Editor’s Note: A Commentary on this report is on page 176.
International medical graduates (IMGs) are filling an increasing proportion of U.S. family medicine residency positions. The results of the 2005 National Resident Matching Program (NRMP) indicate that 24.3% of all matched positions in family medicine were filled by non-U.S. citizens educated internationally, marking the seventh consecutive year when more positions in family medicine were filled with non-U.S.-citizen IMGs than the previous year (see Table 1).1 These changes in family medicine residencies parallel those in medicine in general. Twenty-five percent of all pediatrics and 35% of internal medicine residency positions were filled with IMGs in 2005,2 with the majority of these IMGs being non-U.S. citizens (69.8% and 78.6%, respectively).1
Data regarding IMGs who are U.S. citizens versus those who are immigrants can be somewhat difficult to differentiate, but we do know where IMGs have commonly trained. According to the 2004 American Medical Association Membership Fact Book, the top ten countries for medical school training for international medical graduates in family medicine were India, the Philippines, Mexico, Pakistan, Dominican Republic, the former USSR, Grenada, Italy, Egypt, and South Korea.3 U.S.-trained residency faculty may not understand the medical school training of IMGs, nor aspects of their culture that influence their interactions with patients, colleagues, and faculty. For example, in contrast to other countries, U.S. health care emphasizes patient autonomy over physician paternalism,4 as well as greater attention to psychosocial factors such as patients’ mental health, family dynamics, and the physician–patient relationship.5 Charting formats, reliance on laboratory tests, and medications differ internationally as well.
While the proportion of IMGs in family medicine residencies continues to grow, there has been little discussion of how this trend affects medical education. Differences in medical education between the United States and other countries may require residency faculty to cover specific content not commonly taught abroad.6 For instance, with a few exceptions, such as England, Australia, South Africa, and the Netherlands, applied behavioral science and psychology is much better developed in the United States than elsewhere in the world.7 “Behavioral science” is a widely used term in family medicine that encompasses traditional psychiatric diagnosis and treatment, interviewing skills, and physician–patient interaction.8
Through observation and informal discussions with IMGs in our family medicine residency program, it became evident that many had little exposure to behavioral science in their preresidency education. As our program matched greater numbers of IMGs, physician faculty increasingly commented that these residents did not appear to appreciate the psychological and social components of family medicine’s biopsychosocial foundation. In addition, comments by the IMGs with whom we worked suggested that many of the common mental health conditions seen in the United States were not commonly diagnosed or treated in their home countries.
Our aim in this study was to better understand the subjective experiences and perceptions of behavioral science among our residency program’s IMGs, including gathering information about their previous training and experience in behavioral science before coming to the United States. We hoped to use this information to improve the behavioral science education in our program. As the goal of inquiry was to describe others’ perspectives and personal histories, rather than deductively test hypotheses, we chose to use qualitative methods, a method of inquiry that has been shown to be very useful for this purpose.9 While systematically obtaining and analyzing narrative accounts may be a precursor to designing a quantitative survey,10 qualitative inquiry may be used alone as the optimal approach for inductively synthesizing descriptions from narrative data.11
As in any discussion of cross-cultural differences, the tremendous variability in the backgrounds of IMGs must be acknowledged. Generalizations will always be qualified and may not reflect the experience of all IMGs.
Through an announcement at a regular monthly resident-faculty meeting, we invited all family medicine residents who had completed medical school outside the United States to participate in an individual interview. The interview’s purpose was described as helping faculty to better understand residents’ previous behavioral science education as well as their views on specific elements of our behavioral science curriculum, such as psychiatric diagnosis and the physician–patient relationship.
In keeping with qualitative methodology, selection of participants is guided by the study topic,12 which results in much smaller samples than in quantitative investigations. Data analysis involves coding and classifying transcribed interview segments into categories or domains. Analysis of narrative data inductively creates these categories. Saturation, the point at which analysis of additional participants’ protocols does not yield further categories, typically occurs with six to eight participant interviews.12 Therefore, we sought to recruit at least 50% of the 16 IMGs from our family medicine residency program to obtain an adequate sample.
During the last quarter of the 2004 academic year, ten first-, second-, and third-year residents (five men and five women) volunteered to be interviewed. Five residents obtained their medical training in India and the additional five trained in each of the following countries: Macedonia, Bosnia-Herzegovina, the Philippines, Egypt, and Iraq. As indicated previously, India represents the most common country for medical school training for international medical graduates in U.S. family medicine.3 Participants graduated from medical school between 1981 and 1999, with eight graduating after 1994. Three residents had worked as physicians in their home countries for an extended period of time prior to starting residency. All ten participants had lived in the United States for at least one year prior to starting residency.
Two residents who did not participate in the interviews completed medical school training in India. The remaining four had trained in Montserrat, Pakistan, Uzbekistan, and the Dominican Republic. These residents had completed their medical school training between 1976 and 2001, with four graduating prior to 1990 and two after 2000. Three of these residents had worked as physicians for an extended period of time in their home countries prior to starting their U.S. residency. Residents in both groups had completed an observership or its equivalent in the United States.
We interviewed residents individually in a private setting while taking notes and tape-recording the sessions. The notes and tapes were used to cross-check when a respondent’s words were unclear.
Interviews averaged approximately one hour and followed Spradley’s guidelines.13 Our initial queries were broad, open-ended, “grand-tour” questions, which we followed with more specific, smaller scale questions. Interviewees’ answers to our subsequent compare-and-contrast questions clarified categories and their conceptual boundaries. List 1 presents sample interview questions.
We analyzed the interview transcripts according to methods developed for ethnographic13 and marketing14 interview data. Our review was influenced by the Constant Comparative Method,15,16 in which narrative segments are highlighted, organized into categories, and labeled according to the investigator’s analysis of their shared meaning.16
We each individually coded and provided initial thematic labels for interview segments. We then compared these initial analyses, discussing them until we reached agreement on category content and boundaries. This process, termed “double coding,” enhances the reliability of qualitative data.17
We developed names for the seven categories identified that summarized their content. When using this method, the end result is typically a set of descriptive categories, some of which may be related.15,16 The results may be presented as a set of categories, each featuring an explanation of its content and illustrated by interview segments.9,11,15,18 The categories were then given a label and an accompanying description. We chose a “story line” to highlight each theme. These story lines, in italics below, are quotations from the respondents that illustrate the key message of each theme.
As a validity check, we presented the categories that were identified and their accompanying descriptions back to the interviewees to verify accuracy.19 This process, “member checking,” was employed by Addison20 in his qualitative study of family medicine residents’ professional socialization. Based upon the residents’ feedback, we modified some of our initial categories and explanations.
International medical graduates’ behavioral medicine training prior to coming to the United States
Medicine was the focus.… You didn’t really study psychiatry unless you were planning to choose it as a specialty.
Many of the ten IMG residents we interviewed reported limited education in psychiatry and behavioral science prior to residency. Some residents described completing one or two psychiatry courses in medical school, including training in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition). However, most clinical rotations in psychiatry took the form of observerships or group walking rounds in institutions for patients with severe mental illness. One resident observed:
I had minimal training or no training in anxiety and depression. I was in a mental hospital and I had one month. It was in my fourth year. We had lectures for two weeks and two weeks in an institution. We looked at locked-up people all the time. It was a crazy hospital. We did not interview patients; we just walked through. It was like looking at specimens.
All of the residents had Educational Commission for Foreign Medical Graduates (ECFMG) certification, providing them with additional exposure to U.S. psychiatry. However, several interviewees spontaneously reported that they had only learned the DSM-IV psychiatric criteria through preparing for the ECFMG examinations and had never used the system in clinical practice.
Mental health and psychosocial content as part of clinical medicine
You practically never do this… [in my country]… psychiatry is for the mad man.
Regardless of where residents trained prior to coming to the United States, there was general consensus among our interviewees that mental health issues were not addressed by primary care physicians in their home countries. A frequently mentioned reason for this practice was to avoid offending patients, as one resident’s comment demonstrates:
You would never approach that issue [mental health]. If you did, they would brush you off. Being mentally ill would mean you are psychotic.
Patients with severe psychopathology such as depression with suicidal ideation or schizophrenia would be admitted to a psychiatric hospital and referred to a psychiatrist. Less severe anxiety or mood disorders were not addressed by physicians and, for many residents, did not qualify as “medical problems” needing intervention. Because of this emphasis, psychiatric training was seen as largely irrelevant to family physicians. Many mental health conditions treated in U.S. ambulatory primary care were not seen as illnesses to be diagnosed and treated, but as unpleasant, yet normal, parts of life. A resident from India remarked:
In India, if I am depressed, it is normal. I would not bring it to a doctor. We really do not see this kind of depression as a medical condition in India. It is just part of life.
Furthermore, strong religious faith was perceived to be a buffer in coping with difficult life events. Residents suggested that Americans often become “depressed” in response to events that people in their home country would more likely accept as fate. According to another resident:
It [the resident’s country of origin] is a religious society, so if there is a difficult life event, people accept it and move on. The strong belief in God means that if something bad happens, that is because of God.
Even in countries in which primary care physicians inquired about and treated psychiatric symptoms, there was little diagnostic specificity. One resident remarked:
Mental health does not look the same there as it does here. In my country [Bosnia], our people are simply “nervous.” All psychiatric problems, depression, posttraumatic stress disorder, everything, it is just “nervous.” I learned about outpatient mental health care when I was passing the CSA [clinical skills assessment]. I had to read the book. It was something I was never really formally trained in. People in my country, they come to the office and say they are nervous, so we just give them some benzodiazepines. [Interviewer: “What would give a patient a diagnosis of ‘nervous’ in Bosnia?”] Just being nervous, all the psychiatric problems you see here is just being nervous.
Most respondents recognized that mental health and psychosocial interview questions were important, even in patients with focal biomedical complaints. However, they were strongly influenced by the norms of their home countries, where raising these issues would insult patients. For these residents, a key barrier was their lack of comfort and skill in asking “personal” questions that could make the patients uncomfortable, particularly with English as a second language. For instance, a resident commented:
The language is different, and it is hard to ask questions the way you would want to here in the United States.
A few respondents, particularly those who had been trained not to ask patients psychosocial questions, appreciated the permission to broaden their understanding of patients and enjoyed their newly found freedom to explore emotional concerns, as this resident’s remark shows:
Here [in the United States], what you are doing is paying attention to how the patient is feeling. Back home, we ignore patient’s feelings—it’s a normal part of life and we ignore it. Here, you pay attention to what the patient is feeling and treat it…. I think it is a lot better here.
However, a few residents found this requirement burdensome. Attention to psychosocial concerns was a time-consuming process that, along with prevention counseling, they felt unnecessarily prolonged and complicated patient encounters. One interviewee remarked:
We make a big deal out of the mental health history here. We have to acknowledge every single complaint in order to satisfy the patient. I do not believe in that. It is not feasible to acknowledge all the patient’s symptoms. It will just have to break down.
Training in medical interviewing
We had no formal training. Nobody taught me how to talk to patients.
Residents’ formal training in medical interviewing appeared to be dependent on country of origin and ranged from purely observational learning to a combination of didactics, clinical teaching, and formal evaluation. One resident described receiving intensive observation of his patient interaction skills:
The attending would evaluate us—how to ask questions, how to shake hands, which side to approach patients; there are rules for this.
The residents from Egypt, Macedonia, and the Philippines reported at least a moderate amount of training in this area, including formal lectures and clinical instruction on “bedside manner.” One resident described training experiences similar to those in U.S. medical schools:
We had a semester course in medical school with lectures about how to take the interview. Then, we would divide into groups of 10 or so, and 10 of us would have one patient, and we would do the interview. The attending would then evaluate us. This would include bedside manners and training in how we interact with patients.
However, the majority of residents reported having little formal training in medical interviewing and learned these skills primarily through modeling by clinical faculty and senior-level students. Moreover, residents stated that they primarily focused on the content of the medical interview rather than the interpersonal aspects, as this interviewee’s comments demonstrate:
They [faculty in home-country medical school] were not really worried about how we spoke to the patient. The assistant professor wouldn’t worry whether we were considering the patient’s feelings.
The physician–patient relationship
There is more of an equal relationship between the doctor and the patient in the United States.
Residents described many differences between U.S. family medicine and their previous training experiences with regard to the physician–patient relationship. These differences reflected a consumer-oriented versus a paternalistic view of patient care. For example, patients receiving care in the United States were perceived as more inquisitive and active in medical decision making, as one resident observed:
Here, everyone wants lots of details about what’s going on, how the disease process works and why this medicine. They want options.
By contrast, health care in residents’ countries of origin did not demonstrate an ongoing physician–patient relationship. Clinics treating the poor in these countries did not provide the level of privacy conducive to a trusting relationship. In addition, physicians would only see acutely ill patients, with little attention to interpersonal or psychosocial issues, as one resident’s remarks illustrate:
I worked in a clinical setting [in India] for three years before beginning residency. There is no doctor–patient relationship. You have multiple patients in the same room. You do not have any kind of relationship with them. They are all lined up to see you. In India … the patient just walks in the room, there is an exam table, and you ask the patient what is going on.
Residents were often challenged by assertive U.S. patients who did not automatically defer to their physicians. Interviewees observed that rather than having immediate faith and trust in their doctors, American patients would question physicians’ decisions and judgment. In their home countries, residents perceived patients as very trusting, cooperative, and compliant in their interactions with physicians. In fact, alternative behaviors by patients were not tolerated, as one interviewee remarked:
In India, the doctor is God-like. “The doctor cured me, saved my life, my God. …” Whatever the doctor says, that’s enough. … Patients don’t ask questions, they don’t doubt. That wouldn’t be taken very nicely. “I am the physician. If you are coming to me, my rule goes.”
Residents had rapidly become sensitive to U.S. patients’ expectations for good “customer service.” According to one interviewee:
Here, as I was told, you are a service for the needs of the patient. So, you balance your approach to make the patient happy.
Residents also expressed more concern about litigation in the United States compared to their previous experiences. According to the IMGs we interviewed, medical litigation was rare in their home countries. They appeared to appreciate the significant role that lawsuits played in guiding medical documentation as well as discussions with patients. One resident observed:
Here, we provide everything for the patient, but we still worry we’ve missed something and we will be sued.
Perceptions of family life in the United States
In this country, you don’t discipline children. You give them medicine.
While not a formal interview topic, U.S. family life and how it differed from their own culture was the subject of numerous spontaneous comments. Respondents were surprised by U.S. family dynamics, child-rearing methods, and marital issues that they observed through clinical interactions and popular media (for instance, talk shows). A common theme was that in the United States, social and family problems were often converted into medical conditions. Most IMGs had little experience with psychiatric conditions such as childhood attention deficit hyperactivity disorder (ADHD) and were disturbed about diagnosing and medicating what they perceived to be simply misbehavior. One resident remarked:
Parents in this country, they let the kids do whatever they want. … ADHD is not diagnosed in my country—it’s simply a matter of discipline. Here it seems to calm down parents and teachers when you give the kids medicine.
Most interviewees found it odd that the state could become involved with parents who physically disciplined their children. Government-supported removal of children from their family home was seen as inappropriately intrusive. For instance, a resident observed:
In my country, parents even beat the children at home—it’s not considered abuse. Teachers can hit the child with a cane—there is no child protection. Parents have a free hand to discipline as they want. Strict parents are very effective. Their children do well in school and college. Here, the slightest bruise and the child is taken away.
Families in the United States were often characterized as isolated from extended support networks. Residents expressed discomfort with the lack of family connection they observed for many elderly patients. Hospitalized geriatric patients who received no visitors and adult children who placed parents in impersonal nursing homes were particularly disturbing, as this interviewee’s comment suggests:
Back home, families are crucial. Here people are left alone. You have a chance to get depressed much more here.
The dyadic marriage contract common in the United States and Western Europe was also seen as unduly isolating. In less industrialized countries, marriage is often a union of two clans or extended families rather than simply two individuals. One interviewee observed:
At home, the whole family is controlled by those around you. It is not just the husband and wife. When you think about it, there is more separation and divorce in the United States. At home, if I divorce you, my sister will have a bad name, and it will be bad for my family. Family support keeps us together.
Similar to child abuse, partner violence was seen by some IMGs as appropriately handled by the extended family rather than the medical-legal system. Another resident commented:
Back home, if I hit my wife, they would not take that to the doctor. There is family support. Women are abused here, and they often do not want to do anything about it. Back home, women are hit and their Dad says “come home.” Here, women get put out on the street.
Recommendations for improving IMGs’ understanding of the psychosocial aspects of patient care
Start.…[teaching the content] sooner, direct observation, and tell us how to ask the questions.
The residents we interviewed had three general suggestions for improving IMGs’ knowledge of psychosocial aspects of family medicine: Early exposure to behavioral medicine during residency, observation of good quality physician–patient interactions, and instruction in specific wording of psychiatric diagnostic interview questions.
Because of the importance that family medicine places on interviewing, mental health, and the doctor–patient relationship, and the limited exposure to this content in many international medical schools, respondents felt disadvantaged at residency outset compared with U.S. graduates. This specific deficit appeared to be greater for psychosocial than biomedical knowledge. Several residents suggested that a preresidency observership with a behavioral medicine emphasis would be helpful, as well as prompting from faculty preceptors. Two interviewees’ remarks are illustrative:
Do it sooner when we are in our observership or at the beginning of training.
Preceptors should remind us to look out for these kinds of things.
Direct observation of faculty family physicians in clinical encounters was also suggested. In particular, the IMGs we interviewed, probably because of fear of offending patients, were very concerned about the correct wording of psychosocial questions. Several explained that they were first exposed to DSM-IV psychiatric diagnostic criteria while studying for the United States Medical Licensing Examination (USMLE). However, they felt unsure about how to inquire about psychiatric symptoms. Querying patients about sensitive issues such as abuse or suicidality made residents particularly apprehensive. Two interviewees commented:
First you are very uncomfortable, then you feel better and better … how to ask questions, how to ask about suicide. For me, that was very embarrassing. I was surprised people respond normally to these questions—“How will this influence her relationship with me?”
In my country, we learned psychiatry mostly from books. I didn’t really learn the DSM until I studied for the USMLE, but reading the DSM isn’t enough. If you could tell us what questions to ask, it would help. We need a cheat sheet, a card, like the mini mental status exam, a protocol.
Specific challenges for the IMG
Do you have all day?… Everything is unique.
The residents we interviewed described many unique challenges to adjusting to health care, medical education, and the “rules” of medical practice in the United States. Documentation and charting formats were often seen as novel and confusing. Many residents were unclear about how to interact with support staff. They often felt that they had to prove themselves to faculty. In particular, because of their training outside the United States, many felt that they were being scrutinized more closely than were their U.S.-trained peers.
A common concern was documentation. Residents highlighted differences in charting format for the medical record, as well as the recognition that patient charts were also legal documents, as these two IMGs’ comments show:
I never heard of SOAP [subjective, objective, assessment, plan] notes until this program.
Documentation is a huge issue here. Not just documenting in a professional way, but in a legal way. Every word is important.
Residents also expressed concern about not offending nurses and medical assistants. They recognized that U.S. nurses and office staff would not automatically defer to physicians as they would in IMGs’ home countries. However, this left one resident with some confusion about how to deal with support staff:
I don’t know how to interact with other staff in the office, like nursing staff. In India, they would never question a doctor. In India, you’d expect the nurse to do things right. Also, it is hard to figure out who does what here. At home, the doctor would draw the patient’s blood.
Last, IMGs expressed anxiety about being terminated from their residency and feeling a constant burden of “proving” themselves to faculty. Several residents made comments to this effect:
It took me three years to join a residency program. I am so scared. I do not feel secure. I feel like I might get kicked out.
As a third-world graduate, you have to do double the work to be accepted.
I don’t know what’s expected of me when I precept patients. The preceptors don’t know my medical knowledge. With residents from the U.S. schools, they have an idea about their knowledge base.
Over the next several years, IMGs are likely to represent an increasing proportion of family medicine residents. Their previous education is likely to be more variable than that of U.S. graduates, particularly regarding psychosocial content. Family medicine educators who understand differences between the preparation of IMGs and U.S. medical graduates will have a foundation from which to effectively teach psychosocial content and other material not commonly addressed in non-U.S. schools. Additionally, through appreciation of the values and world-views of those trained outside the United States, faculty physicians may have a broader context from which to consider and more accurately evaluate these residents’ performance.
Differences in educational process and content are simply differences and are not inherently superior or inferior. Nevertheless, the IMGs we interviewed frequently commented that where the American medical system differed from their home country, they needed to understand and modify their patient care style to “connect” with U.S. patients and meet residency standards for family physicians. Family medicine, with a distinct biopsychosocial philosophy, is not widely established outside of the United States. As a result, family medicine principles such as the doctor–patient relationship and the assessment of psychosocial factors contributing to illness were new concepts for many of our respondents.
The interview topics we pursued were primarily derived from spontaneous comments that residents made while completing clinical rotations with us. Additional themes, such as perceptions of family life in the United States, arose from residents’ observations during the interviews. More recently, we have begun examining other topics with IMGs such as medical ethics, end-of-life care,4 pharmacotherapy, medical technology, and differences in diseases and diagnostic practices.21
The narrative data we collected do suggest several possible modifications to family medicine education. We incorporated many of these ideas into our residency program. New-resident orientation now includes discussion of the consumer model of U.S. health care. We encourage residents to recognize that when patients question them, they are not being disrespectful but are attempting to understand and collaborate in their care. Additionally, residents are instructed on how to negotiate with patients about treatment options. Orientation also includes attention to documentation: we now provide and discuss good examples of quality histories and physicals, as well as progress notes. Residents are reminded that medical charts may be read by multiple audiences, including insurance reviewers and attorneys.
The IMGs we interviewed gave us concrete suggestions for improving their psychiatric interview knowledge and skills. Based upon this feedback, we developed laminated cards for common primary care psychiatric conditions with examples of verbatim questions for each symptom. We also introduced a first-year rotation in behavioral science as a complement to our standard second-year block so that IMGs would have earlier exposure to psychosocial content, such as common outpatient psychiatric conditions, common family constellations, the physician–patient relationship, management of interpersonally difficult patient encounters, and the customer service perspective. This also provides residents the opportunity, early in their training, to observe faculty-led clinical encounters as well as lead these encounters with direct observation and feedback by the psychologist.
Finally, we were pleasantly surprised at interviewee’s responses when we presented our data back to them for clarification and confirmation. The IMGs with whom we worked appeared to find it personally meaningful and were grateful that faculty were interested in their unique experiences and perspectives. Moreover, U.S. medical graduate residents who observed the member-checking session, expressed interest in better understanding the medical training of their fellow IMG residents. Many residents, U.S. and international graduates alike, commented that they had previously avoided any discussion of educational and cultural differences for fear of either offending their internationally trained colleagues (U.S. graduates) or being perceived as inferior (IMGs). As a result, our study and subsequent discussion allowed a more open, nonjudgmental recognition and appreciation for similarities and differences in preresidency education among our diverse residents.
The generalizability of our findings is unknown. Issues such as IMGs’ perceptions of being second-class citizens as well as knowledge of the consumer perspective on the physician–patient relationship are likely to be widespread, while level of psychiatric training may be more country-specific. Although specific conclusions from our study will not necessarily translate to other residency programs and IMGs, we encourage other programs to provide a venue where IMGs can discuss their experiences, education, and clinical training with fellow IMGs, U.S.-educated residents, and faculty prior to and after joining the residency. These discussions may also eventually lead to specific programmatic changes in the residency. Because of the growing cultural diversity in the United States, the perspectives offered by IMGs are often very educational to U.S.-trained residents and faculty.