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Academic Medicine:
doi: 10.1097/ACM.0b013e3181baf5b1
Communication Skills

International Medical Graduate–Patient Communication: A Qualitative Analysis of Perceived Barriers

Dorgan, Kelly A. PhD; Lang, Forrest MD; Floyd, Michael EdD; Kemp, Evelyn PsyD, RN

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Author Information

Dr. Dorgan is associate professor, Department of Communication, East Tennessee State University, Johnson City, Tennessee.

Dr. Lang is professor, Department of Family Medicine, East Tennessee State University, Johnson City, Tennessee.

Dr. Floyd is professor, Department of Family Medicine, East Tennessee State University, Johnson City, Tennessee.

Dr. Kemp is associate professor, Department of Family Medicine, East Tennessee State University, Johnson City, Tennessee.

Correspondence should be addressed to Dr. Dorgan, Box 70667, Department of Communication, East Tennessee State University, Johnson City, TN 37604; telephone: (423) 439-7564; e-mail: (dorgan@etsu.edu).

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Abstract

Purpose: International medical graduates (IMGs) represent a substantial portion of all medical residents in the United States. Yet, IMGs may be disadvantaged in their communications with U.S. patients for a variety of reasons. The authors conducted a qualitative study to examine IMGs' perceptions of the barriers to their communication with patients.

Method: A convenience sample of 12 IMGs participated in interviews that lasted 1 to 1.5 hours. Residents from the Caribbean, Colombia, Denmark, India, Iran, Pakistan, and Peru participated in individual interviews conducted on-site at one of three clinics. Interviews were transcribed and then coded independently and jointly. The authors used a qualitative analysis of interview transcripts to identify primary and secondary themes.

Results: IMGs' perceptions of the barriers to communication with their Appalachian patients fit into two broad themes: educational barriers and interpersonal barriers. Within each of these themes, the authors identified secondary themes: education-related barriers were science immersion and lack of communication training, and interpersonally related barriers were unfamiliar dialects, new power dynamics, and different rapport-building expectations.

Conclusions: The analysis of the interview data yielded several important findings that residency programs should consider when designing orientations, training curricula, and communication interventions. Programs may need to address challenges related to regional dialect and “informal” English use, as well as communication barriers associated with cross-cultural differences in norms, values, and beliefs. Programs also need to draw on multilayered interventions to address the multidimensional challenges of cross-cultural physician–patient communication.

Communication is a universal activity that varies greatly across cultures.1 An individual's cultural background has been shown to affect various communication-related factors, including willingness to communicate, notions of communication competence, and interpersonal request-making behaviors and beliefs.1–3 Entering a new and unfamiliar culture can profoundly affect communication, producing anxiety and resulting in greater avoidance of and less satisfaction with interpersonal interactions.4,5 However, in cross-cultural encounters between physician and patient, neither party may have the option of withdrawing from the encounter.

The anxiety experienced in such an unfamiliar situation may explain the greater attention provided to helping international care providers who practice medicine in the United States. Davis6 suggested that the cultural adjustment of foreign-born nurses could be eased if their colleagues explained the U.S. health care culture. Others have concluded that cultural sensitivity training could improve emotional resilience and help international medical graduates (IMGs) attend to important nonverbal and verbal interactional cues.7 Yet, whereas scholars focus on how best to help international health care providers adjust to a new system and new communication expectations, they also caution about perpetuating a reductionist perspective.8 Efforts to respond to the opportunities and constraints of diversity in the modern health care system can result—intentionally or unintentionally—in the distillation of cultures into compact lists of traits.8

This study does not seek to underscore a reductionist perspective. Rather, we recognize that current cross-cultural research continues to reveal an association between broad cultural dimensions (e.g., views of power, individualism, and collectivism) and communication,9 including medical communication.10 This study arose from an attempt to understand how a group of IMGs perceive the moderating influence of culture on their communication with their patients. Physicians must be prepared to treat diverse patient populations, including some that have experienced health disparities, such as have been documented throughout the Appalachian region of the United States.11 Medical education curricula, then, play a critical role by providing opportunities for current and future physicians to explore and gain respect for the “multiplicity of beliefs and values”8 of patients from various backgrounds. At the same time, though, physicians must also explore and understand the impact of their own multilayered cultural backgrounds (e.g., the aspects of the dominant culture, religious culture, and socioeconomic status) while adjusting to their patients' needs.12

The pressure to develop, implement, and assess medical education curricula will only become more pronounced, especially since the Western health care system increasingly serves a multiethnic society.13 Between 23% and 28% of physicians practicing in the United States, Canada, Australia, and the United Kingdom are IMGs.14 Although the Educational Commission for Foreign Medical Graduates certification process screens out profoundly ill-prepared IMGs, the process does not capture all communications-related deficiencies of those IMGs admitted into residency programs.15 Searight and Gafford's16 study of IMGs' perceptions of and experiences with behavioral science education helps shed some light on possible IMG–patient communication challenges; however, a fuller examination of IMGs' perceptions of their cross-cultural communication challenges is warranted. In our own experience of training and assessing IMGs' communications skills, we came to recognize that we knew little about the challenges that foreign-born and foreign-educated residents face when interacting with patients in their new host culture. Because of the inductive nature of this research, we used a qualitative approach, which permitted IMGs to describe their perceptions of the barriers to communication with their largely rural or suburban Appalachian patients.

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Method

Study design and sample

We studied IMGs enrolled in three family medicine residencies that emphasize the practice of patient-centered communication and serve a predominantly low-income, white, and rural-suburban population in southern Appalachia. Following IRB approval, one of us (K.A.D.) contacted 100% of the foreign-born and foreign-educated IMGs in these family medicine residencies; the contact letter described the study purpose and requested voluntary participants. Two residents declined to participate, for unspecified reasons. Each resident provided written informed consent before the interviews were conducted. Seven female and five male residents participated; their cultures of origin were the Caribbean (n = 1), Colombia (n = 1), Denmark (n = 1), Iran (n = 2), India (n = 4), Pakistan (n = 2), and Peru (n = 1). The IMGs are identified by number (e.g., Participant 8) to preserve anonymity.

We ultimately sampled approximately 86% of IMGs enrolled in these three family medicine residency programs at the time of this study, but the purpose of this study was not to generalize to other programs. Rather, the qualitative techniques that we used provided insight into participants' perceptions and experiences17,18 and helped to uncover variables rather than to test variables.17

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Data collection

We applied accepted qualitative techniques17–21 during data collection, including using a semistructured guide developed to promote participant disclosure that would help reveal previously unanticipated themes. To preserve consistency, K.A.D. served as the only interviewer, although all of us participated in developing the interview guide. Approaching participants in a way that, in the phrasing of Rantanawongsa and colleagues,19 allowed “respondents to reveal their perspectives in their own way and in greater depth,” K.A.D. used probing and clarifying questions18 during the 1- to 1.5-hour-long interviews. List 1 presents examples of primary and secondary interview questions. For this report, we revised some of the sample questions (e.g., by removing precise geographic identifiers) to preserve confidentiality.

List 1
List 1
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Data analysis

We followed grounded theory methodology17,21 in transcribing audio recordings and then independently coding the interview transcripts. We used NVivo 2.0 software (QSR International Inc., Doncaster, Victoria, Australia) to organize emergent categories and their interrelationships. One of us (K.A.D.) conducted open and axial coding, consistent with prescribed qualitative techniques, such as constant comparison.17 We used two techniques to increase the trustworthiness of our findings.17,18,21 First, two independent coders (a graduate-level communications student and an internationally trained physician not previously associated with this study) checked for researcher bias and helped increase the credibility and reliability of coding procedures. One of us (K.A.D.) worked with the first coder, and both independently read the transcripts to identify emergent themes. During axial coding, the author and the coder worked independently, and then jointly, to identify relationships between categories. The second independent coder partnered with one of us (K.A.D.) to conduct focused coding of the transcripts.21 This same author and the second independent coder used the initial thematic categories to review the transcripts again to check for consistency and to identify any overlooked themes. Second, after completion of the independent coding, two of us (F.L. and M.F.) reviewed a subset of the interview transcripts to evaluate the trustworthiness of the emergent primary and secondary themes. We resolved disagreements through discussion. This report incorporates numerous quotations from participants to further support our claims. Quotations from IMGs were edited only to promote clarity and readability, so as to preserve the integrity of the data, but each speaker's voice was retained as much as possible.

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Results

During the inductive analysis,17,18 two broad themes emerged of IMGs' perceived barriers to communication with their Appalachian patients: (1) educational barriers and (2) interpersonal barriers. Within these primary themes, secondary themes emerged. First, education-related barriers included the fact that IMGs had, in their culture of origin, been immersed in science-focused education without an education about communication, specifically physician–patient communication. Second, interpersonally related barriers included the fact that IMGs faced communication-related challenges in interacting one-on-one with patients because of unfamiliar dialects, new power dynamics, and different expectations about rapport building. Of course, there is an interaction between the two primary themes, because themes in qualitative research are interrelated and not necessarily mutually exclusive.17 Communicators' backgrounds, attitudes, values, beliefs, and skills intermingle, affecting the entirety of the health-related communication encounter.22 Learning a patient-centered approach to communication involves learning a new set of interviewing skills; the willingness to take such an approach entails a respect for the perspectives and backgrounds of patients, including their attitudes and complex values systems.

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Primary theme 1: Education-related barriers

One barrier to cross-cultural communication with patients was that IMGs had not studied communications in their foreign medical training, a finding similar to previous research.13 This study offers an examination of the ways in which such a lack of communication training may affect the performance and interactions of some IMGs in their residency programs. Essentially, what emerged through this study was that a focus almost solely on science and a general lack of study of communication may result in additional confusion and frustration when an IMG joins a residency program in the United States.

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Science immersion.

Participants often mentioned that they came from cultures that highly value education; however, in those cultures, “education” tended to be defined in a specific way as a focus on the hard sciences. Participant 1 stated that “education is very important” in her culture of origin and described her educational background as targeting “the sciences.” Participant 2 explained, “We have three years of basic science, which is anatomy [and] physiology, and, after that, we have one year … where we learn particularly about the disease and diagnosis.”

Participant 10 explained that, in her culture of origin, that there has long been “an expectation to be a doctor or engineer.” She reflected that, whereas the medical profession in her country used to focus on “healing,” now, students face “enormous pressure” to compete and succeed in a few respected science- and technology-focused disciplines.

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Lack of communication training.

The role of communication in medical practice seemed to be minimally addressed until late in the medical programs of most IMGs, who reported developing their communication skills through experiential means before entering their residency programs. Participant 7 said, “You have to learn on your own. You have to observe how this doctor is approaching the patient. We were not taught by specific lectures.” Participant 9 explained that physician–patient communication training was done “by trial and error but not formal teaching.” According to this same participant, this lack of formal training seemed to extend to “zero education” about how to communicate with patients and families about such issues as death and dying, issues apparently of particular concern to him.

In most of the participants' educational backgrounds, communication training seemed to be an afterthought, something addressed immediately before or during their clinical work. As Participant 2 said, “I think one of the weakest point[s] in our country is [that] they don't teach you much about how to interact with a patient, as they do here. We just learned by [spending] two years in the clinic.”

The communication training within many of the IMGs' cultures of origin was scant and limited in scope. For example, their pre-United States communication training seemed to be mainly restricted to learning how to take medical histories and gather information from patients. Participant 9 explained that, although he had enjoyed the “human development” course in his medical school, such courses had been “taken as a joke” by other medical students, and most “just want science, science, science.”

What also emerged was that the overall lack of communication training seemed to have emotional and behavioral consequences for many IMGs. For example, some reported that they had experienced confusion related to communication training and assessment on entering their residency programs, because they had never experienced such pedagogical techniques. In her first videotaped interaction with a standardized patient (SP), Participant 11 said she mistakenly thought the interaction was only about “whether I [was] able to diagnose the patient and come up with a good differential.” She realized only after faculty feedback, “Maybe I did the wrong thing,” adding that the interaction with the SP was supposed to be about “communication skill and how you talk with the patient, how you listen to the patient.” Of potential significance was this participant's claim that such communication techniques also were not fully understood by “the rest of the foreign grads.” Others, such as Participants 1 and 9, expressed frustration over the use of SPs and videotaping. These participants worked in different residency programs, but both stated that such training techniques produced artificial physician–patient exchanges. Participant 1, in fact, noted her frustration about the videotaping, finding it “invasive.”

In addition to the emotional consequences of facing new communication training expectations, there seemed to be some behavioral consequences. Participant 4 told of his struggles with certain communication training, emphasizing facilitatory skills, such as using open-ended questioning. Because he did not have a “specific course” during his medical education on how to interact with patients in his culture of origin, he learned experientially. One lesson he admitted to learning in medical school was to curtail his use of open-ended questions: “When you ask something, the patient speaks a lot. And you have to say ‘Okay, okay, hold on.’” With regard to communicating with patients in his residency program, he added, “But it's different here.” He understood that a change of cultures meant that he needed to develop a new set of facilitatory skills, including now using open-ended questions, but he acknowledged having problems in adopting this new skill, because, in his culture of origin,

[T]he patient wants to speak a lot. The patient [says], “But I remember that pain I had two years ago because I ate something, da, da, da.” You say, “Okay, how is that pain?” Sometimes you have to interrupt that patient. But it's because, in our culture [of origin], the patient speaks a lot, a lot, a lot. But, here, the patient normally gets to the point.

In fact, this participant had sought communication training on coming to the United States, partly because he had to learn how to use open-ended questions.

Most participants reported the absence of formal communication curricula during their non-U.S. medical education, but there were notable exceptions. A few participants reported exposure to communication training similar to that in the United States. As Participant 5 said, “We [had] a lot of communication courses. We had patients that were actors. And [we were given] all kinds of different situations we had to act out in role-playing, videotaping, and feedback. We had a lot of training, actually.”

Participant 8 said that his medical school had begun incorporating communication training, adding that they were “dealing with our [earlier] mistakes” of having ignored communication education. Some IMGs reported finding value in their U.S.-based communication training, with Participant 4, as previously mentioned, seeking independent training in the United States before entering his residency program:

I went to New Jersey for five days, working with Kaplan … to know how I have to interview my patients…. So I learned … how to work with the patients, how to ask open-ended questions, and [how] to focus [on] the patient in the interview. [That training] really helped me here.

This same participant reported that he wanted even “more training in communication skills with patients here.” Participant 10 also favored communications training, saying that she thought new residents from her country should seek training, especially in “team building among colleagues,” and education about “cultural differences,” adding that such training was “very, very, very lacking” in her culture of origin.

Many IMGs in this study reported coming from backgrounds in which the hard sciences were emphasized to the point of nearly excluding any education about communication. Several participants reported having to learn about physician–patient communication only through observation and experience during the later years of their medical education. Consequently, some seemed to become frustrated or confused on entering their Appalachian residency programs and being confronted with unfamiliar pedagogical techniques.

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Primary theme 2: Interpersonally related barriers

IMGs reported experiencing some difficulty in adjusting to dyadic interactions with their patients in a new health care system; this reported difficulty even extended to those who had previously practiced in their home countries. Because of entrenched beliefs and developed skills, their earlier experience may actually have complicated some IMGs' initial adjustment to new physician–patient communication norms. IMGs stated that their communication abilities were stronger in their cultures of origin, in large measure because they understood the beliefs and behaviors of patients in “the same culture.” As Participant 4 explained about interacting with patients in his home country, “I can communicate better with them. I know what they want.” Several IMGs recognized that, once they moved into a culture that was new and unfamiliar to them, their own behaviors were perceived by those in that culture as “strange” and “different,” which, as Participant 7 said, made interactions “not very comfortable.” Several interpersonally related challenges emerged, in particular new dialects, a change in power relationships, and different expectations of rapport building.

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Unfamiliar dialect.

What changed for these IMGs was the type of English in which they had to communicate. Most reported having had extensive formal training in the English language; however, the overall U.S. dialect, and particularly the regional dialect in southern Appalachia, seemed to present challenges in their interactions with patients. Even before entering their residency program in southern Appalachia, a few IMGs identified the U.S. vernacular language as a barrier in physician–patient interactions. For example, Participant 11 explained that, during the Clinical Skills Assessment, she had to evaluate a patient who was clinically obese; the participant asked the patient if she had “tried anything” to address weight loss. The resident continued in explaining her response to the patient, “Somebody who has not lived here, how would you expect that person to know what Jenny Craig is and the Atkins Diet is or what the South Beach Diet is?”

Several IMGs stated that they had previously experienced communication barriers related to colloquial language use; these challenges seemed to be magnified by the regional dialects encountered in their residency programs. For example, even though Participant 4 had undertaken U.S.-based language training, he still experienced difficulties on arriving in southern Appalachia: “My challenge was to understand the Southeastern dialect. It was very difficult. The first week was a nightmare.”

Regional dialects were frequently cited as barriers in physician–patient communication. As Participant 9 explained, “[A]t first, it was just nasty. They [patients] just didn't like me and I … didn't like them because I could not communicate.” In addition, Participant 2 stated, “I learned my English just from a book. When I first came here, the first couple of months, I had a problem understanding.”

At the same time, participants indicated overall that their speaking standard (formal) English as a second language was not a communication barrier. Rather, what they did cite as a barrier was their patients' spoken dialect, including the colloquial expressions and accents unique to this region of the United States. In fact, only 3 of the 12 participants stated that they would like additional English-language training, but those participants were mostly concerned about interacting in “informal” English. Regionally unique expressions complicated physician–patient encounters, apparently requiring many residents to negotiate even more to achieve understanding. For example, Participant 4 recounted a conversation with a female patient who asked about her test results: “How are my testes?” [the patient asked]. I say, “What is that? No, no—you mean [to ask what are your tests], what is the report? You want to know about your test [emphasis added], not testes, because you are a female.”

A few IMGs identified their own dialect as a source of problematic communication with their patients. Participant 9 said, “Understanding ‘hillbillies’ is really hard,” but he also admitted that his patients initially did not like him because they could not understand him. Participant 2 explicitly stated that some patients “have a problem understanding my accent.” Likewise, Participant 1 offered, “I have an accent, and they have an accent, and at first I had to slow down and [try] to figure out what they're saying. There [are] a lot of colloquial terms for this area, [and] I don't know what some mean.”

What may be of particular importance in these findings is the fact that that most IMGs seemed to focus on the patients' regional dialect as being the source of problematic communication. For example, although Participant 1 first talks (above) as if both parties are contributing to the challenge, she almost immediately switches back to focus on the patients' language. Overall, what was lacking was an explicitly stated recognition by most IMGs that their dialect also may pose a problem for patients, which underscores existing arguments that medical education must emphasize the development of analytic skills.8 That is, physicians working across diverse populations must be able to gather relevant information and analyze it critically, including information on how both their and their patients' dialects may affect the medical encounter.

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Physician–patient power dynamic.

A second element that emerged in this study involved power differentials in the physician–patient relationship, which at times served as a source of problematic communication. As Participant 3 explained, physician–patient relationships in Eastern cultures are “completely different” from those in Western cultures. Most of the participants described coming from, and being trained in, cultures in which physicians were regarded with a great deal of respect, and the physician–patient relationship was more vertical—that is, the physician had the authority in the relationship and, therefore, made the decisions. Several IMGs reported that patients in their cultures of origin believed that physicians were godlike. As Participant 8 said, “They actually treat us as God. The people, the general population, would treat what [physicians] say as the last word.”

Other IMGs described patients in their cultures of origin as being “uneducated,” which, in the words of Participant 3, requires physicians to “be a little strong” when telling patients what they need to do. In essence, several IMGs described using more of a “tell” approach with patients in their cultures of origin than is acceptable here. That is, physicians were used to dictating treatments to patients with little explanation. This approach may have been used because, as Participant 7 said, patients in certain cultures “don't argue with their doctors, and whatever the doctor says is the word.” Yet, IMGs' perceptions of patients in their cultures of origin also may have been influenced by the socioeconomic status of the patients with whom they worked. For example, Participants 5, 7, 9, and 11 briefly suggested that educated, middle-class or well-to-do patients in their cultures of origin tended to be less passive and less compliant than were uneducated, impoverished patients, and the latter group was the population with whom most of these IMGs apparently worked. Future research should consider the potential impact of socioeconomic status on perceived cross-cultural barriers in physician–patient encounters.

IMGs' descriptions of interactions with their patients in the southern Appalachian clinics suggested a power differential that contrasted with what they had experienced in their cultures of origin. Many IMGs reported providing their Appalachian patients with a greater amount of information and a greater degree of involvement in decision making than they would have provided to patients in their home cultures. For example, Participant 2 gave patients “more opportunity to talk” and “involved” them more in “decision making.” Several IMGs initially struggled with their Appalachian patients' expectations of a more horizontal physician–patient relationship, in which physicians share power, responsibility, decision making, and even talk-time with their patients. This expectation of a horizontal relationship may conflict with participants' clinical experiences in their cultures of origin. For example, Participant 1 mentioned several times that she had to work harder and be more cautious in her communications with her Appalachian patients than was necessary at home: “Back home, we could tell our patients anything. We talked to them [freely], and we're just so relaxed with each other. Here, you have to be careful about what you say.”

Participant 1 added that she had experienced “a bit of frustration” because her Appalachian patients would “take offense” at the frank talk she was used to with patients in her culture of origin. Most participants suggested that they had to change from using the “tell” approach they used in their cultures of origin to using an “explain” approach in the United States. That is, IMGs characterized their interactions with their new patients as largely involving discussion, negotiation, and explanation. Some participants seemed to partly attribute this new physician–patient power differential to the fact that their current patients had access to more education and information than did their patients at home. Participant 2 reported that he had to “explain all the details” to his U.S. patients, stating that the “cultural difference” was due to the fact that “the knowledge of the patient about the disease is higher than” that of patients in his culture of origin. Participant 8, from a separate residency program, stated that the “medicine seeking” among his current patients was quite different from how patients interacted with physicians in his home country. He suggested that his U.S. patients were more demanding, stating that they felt “entitled,” coming into appointments saying, “‘I need this. I know what I need.’ They know exactly, ‘This medicine is what I need.’” In fact, several participants reported being caught off-guard by the assertiveness of their U.S. patients when it came to direct requests for specific medications.

Overall, IMGs described mixed reactions regarding their Appalachian patients' involvement in their own medical care. Participant 7 said, “The good thing is [that] the [U.S.] patient knows what is happening to him. This is a very good thing. In my country, most of the time, the patient didn't want to know [the diagnosis]. They just wanted to get better.”

However, Participant 6 stated that he did not think it was good for his current patients to have access to so much medical information (e.g., on the Internet) because “they don't have the basic knowledge” to evaluate the information. He added that patients “keep asking more questions because of the information available to them.”

In the end, most of the IMGs suggested that changes in power dynamics could complicate their interpersonal encounters with their Appalachian patients. For some, this difference seemed to produce frustration, because they had to adjust from more vertical physician–patient encounters to more horizontal, power-sharing interactions. This finding might be explained, in part, by recent research into the association of cultural dimensions with medical communication.10 Specifically, cultural values, beliefs, and programming seem to have some impact on how much information the physician provides the patient and on how much emphasis the physician places on rapport building. The latter issue also emerged as a finding in this study, as will be discussed below.

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Different rapport-building expectations.

A third interpersonally related barrier that emerged was the change in cultural expectations of rapport building that several IMGs reported. They described having to change their interaction and relationship-building styles on entering their U.S. residency programs. For instance, Participant 2 explained that he connected with patients in his culture of origin and the United States in different ways. Because of the “cultural difference,” he communicated “emotional support” in a manner suited to the patient's “own culture.” Furthermore, with his Appalachian patients, he would “summarize” their conversation to show his patients that he was “really listening,” but he said he did not use that technique in the “old country.” Participant 1 similarly noted that “tradition” allowed her to have a strong relationship with patients in her culture of origin and that, because of the respect for physicians there, she could be more “open” with those patients. However, on entering the U.S. residency program, she found that she had to be “so different in [her] approach” with her Appalachian patients. Participant 3, from a different cultural background and a separate residency program, also reported changing her interaction styles when it came to connecting with her Appalachian patients:

Here I try to be more friendly, more approachable. When you enter the room, say who you are and shake hands. Say, “Good morning,” and ask, “How are you doing today?” Not just barging in and saying, “What's wrong with you?” I have seen my colleagues doing that in India.

Most IMGs stated that they came from programs in which physician–patient communication emphasized, first, gathering information to make a diagnosis; afterward, the emphasis was generally on telling the patient what to do in terms of treatment. Indeed, many of their descriptions of their medical education experiences indicate that cultural norms interacted with structural constraints. For example, Participant 11 described having previously trained in her country in a hospital with open wards that had “many beds” and that she conducted medical interviews in a crowded, nearly public setting. This experience may explain, in part, why, during her initial videotaped interactions with SPs in her U.S. residency program, she thought she was supposed to simply gather a “proper history and come up with the proper decision” about the diagnosis. Addressing patient emotions and connecting with the individual patient did not seem to figure into her framework of communicating with patients. These findings point to the possibility that an attempt to form individual relationships with their patients is a luxury for some physicians. As Participant 12 stated, her previous medical experiences had been in a hospital where physicians were separated from waiting patients by nothing more than a curtain; therefore, as she explained, there was little opportunity to stand, shake hands, and chat.

Participant 12's description may help elucidate the abrupt behavior that Participant 3 reported above. For many of this study's participants, structural constraints, including treating large numbers of patients in a short amount of time, seemed to interact with broader cultural norms about what physician–patient rapport looks like and how it develops.

Whereas there may be “consensus” among U.S.-born and -educated providers about techniques for building a relationship with patients,23 what we found among several of the study participants was the perception that the rapport-building efforts expected in their residency programs were artificial and impractical. Participant 9 characterized current techniques for developing rapport as “forced,” adding, “Building rapport, I do that on my own. I see rapport built up over time.” This resident also expressed frustration because he disagreed with his residency program's emphasis on certain rapport-building techniques (e.g., allowing the patient to set the agenda): “There are patients that will talk all about themselves and go on and on and on, and you don't have time. I mean, [the] reality is that we don't have an hour to spend with the patient.”

There were some exceptions regarding this finding. For example, a couple of participants indicated that their medical education had provided training in connecting with and building a relationship with patients. Participant 6 reported that rapport-building training in his culture of origin lasted “just a few weeks” and occurred late in his medical education, when he observed an attending physician who “started trying to show us how to interact with the patients.” He added, “You could do it [chat with patients] if you like. They [instructors] would not object to that. If you wanted to do it, [chatting] was an optional thing.”

In the end, however, the programming in their own culture,9 especially during their education, may have affected the IMGs' willingness to accept new notions of rapport building. Participant 10 reported that, as a consequence of their medical education, many of her colleagues from her culture of origin had gained information but not “empathy.” Most IMGs seemed to recognize that connecting with their Appalachian patients required approaches different from those they used in their cultures of origin; however, there apparently also was lingering resistance. In fact, there seemed to be a general sense that participants felt caught off-guard by the move toward a more focused and facilitatory style of rapport building. Ultimately, the challenge that IMGs encounter in rapport building may come from their definition of “rapport.” Several suggested that they initially saw their focus as being on gathering information and arriving at a diagnosis and treatment plan and that building rapport with their patients was a naturally occurring development over time. Most of these participants came from cultures where physicians were authority figures, and several participants were also trained in health care settings where they had to be problem-focused from the start of their patient encounters because of the realities of their health care system. Those facts and experiences seem to have translated into resistance on the part of some IMGs to new approaches to developing connections with their patients.

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Discussion

Like many groups of IMGs, the participants in this study were a diverse group of physicians from several countries. Consequently, the problems they identified in adapting to the U.S. culture varied, although common themes emerged; we attempted to identify both commonalities and divergences. The interviews we conducted yielded several important findings.

First, barriers to cross-cultural physician–patient interactions arguably developed even before these participants began to practice in the United States. The interview data allowed us to identify education-related barriers. Just as Searight and Gafford16 had found a lack of education in psychiatry and behavioral science among their study's IMG participants, we found that the previous medical education of many of our IMGs largely focused on the “hard” sciences. Moreover, there was a distinct lack of education in physician–patient communication. Of course, there were exceptions, which indicated that some international medical schools are placing a stronger emphasis on communication skills. Second, IMGs also reported interpersonally related barriers to physician–patient communication. Specifically, they identified challenges with dyadic interactions due to encountering new dialects, changes in physician–patient power, and different expectations with regard to physician–patient rapport building when they began to adapt to their Appalachian patients.

This report is not intended to essentialize all IMGs' experiences or to compile a neat, compact list of cultural attributes, both of which have understandably been criticized in cross-cultural medical communication research.8 Rather, we attempted to explore IMGs' perceptions of their communication with patients, including the perceived and actual barriers to that communication. As described by Lincoln and Guba,20 a perception is a “partial, incomplete view of something that is nevertheless real.” Consequently, this study was not intended to capture the reality of all IMGs' communication barriers with their Appalachian patients. If we had interviewed other populations, such as residency program faculty, patients, or U.S.-born and -educated residents, our study would likely yield different findings. However, in our efforts to understand the complex, multidimensional nature of physician–patient communication, we must explore the perceptions of IMGs to gain an understanding of their experiences and worldviews.

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Implications for IMG training in communication

The findings of this study seem to underscore previous calls to look beyond language differences as the Western health care system continues to diversify. Specifically, some medical researchers and practitioners remind us that language is not “the main feature of belonging to an ethnic group.”13 During orientation, training, and intervention efforts, residency programs must also focus on the latent features of cultures, such as the differences in norms, values, beliefs, attitudes, and expectations.13 Whereas language—or, more specifically, dialect, vernacular, and accent—was one barrier to communication that emerged in this study, new and unfamiliar cultural norms and expectations were more often cited by these IMGs as sources of problematic communication with patients. Perhaps more important, the participants at times had difficulty explaining the complications they were facing, often broadly and generically attributing those complications to “cultural differences.”

Previous medical communication scholarship reminds us that health care encounters must be seen as a partnership, with providers and patients serving as teachers and learners of relevant “ethnocultural and social circumstances.”8 Therefore, orientation, training, and intervention efforts must also stress that both parties—the physician and the patient—are cultural beings who bring to each encounter their own cultural backgrounds, including experiences, values, beliefs, skills, and attitudes. Some urge that we encourage thinking beyond narrow cultural paradigms by having medical students create “mini-ethnographies” of patients (including relevant cultural background, migratory histories, and health information). Such pedagogical tools could help residents consider the impact of their personal and culturally programmed experiences, values, and beliefs on their medical encounters with patients. This sort of reflexive writing18 may be especially helpful for those who have experienced a previous lack of communication training during their medical education. Although it is important that we do not generalize from the findings of this study, the experiences and perceptions of the study participants seem to underscore the need to give residents opportunities to reflect on how their own backgrounds and cultural influences may affect their own communication with patients. In writing these mini-ethnographies, IMGs may begin with more narrow views of a culture's association with communication, but, over time and with program-level and peer encouragement, they may develop insight into the association between culture and medical communication.

IMGs enter a U.S. culture in which patients may share general beliefs such as individualism and sharing power with authority. As recent studies have found, broad cultural orientations do seem to affect medical communication, including perceptions of appropriateness about sharing information, flexibility of physician–patient roles, and attention to rapport building.10 Just as do all humans, these IMGs have spent their lives being influenced by their cultures. A number of participants in our study indicated that they had been raised and educated in cultures that programmed patients to elevate physicians to a godlike status, programmed physicians to be directive during medical interviews, and programmed both physicians and patients to see the physician as having the power to decide the fates of patients without being questioned or challenged.

In contrast with such experiences, interactive, relationship-centered models in particular may pose several problems for IMGs.8,23 These models challenge physicians to turn from treating the medical encounter as a time for simply taking a history, making decisions, and telling the patient what to do to treating it as a time of greater two-way communication with the patient. Thus, residents who lack training in communication are expected to learn new skills, including information analysis skills8 and the ability to explore patients' perspectives, ideas, concerns, and expectations.23 Perhaps an even greater challenge is the attitudinal shift embedded in such interactive, relationally driven models. They require that residents value their patients' perspectives as much as they value their own diagnostic interviewing and therapeutic interventions.

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Communication training preferences

Because of the multilayered barriers that emerged in our study, we believe that communication interventions addressing IMGs' perceived and actual physician–patient communication barriers should also be multilayered. During our interviews, IMGs mentioned three particular communication training preferences. The first of these preferences had to do with videotaping of interactions with SPs. Whereas some IMGs, on entering their residency programs, expressed confusion about or resistance to videotaping these interactions, most came to view the recordings as being helpful to their adjustment to a new set of expectations. These videotaped encounters became even more helpful because of subsequent conversations with sensitive and caring faculty evaluators who carefully explained the new communication expectations while emphasizing an IMG's specific strengths and areas of improvement. At least according to many of the IMGs that we interviewed for this study, residency programs should clearly and carefully explain the purpose of working with SPs, especially because some IMGs may come from medical schools that did not use this approach. Moreover, faculty evaluators should have a basic understanding of respected and varied cultural communication models8–10 to help contextualize IMGs' existing communication skills and norms, as well as the skills and norms expected by the IMGs' host culture. Ultimately, practicing with SPs from the host culture could be valuable to help IMGs adjust to new communication norms, assess complex and multidimensional problems, and monitor progress.

The second preference that IMGs mentioned had to do with working with SPs during a special IMG-only orientation before beginning the residency program. The IMGs expressed an interest in participating in an orientation that went beyond an overview of the residency program. They wanted an opportunity to begin understanding the cultural norms, beliefs, and values of their host culture and their residency program, as they would affect communication expectations.

For their third preference, the vast majority of participants indicated that they wanted to continue learning through observation of their peers and attending physicians. Given that most IMGs cited observation as their primary means for communication training in their non-U.S. medical education, this technique may be a familiar and comfortable one, in addition to being an effective one.

These three IMG-suggested approaches may be especially helpful when coupled with other, more prescriptive and formal techniques. For some IMGs, intense assessment of and intervention around language and accent may be appropriate. One important finding of this study was that IMGs generally did not think that their skills in speaking standard (formal) English served as a barrier to their interactions with patients; rather, it was the informal regional dialect that seemed to be a perceived source of problematic communication. In addition, whereas the majority identified their patients' dialect as a barrier, few cited their own dialects as a source of problematic communication with patients. Thus, some IMGs may need assistance in understanding the barriers that are related to their English-speaking skills. Interventions in this area may require an IMG to spend time (outside of the medical office) interacting in the local vernacular, rather than returning home to a spouse, friend, or family members who may prefer to speak in their primary language or who may also struggle with unfamiliar dialects.

Some other tools that may help address these multilayered challenges include a set of noontime conferences, workshops, or communication modules such as DOC.COM (available at: [http://www.aachonline.org]) or GME-Today (available at: [http://www.mebn.net/templates/mebn/gme_publications.htm]). In addition, the Educational Commission for Foreign Medical Graduates' Web site (www.ecfmg.org/acculturation) offers suggestions for helping IMGs make the transition to being effective residents. These options include seminars or workshops on understanding the differences between the U.S. health care system and other countries' systems.

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Study limitations and implications for future research

The findings presented here must be placed in the context of several important limitations of the study. First, the IMGs interviewed for this study rarely reported that their formal English-speaking skill was a barrier to their communication with patients; instead, they identified the barrier as being the informal, colloquial use of English among their southern Appalachian patients. Yet, informal observations of and discussions with patients, peers, and faculty suggest that there may, indeed, be a more significant problem than was captured in this study. In our Department of Family Medicine, it has happened that frustrated patients request a change of physician because they are unable to understand the IMG; however, the IMG may not know about this request.

Second, study participants frequently noted their problems with understanding regional dialects, which can be a challenge even to those from elsewhere in the United States or from Canada. It has not been established whether the southern Appalachian dialect is any more problematic than other regional dialects. Future research should include multisite studies to explore whether various regional dialects and local idioms throughout the United States challenge IMGs. Such research may help program directors and residency faculty identify problematic dialectic encounters for incoming residents.

Third, and surprising to us, IMGs generally did not report that nonverbal communication, such as that around different cultural norms of eye contact, use of physical space, and touch, challenged their interactions with patients, even though such differences continue to be reported in cross-cultural medical communication research.10 Again, however, informal observations within the three family medicine residency programs suggested that this concern may not have been captured during the interviews. Moreover, it may be telling that the IMGs interviewed did not perceive these differences as barriers to their communication with patients, perhaps as a result of the IMGs' lack of exposure to human communication education and research.

Finally, our study only hinted at the interplay between physicians' and patients' cultural background and socioeconomic status. Future research should examine the role socioeconomic status plays in physician–patient communication, both in the physician's culture of origin and host culture. Such issues were beyond the scope of this study, but other research has found that the wealth of a nation, in addition to broad cultural characteristics, seems to have an impact on medical communication.10

Because of the qualitative nature of this study, there is no intent to extrapolate the findings to other IMG populations or residency programs. Data collection was limited to 12 interviewees, and the IMGs' communication-related experiences were captured in single interviews. Because most of the participants had never formally studied communication as a discipline, several had problems citing specific communication-related “cultural differences” during the interview. They acknowledged that differences existed, but they were hard-pressed to provide a comparative analysis of their cultures of origin and the U.S. culture. Furthermore, it must be underscored that only the residents were interviewed about their perceptions of existing barriers. Future research should incorporate a comparative analysis of the perceptions of residents, faculty, medical staff, and, perhaps most important, patients concerning IMG–patient communication barriers.

Given these study constraints, the personal narratives and resonating disclosures offered by the participants can direct future inquiries about real and perceived IMG–patient communication barriers. The participants were interviewed across various program years. A longitudinal study could be useful to further describe acculturation-related communication barriers and to discover other unexamined cross-cultural challenges and rewards. Such a longitudinal study also may better reveal regional, ethnic, and religious cultural differences and commonalities within and between IMG groups, whereas this study mainly captured similarities across cultural groups. In addition, the barriers to communication in urban and more demographically diverse residency sites are likely to identify factors that did not surface in this study. Still, this study offers IMGs' perspectives and experiences, thereby helping to provide a foundation for dialogue among IMGs, program directors, medical faculty, behavioral scientists, and patients, all in an effort to strengthen physician–patient interactions.

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Acknowledgments

The authors wish to thank Dr. Donald Rubin (the University of Georgia) for his invaluable advice during the formation and design of this project; Linda Bambino and Dr. Jignesh Shah, who, while at East Tennessee State University, gathered secondary research and assisted in data analysis; and the two reviewers whose comments helped strengthen this article.

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Disclaimer

This research was supported by a grant (RDC# 05-043m) from the East Tennessee State University Research Development Committee.

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