number of categories. Then, the results of the analysis were used to seek further explanation of the current situation of the teaching of English from the points of view both service users (students) and other stakeholders at the Faculty of Medicine.
Subsequently, the results of both PSA and TSA were then translated into learning needs (LSA), that is, what the learners need to learn in order to achieve the target needs. The results of these analyses become the basis for suggesting language programs, which are later translated into English curriculum and syllabus for students of Faculty of Medicine UNRAM.

Present Situation Analysis (PSA) Levels of English
Every year the first year students of Faculty of Medicine UNRAM must take an English placement test using the English Communication Skills for Civil Services test designed by ODA-LAN-BC (1998) at UNRAM Language Centre. Its purpose is to provide information for students and management about their levels' of English. To get more valid descriptions of students' English ability, the data are taken from the five-year documents available at Language Center and Faculty of Medicine UNRAM as presented in the following

Chart 1. Students' levels of English in five years
The chart above shows students' English levels for 5 (five years). As presented on the chart, the levels of English of students registered at the Faculty of Medicine UNRAM are relatively low compared to the demand of English in this faculty. Most of them are below the intermediate level.
Except for 2013 intake, most of them are in pre-intermediate level and some are still at the elementary and basic levels. The data are a bit surprising in the sense that the input of the Faculty of Medicine is supposed to be those who have good academic ability at senior high schools, which also means that their English should have been adequate to anticipate their study. Following Dudley-Evans & St. John's (1998) concepts, that is, ESP program ideally starts from an intermediate level, most of them are not ready or deserved for ESP programs.
The chart below shows another way to translate data of students' English levels regarding readiness to attend ESP courses. Chart 2. Students' readiness to attend ESP programs As presented in Chart 1 above, in five years the number of students having English ability lower than intermediate outnumbered that in higher than intermediate. Although the comparison is fluctuated, the higher level students never achieved 50% (in 2017). Even, in 2015 --the worst English achievement in five years --the comparison of higher and lower of intermediate is 13.24:87.76. The data means that it takes long times and extra efforts to achieve English competencies needed to meet Graduate Profile and SKDI.
From data on English entry behavior above, the design of language programs cannot go directly to ESP programs. There should be negotiations to bridge students' current ability and the expected learning outcomes, following Krashen's (1982) comprehensible input (i +1) and Vygotsky's (1978) Zone of Proximal Development (ZPD).

Target Situation Analysis (TSA)
Documents analyzed to formulate the target needs of students of Medicine UNRAM were the Profile of Faculty of Medicine (2016), Competency Standards of Indonesian Medical Doctors (SKDI) (Perkonsil, 2012).

Analysis of the profile of Faculty of Medicine UNRAM
The needs of English for students of Faculty of Medicine UNRAM are explicitly stated in the vision of Faculty of Medicine UNRAM stating that the education program is to produce medical doctors fulfilled the requirements of Competency Standards of Indonesian Medical Doctors (SKDI), excel in archipelagic medicine, actively take roles in the development of science and technology in medicine, and capable of competing internationally. This vision statement implies that English at Faculty of Medicine plays crucial roles in that it is needed to:  produce competent medical doctors based on SKDI, which require English for both academic and job (results of SKDI analysis are presented below);  along with the development of tourism in Lombok NTB, prepare archipelagic medical staff capable of providing services in small islands (Gilis) now becoming tourism destinations;  take parts in the development of science and technology that needs academic English; and  produce graduates having international competitiveness that requires comprehensive English proficiency. To achieve all those needs, graduates need to be equipped with comprehensive levels of English proficiency, both spoken and written. English is also needed as the requirement of graduation (450 on TOEFL score) and for Clinical Rotation Program in hospital, which requires English 'morning report" and journal report. Considering such needs, there must be reformulation of the formats of teaching and learning English at the Faculty.

Analysis of SKDI Document
The Competency Standard of Indonesian Medical Doctor (henceforth SKDI), as a guideline for providers of medicine education in Indonesia, consists of 7 competency areas: (1) glorious professionals, (2) self-awareness and self-development, (3) effective communication, (4) information processing, (5) scientific basis for medical science, (6) clinical skills, and (7) management of health problems (Perkonsil, 2012). Of those 7 areas, the needs of language proficiency arise dominantly from competency areas 2, 3, 4, 6, and 7. The language needs are generally emphasized on communication and information in Indonesian language context; however, since the demand of millennial world which requires global communications and the Vision-Mission of Faculty of Medicine UNRAM to produce graduates internationally competitive, the needs of communication and information must be extended from Indonesia contexts to international ones.
The results of the language-related competency from SKDI analysis are summarized in the table below:   To build self-awareness and self-development, medical doctors are required to practice lifelong learning and to develop new knowledge. To do those, they need to have both spoken and written English ability.  Effective communication areas relate to medical doctors' competency to communicate to related parties (patients and family, job partners, and community). The duties include developing relationship through verbal and non-verbal communication, empathizing verbally and non-verbally, listening to patients actively to explore problems, conducting management of consultations and referrals, building interpersonal communication. In community, medical doctors are required to advocate with related parties in order to solve problems of individual, family, and community health. Those require good command of English both spoken and written English with more emphasis on oral communication.  In relation to information processing areas, medical doctors require English for accessing and evaluating information and disseminating information and knowledge effectively to improve the quality of health services. They require both spoken and written language, dominantly reading and writing ability.  Clinical Skill Areas relate to perform diagnostic procedures and conduct educations and counseling. In this area, medical doctors need spoken English.  Management of health problems requires medical doctors to carry out promotions, consult and refer patients based on procedures, make written medical instructions, and write medical records and correspondence. These also needs spoken and written English. The needs mentioned above more relate to the needs of English for occupation after they finish their study (English for Job). From the analysis of Guidebook for the Implementation of Medical Education at Faculty of Medicine UNRAM, it is found that in addition to producing graduates capable of competing at an international scale as stated in Vision-Mission, English is needed as a graduation requirement and during clinical apprenticeship in hospital. The students are required to have TOEFL score at least 450 as a requirement for graduation (p. 48 on Guidebook, 2016). For clinical rotation or apprenticeship, English is needed for morning report and journal report in each station (polyclinic).
From two document analyses -SKDI and Guidebook of Faculty of Medicine UNRAM --, it is summarized that English is needed by students of Faculty of Medicine UNRAM for (1) preparing their study (English for Academic Purposes), (2) meeting graduation requirement and clinical rotation (clinical apprenticeship), and (3) preparing for job and professional development. These findings are also supported by the findings collected from subject specialists and management through questionnaire and discussion. They all agree that students of medicine require English for multi-purposes, but the immediate one is the ability to read academic resources to support their study.

Discussion and implication
Results of the present study have indicated that to a great extent students' level of English proficiency and readiness to meet SKDI was still low. This finding implies that they need to have good training in English for General Purposes prior to taking part in ESP for Medicine Sciences. In this relation, Kurland (2000) and Dudley-Evans & St. John (1998) suggest that students taking part in ESP are required to have high levels of English and are ideally at the Intermediate level. With the current levels of English, it will be difficult for students at Faculty of Medicine to achieve the expected goals as the phases of students learning processes are not well scaffolded (Vygotsky, 1978). At this point, there must be negotiation in designing the programs to bridge the big gap between the current levels of English and the expected learning outcomes (to be able to read academic references).
This study also reveals there is a wide gap between the target needs, students' current levels of English and the expected target needs. It is therefore very likely that the mid-term and longterm goals will be difficult to be achieved when students' basic language needs are not well facilitated. Therefore, there must be a renewal of the current curriculum and learning module at the Faculty of Medicine to bridge the current reality.
As mentioned above, from the analyses of documentary data, the goals of learning English for students of Faculty of Medicine UNRAM can be grouped into 3 periods: (1) Short-Term Goals, (2) Mid-Term Goals, and (3) Long-Term Goals. 1. Short-Term Goals. The immediate goal of learning English for these students is to prepare them to become students. As students, they need English to facilitate their study, which means that they are required to have English proficiency for accessing academic information from academic resources such as textbooks, journal articles, etc. on their field written in English. Therefore, they need to be equipped with academic English especially academic reading. In academic reading, the learners need to be trained to become critical readers, capable not only of restating (what a text says) but also of describing (what a text does) and interpreting (what a text means) (Kurland, 2000). It implies that academic reading (critical reading) requires high levels of English and takes times to learn. As Dudley-Evans and St. John (1998) suggest that the ESP program be ideally for Intermediate level students. With the current levels of English of students of Faculty of Medicine UNRAM as reported above, it will be difficult to achieve the expected levels. There must be negotiation in designing the programs to bridge the big gap between the current levels of English and the expected learning outcomes (to be able to read academic references). It is suggested that prior to entering academic English/reading, there must be a General Academic English/Reading) first as a bridge. 2. Mid-Term Goals. In Mid-Term Goals, English is needed as a requirement for Sarjana Kedokteran (S. Ked.) graduation and for Clinical Rotation (Clinical Apprenticeship) in hospitals. Guidebook for Academic for Faculty of Medicine requires TOEFL score at least 450 as a graduation requirement (Guidebook of Faculty of Medicine UNRAM, 2016). It means that students need to equip themselves with materials and strategies commonly tested on TOEFL test. As an international standardized test, TOEFL requires high levels of English proficiency covering listening comprehension, structure and written expressions, and reading comprehension. In addition to mastering TOEFL, students are also required to have English for apprenticeship in hospital to do Clinical Rotations, which require English for journal report and morning report on every station. In other words, in the midterm period, the students need English for TOEFL preparation and English for Academic (journal reading and report). 3. Long-Term Goals. As the analysis of SKDI and the Guidebook of Faculty of Medicine UNRAM, it is found that in long term, the goals of learning English are for preparing graduates to be able to compete at international scales and for professional development including for further study. Global competition requires comprehensive English proficiency at all four skills and professional development needs advanced academic English skills for maintaining and updating their knowledge through reading journal, writing journal, and attending seminars and workshops, and further study (specialist/S2/S3). All need active English including the achievement of TOEFL score at least 500 for post-graduates in Indonesia. From the explanation above, it can be concluded that the needs of English for students of Faculty of Medicine UNRAM is high (strong position) starting from being students to job competition and professional development. There are overlapped areas among the periodic goals mentioned above, that is, the academic English is needed in short term, midterm, and long term. It means that readiness from the beginning will facilitate the needs of academic English in the following periods. It also applies to the mastery of TOEFL, that is, the mastery of TOEFL as a graduation requirement can facilitate the needs of TOEFL for applying job and further study.. Based on the analyses above, the language learning programs needed by the students of faculty of Medicine can be summarized as follows: Based on students English entry behavior (levels of English) mentioned above and the target needs based on Graduate Profiles of Faculty of Medicine UNRAM and Competency Standard of Indonesian Medical Doctors (SKDI), there is big gaps between the students' current levels of English and the expected target needs. Therefore, there must be a negotiation in designing the language programs to bridge the current levels and the target needs. The recommended language programs provided to accommodate various needs are as follows: 1. To achieve short-term goal, that is, to prepare students to access academic information during their study, they need English for academic purposes. According to Dudley-Evans and St. John (1998), the ESP program is ideally for Intermediate level students. From the data on students' entry behavior, ranging from 55% to 87% of the students (see Table above The implication of these findings is that the management of the Faculty of Medicine the University of Mataram needs to reconsider the policy of English language learning and provide more supports for various ways of students' English improvement. With the present situation for learning English for students of medicine, it will be difficult to achieve those target needs.

Conclusion and further investigation
The level of English of students registered at the Faculty of Medicine UNRAM is still low compared to the needs of English. 50 -60% of them are lower than Intermediate levels as minimum requirement of ideal ESP programs.
Being able to compete at international scales (stated at the Vision of the faculty) requires high levels of English for survival in study (as students), for meeting graduation requirement (450 on TOEFL score) and for clinical rotation or apprenticeship in hospitals, and for job completion and professional development.
The goals of learning English can be grouped into three periods: Short term Goals (to prepare students as students), Mid-term Goals (to meet graduation requirement and prepare for clinical rotation in hospitals), and Long-term Goals (to prepare alumni for job competition and professional development).
The language programs need to be prepared for students of Medicine to achieve competencies needed in Graduate Profiles and SKDI are: (1) General Academic English (GAE/R), It is suggested, then, that to meet its Vision and Mission, the Faculty needs to change the policy of teaching English at the Faculty. As a part of Block System, the amount of time learning English is very limited so that it is difficult to plan the programs. As the results, it is impossible to achieve the expected goals. In this situation, English will just become a formality in a curriculum without significant contributions.

Declaration of conflicting interest
The authors state that there is no conflict of interest concerning the publication of this paper.