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Overcoming Cultural Barriers: International Medical Graduates in the United States FREE

Kevin Fiscella, MD, MPH; Richard Frankel, PhD
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JAMA. 2000;283(13):1751. doi:10.1001/jama.283.13.1751-JMS0405-6-1.
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Published online

It is widely accepted that cultural differences between physicians and patients can shape medical encounters and affect quality of care. A large body of research documents the effect of patients' race or ethnicity on physician decision-making and demonstrates that health-related beliefs affect health outcomes.1,2 While many training programs have focused attention on teaching US medical graduates (USMGs) to overcome cultural barriers, little attention has been given to the effect of cultural difference on encounters between international medical graduates (IMGs) and their patients.

As a framework for discussing the major cultural challenges facing IMGs in providing care to patients in the United States, we use a model3 that describes 3 core tasks of the health care provider—gathering data, developing rapport, and educating and motivating the patient—each of which can present difficulties to IMGs who are not fully acculturated to US society.

Residency programs trying to improve IMGs' data-gathering skills have focused primarily on teaching essential English-language skills to IMGs educated in non–English-speaking countries.4 Considerably less attention has been given to teaching IMGs to recognize regional patient dialects, colloquial speech, body language, and speech inflection, yet studies show that even IMGs who are proficient in standard English may find it difficult to understand patients' more subtle or informal means of communication.5 Formal English classes may not prepare an IMG to recognize a patient's use of the phrase "high blood" to refer to hypertension, for example, or to understand a substance user who says "one day at a time" to allude to the philosophy of Alcoholics Anonymous.

Developing rapport and responding to patients' emotions may also be a challenging task for medical graduates from non-Western countries. A 1999 study of the role of race and gender in the patient-physician relationship indicated that patients report more satisfaction in a given medical encounter when their physician is of the same race and/or ethnicity.6 Both IMGs and US medical graduates who belong to ethnic or racial minorities may find it difficult to establish rapport with patients who do not share their appearance or background.

Furthermore, many IMGs come from developing countries where epidemic disease, physician shortages, and disparities in education leave little room for exploration of the patient's story as a focus for clinical training. As a result, some educators have suggested that communication skills are not a primary concern of these countries' undergraduate medical curriculum.7 Graduates may find it difficult to shift priorities once they arrive in the United States.

Further complicating IMGs' efforts to establish rapport with their patients is the widely held but infrequently substantiated perception that IMGs are not as well-trained or as qualified as their US-trained counterparts.8 A 1997 study of residents in a primary care training program identified "fear of patient bias" as a major factor shaping IMGs' approach to their US patients.9 These fears of rejection or of being singled out may cause IMGs to be appear more aloof in their interactions with patients, or to insist more unyieldingly on their own authority as physicians.

Finally, differences between IMGs' and patients' health-related beliefs may affect patients' adherence to these physicians' medical advice. A 1990 study of foreign-born IMGs found significant disparities between patients' and IMGs' attitudes toward health-related issues such as family involvement in health care, the meaning of facial expressions, and the use of life-sustaining technology.10 Although it is not clear whether these differences were owing to residents' foreign upbringing or their education in a foreign medical school, they had the potential to change patients' trust in their physicians' instructions.

In the future, medical educators will need to take cultural differences into account when training IMGs for practice in the United States. Tools such as mixed IMG and USMG support groups, international student retreats, cultural-sensitivity training, and standardized patients may prove useful in achieving this goal.

REFERENCES

Kleinman  AEisenberg  LGood  B Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88251- 258
Link to Article
Stewart  MA Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;1521423- 1433
Cohen-Cole  SA The Medical Interview: The Three-Function Approach.  St Louis, Mo Mosby Year Book1991;
Rosner  FDantzker  DRWalerstein  SCohen  S Intensive one-week orientation for foreign medical graduates entering an internal medicine residency program. J Gen Intern Med. 1993;8264- 265
Link to Article
Foresst  DVRyan  JHLazar  V American familiar language and the FMG psychiatric resident. J Psychatr Educ. 1978;268- 82
Cooper-Patrick  LGallo  JJGonzales  JJ  et al.  Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282583- 589
Link to Article
Haveliwala  YA Problems of foreign born psychiatrists. Psychiatr Q. 1979;51307- 311
Link to Article
Mick  SSComfort  ME The quality of care of international medical graduates: how does it compare to that of US medical graduates? Med Care Res Rev. 1997;54379- 413
Link to Article
Fiscella  KRoman-Diaz  MLue  BHBotelho  RFrankel  R "Being a foreigner, I may be punished if I make a small mistake": assessing transcultural experiences in caring for patients. Fam Pract. 1997;14112- 116
Link to Article
Pajak  GG Cultural factors in the interaction between foreign medical graduates and their American patients in a hospital setting. Dissertation Abstracts Int. 1990;503872- 3873

Figures

Tables

References

Kleinman  AEisenberg  LGood  B Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88251- 258
Link to Article
Stewart  MA Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;1521423- 1433
Cohen-Cole  SA The Medical Interview: The Three-Function Approach.  St Louis, Mo Mosby Year Book1991;
Rosner  FDantzker  DRWalerstein  SCohen  S Intensive one-week orientation for foreign medical graduates entering an internal medicine residency program. J Gen Intern Med. 1993;8264- 265
Link to Article
Foresst  DVRyan  JHLazar  V American familiar language and the FMG psychiatric resident. J Psychatr Educ. 1978;268- 82
Cooper-Patrick  LGallo  JJGonzales  JJ  et al.  Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282583- 589
Link to Article
Haveliwala  YA Problems of foreign born psychiatrists. Psychiatr Q. 1979;51307- 311
Link to Article
Mick  SSComfort  ME The quality of care of international medical graduates: how does it compare to that of US medical graduates? Med Care Res Rev. 1997;54379- 413
Link to Article
Fiscella  KRoman-Diaz  MLue  BHBotelho  RFrankel  R "Being a foreigner, I may be punished if I make a small mistake": assessing transcultural experiences in caring for patients. Fam Pract. 1997;14112- 116
Link to Article
Pajak  GG Cultural factors in the interaction between foreign medical graduates and their American patients in a hospital setting. Dissertation Abstracts Int. 1990;503872- 3873
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