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Moving beyond the language barrier: The communication strategies used by international medical graduates in intercultural medical encounters
Patient Education and Counseling 84 (2011) 98–104
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Medical Education
Moving beyond the language barrier: The communication strategies used by international medical graduates in intercultural medical encounters Parul Jain *, Janice L. Krieger School of Communication, The Ohio State University, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 August 2009 Received in revised form 11 June 2010 Accepted 16 June 2010
Objective: To understand the communication strategies international medical graduates use in medical interactions to overcome language and cultural barriers. Methods: In-depth interviews were conducted with 12 international physicians completing their residency training in internal medicine in a large hospital in Midwestern Ohio. The interview explored (a) barriers participants encountered while communicating with their patients regarding language, affect, and culture, and (b) communication convergence strategies used to make the interaction meaningful. Results: International physicians use multiple convergence strategies when interacting with their patients to account for the intercultural and intergroup differences, including repeating information, changing speaking styles, and using non-verbal communication. Practice implications: Understanding barriers to communication faced by international physicians and recognizing accommodation strategies they employ in the interaction could help in training of future international doctors who come to the U.S. to practice medicine. Early intervention could reduce the time international physicians spend navigating through the system and trying to learn by experimenting with different strategies which will allow these physicians to devote more time to patient care. We recommend developing a training manual that is instructive of the socio-cultural practices of the region where international physician will start practicing medicine. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: International medical graduates Physician patient communication Foreign doctors Communication accommodation Convergence Communication challenges Communication barriers Communication strategies
1. Introduction Effective communication skills are essential to a successful physician–patient interaction [1,2]. Culture has an important, but often understudied, influence on medical encounters [3]. Patients report more satisfaction, participation, and positive affect when interacting with a physician from their same ethnic/racial group [4–6]. This suggests shared beliefs are an important aspect of provider–patient relationships that likely influence patient outcomes [4–6]. Furthermore, differences in race, ethnicity, and other aspects of culture are significant factors in determining the impact of communication skills training programs on patient participation [1,4]. To date, research that has considered the influence of culture on physician–patient communication has focused on interactions between U.S. American physicians and foreign-born patients [7,8]. This exclusive focus has inhibited academic understanding of intercultural medical interactions between foreign-born physicians and U.S. American patients.
* Corresponding author. Tel.: +1 614 292 3400. E-mail address: [email protected] (P. Jain). 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.06.022
One in every four physicians in the United States is an international medical graduate (IMGs hereafter) and almost 30% of IMGs are involved in providing care in various primary care specialties [9]. Many IMGs receive their medical training in countries where it is common for physicians to exert a great deal of control, authority, and power in the medical interaction and rely on paternalistic mode of communication as compared to the United States where physicians have been found to employ a wide range of communication styles [10–12]. Furthermore, many IMG physicians complete their undergraduate medical education in countries where models of medicine practice are very different from that in the U.S. For example, a recent study focused on developing an acculturation curriculum for IMG physicians notes that foreign residents find it difficult to understand the concepts of patient involvement and patient autonomy and have limited to no experience with physician–patient communication skills training [10–12]. Although previous research has identified the communication challenges that many IMGs face [10–17], there is no previous research that describes what communication strategies they use to overcome these challenges. Thus, the purpose of this study is to explore the communication strategies IMG physicians use to adjust to interpersonal and socio-cultural differences they encounter when practicing medicine in the U.S.
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1.1. Communication strategies used in medical interactions Medical interactions are considered to be an intergroup communication context because the behaviors of both physicians and patients are governed by the norms attached to their role in the encounter [18]. The intergroup nature of the interaction may be even more salient in intercultural medical situations because of differences in language or physical appearance. One theoretical perspective for understanding how intergroup differences are managed in interactions is Communication Accommodation Theory (CAT) [19,20]. One of the core tenets of CAT is that people will adjust their communication style in intergroup interactions. Convergence is a form of adjustment in which person tries to minimize the differences in communication between themselves and others. For example, a physician who avoids using medical jargon with a patient would be engaging in convergence. The ability to successfully converge is associated with greater patient satisfaction [19]. Thus, it is particularly important to understand the communication strategies used by IMGs who have the difficult task of negotiating medical interactions that are intercultural as well as intergroup. 1.2. Negotiating communication challenges in physician–patient interaction There are a number of communication challenges inherent in intercultural provider–patient interactions, especially when the physician is foreign-born. The three most common sources of difficulty for IMGs include language, emotion, and cultural norms for medical interaction [8,10–14,21]. International physicians, like their U.S. counterparts, undergo rigorous evaluation of their English proficiency and communication skills before getting accepted into the residency programs. To enter any residency program in the U.S., both IMG and USMG physicians are expected to fulfill many requirements including different steps of United States Medical Licensing (USMLE) examination. USMLE step 2 includes a subcomponent of the Clinical Skills (CS) exam in which standardized patients evaluate IMGs on three main aspects: integrated clinical encounter (ICE), communication and interpersonal skills, and English proficiency. However, it is possible to score well on this exam but IMGs may experience difficulty with advanced aspects of language use including colloquialisms, idioms, vernacular terms, accents, regional dialects, voice inflection, and body language [13,21,22]. As would be expected, problems communicating with patients are most pronounced among physicians whose primary language is not English [14,23]. For example, IMGs report that language problems can make it difficult to ask questions about a patient’s medical history in a way that the patient can understand [24]. A second challenge to IMGs is managing affect in medical interaction. Non-verbal communication plays a significant role in emotional expressiveness and the maintenance of relationshipcentered patient care [25]. A physician’s ability to competently manage affect has numerous benefits to patients, such as improved information exchange, greater participation in decision-making, and increased efficacy to engage in preventive care [26]. However, cultures differ greatly in what emotional displays are considered appropriate in the medical context, as well as what type of comforting a physician should provide. Previous research has suggested that norms for experiencing emotions are different in collectivist and individualistic societies [27]. Since many IMGs come from collectivist cultures such as India, Pakistan, and China [9], they may handle emotions quite differently than would be expected by patients in comparatively individualistic societies such as the U.S. All aspects of medical interaction are guided by norms and expectations, which are shaped by culturally acquired attitudes and beliefs [8]. To illustrate, norms for medical privacy in the U.S.
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dictate that physicians reveal medical information directly to patients. However, a survey of 90 doctors from 20 countries found that physicians from countries outside the U.S. feel most comfortable giving the diagnosis of a life-threatening illness (e. g., cancer) to the family of the patient [28]. As with other common communication difficulties IMGs face, it is unknown to what extent they adjust to the various cultural norms of patients in the U.S. 1.3. Objectives Previous research has identified the linguistic, affective, and cultural difficulties IMG physicians encounter when practicing in the U.S. What still remains to be explored, however, is the ways in which IMGs try to adapt their communication to overcome these barriers. Thus, the following general research question is proposed: RQ: What communication strategies do IMG physicians use to minimize differences in language, emotion, and culture when communicating with their US born patients? 2. Method 2.1. Participants Participants in the study were internal medicine residents in a large teaching hospital in Midwestern U.S. Twelve participants, recruited using snowball sampling, completed a voluntary interview and a brief survey exploring physician demographics. Participants ranged in age from 28 to 42 years (M = 32.41, SD = 3.89). Most of the participants were male (n = 8). Participants had lived in the U.S. between 1 and 9 years (M = 4.41, SD = 2.25) and were from six different countries. Six out of 12 interviewees were originally from India, 2 were from China, and the remaining 4 came from the following countries: Jordan, Lebanon, Nigeria, and Philippines. At the time of the interview, five interviewees were in their first year of residency training in the U.S., four were in their second year and three participants were in third year of residency. 2.2. Data collection The first author conducted face-to-face interviews with 12 residents completing their residency at an internal medicine residency program in a hospital in Midwestern part of the U.S. The interviews were conducted between December 2007 and May 2008. Interviews were appropriate for addressing the research question in this study because they allowed participants the opportunity to narrate their experiences and reflect on how they accommodate differences that they experience in the interaction situations [10,12,24,29,30]. Data saturation occurred after 12 interviews, meaning that no new information or themes emerged from data analysis [29,30]. Interviews were conducted in a public location outside the hospital to ensure participant confidentiality and to provide them with a setting where they could comfortably share their opinions. The interviews were audio-recorded for transcription with the consent of participants and lasted 35 min on average (range of 18– 52 min). We used previous research [13,21] to create semistructured interview guide which served mainly as a framework to make sure all the themes that we wanted to explore were covered with each respondent (Table 1). The interviews explored basic themes such as most difficult issues that IMG physicians encounter while interacting with patients, communication strategies they adopt to navigate through those issues, strategies for adjustments to life as a resident, and suggestions for improving the residency experiences for IMG physicians. Participants in the study provided care in both in-hospital settings and office settings and thus recounted both types of experiences.
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100 Table 1 Interview guide.
1. Describe what it is like to be a resident in (name of hospital). Could you elaborate on some of the experiences that you find memorable during the residency period? Prompts: general struggles, how are these different for you because you an international medical graduate? Are there specific challenges that IMGs face compared to other residents? How is the experience similar/different that what you expected? 2. Describe the process of adjusting to living in the U.S.? Working in the U.S.? Prompts: How did you manage the things during the first few months of the residency (explore about support systems, friends, and mentor)? How did you learn to navigate the hospital system? 3. How is being a doctor in the US different from being a doctor in your home country? 4. In ways does being an IMG influence how you communicate with patients? In what ways does it influence how patients communicate with you? 5. What do you think is the biggest problem when you communicate with the patients? Prompts: Probe on trust, adherence, language, culture. What strategies have you found to be helpful that make you, as well as your patient, comfortable during the medical interaction? 6. What type of things you do to help patients understand you (prompts: repeat, change voice inflections). Are there times when you don’t use those strategies that you just described? Could you elaborate on certain instances when you did not knowingly or unknowingly used the abovementioned strategies? 7. In what ways do you change the way you speak or behave to be more like your patient? What are the ways that you adopt so that patients could identify with you and become more comfortable with you during the discussion? 8. To what extent would you have benefited from a training program focusing on communication with patients? If there is a training program, in your opinion what are some of the main issues that such a program should address? 9. What are some of the most important issues that need to be addressed in order to improve IMGs experiences in the U.S.? 10. Is there anything else that you would like to share regarding healthcare system in the United States that has potential implications on your interaction with the patients?
2.3. Data analysis A paid transcriptionist transcribed each audio-recorded interview verbatim. All participant identifiers were then removed and replaced by a code number. Using grounded theory methodology, both the authors carefully read and open coded each of the 12 transcripts individually, focusing on barriers to communication with patients and the communication strategies used to overcome these barriers. Next, both the authors reexamined the open codes to determine how they related to one another, a process referred to as axial coding [29,30]. Finally, the first author reread all the transcripts and finalized coding, focusing on collapsing codes to create themes. We employed several steps to ensure internal validity and rigor of the analysis. First, we also employed triangulation within method by asking questions in different ways that explored the same concept [29,30]. Second, we conducted member checks. At the end of each interview, the interviewer summarized her notes for the participants to check for accuracy. Third, we engaged in peer debriefing by sharing our finding with an IMG physician who was not part of the study. 3. Results 3.1. Language We sought to understand language related difficulties encountered by IMG physicians, the strategies they used to overcome these difficulties, and if the strategies were indicative of communication convergence. Language was conceptualized as verbal and non-verbal communication used in face-to-face interaction with patients. Consolidation of open codes revealed that IMG doctors encountered differences in both linguistic and paralinguistic issues, as illustrated by Table 2. Consistent with previous research [16,21], about one-fourth of the interviewees found it difficult to understand the English words used by the patients. As one physician noted: The spoken English we don’t know very well and how to express. In your mind you think you know this well but actually to express or to say it or to interact with the patient is different. That is a big challenge how you can express yourself and your clinical judgment well to the patient.’’ (A physician from India) More commonly, IMGs had difficulty with more subtle aspects of language, such as paralinguistic cues, pronunciation, and use of colloquialism. Paralinguistic cues were coded as references to
accents, tone, voice inflection, and pace. Pronunciation was conceptualized as the extent to which IMG doctors perceived that their patients had difficulty with the manner in which they uttered specific words. Colloquial language usage referred to the use of slang words, idioms, and other popular lingo. Most interviewees reported difficulties with either one or all of these factors. A third year resident from India explained, ‘‘Our English is the British English and the American English is different but after you come here you start to learn how people pronounce things.’’ Many IMG physicians indicated a number of accommodation strategies indicative of convergence to manage differences in language between them and their patients. Some strategies indicated by the participants were learning to pronounce words in usual North American manner and trying to understand and learn meanings of slang words with the help of media and their North American friends. Many of the doctors noted that they also tried to accommodate for differences in accents by either repeating their sentences or by changing the pace or volume of speech. A third year IMG resident from the Middle East acknowledged that he usually spoke quickly, ‘‘I usually repeat everything I say because I speak too fast, so I make sure my patients understand what I say. I try to make 100% sure that my patients understand what I said.’’ In addition to checking with patients if they understood what was said, participants also tried to compensate for linguistic differences through the use of non-verbal gestures. IMGs frequently reported making a conscious effort to maintain good eye contact, have a friendly disposition, smile, and vocally convey warmth and care. The following quote from one participant illustrates this: ‘‘my strength is trying to be a good communicator and even though my English is not perfect but my eye contact is very good.’’ Although accents did contribute to difficulties in the physician– patient interaction, IMG physicians did not perceive this as a hindrance. One physician, in particular, felt her accent positively contributed to interactions with patients. She explained that her
Table 2 Convergence strategies and barriers to convergence. Convergence strategies Verbal (e.g. repetition) Non-verbal (e.g. eye contact) Emotions (e.g. supportive touch) Barriers to convergence Accent (e.g. British pronunciation) Vocabulary (e.g. difficulty understanding acronyms, slang words) Power Conversational norms Medical information disclosure (e.g. family versus patient)s
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patients were often intrigued by her accent, which usually led to questions about her origin. In this way, even though differences in accent sometimes created initial distance between patient and their provider, in some instances these differences also facilitated the process of building rapport because they led to initiation of informal conversation between patient and provider before provider initiated clinical talk. It should be noted that we only interviewed IMG physicians in this study and not the patients. It is the perception of IMG physicians that differences in their accent do not pose a significant barrier. Future studies should seek patient’s perspectives to understand if different accents of IMGs do pose difficulties for the patients. Thus linguistically our data is indicative of convergent accommodation strategies used by IMG physicians to account for differences. 3.2. Handling emotions The issue of handling emotions was conceptualized by asking IMG physicians how they managed patient despair and crying, patient expressed fear and other negative emotions, and general support needed by patients in moments of uncertainty and distress. IMG physicians reported using both verbal and non-verbal strategies for emotion management. Non-verbal strategies included empathetic gestures such as supportive touch, eye contact, and respectful silence. Verbal strategies included attempts to calm and reassure the patient. One physician noted that, Whenever a patient starts to experience immense negative emotions, I try to listen actively, giving my full attention; once I feel that it is appropriate I start to comfort the patient verbally but I never say I can understand because no one but only the person undergoing the illness could understand the issue. (A physician from India) IMGs frequently associated emotions with disclosure of medical information, particularly delivering bad news. For most of the IMGs, delivering bad news to a patient is the responsibility of the family, not the physician. Thus, many of the physicians reported that they had to learn how to give patients bad news and how to handle the resulting emotions. This indicates communication convergence, because IMGs strove to adapt to the perceived cultural norms of their patients. One IMG gave the following advice for handling negative emotions, ‘‘. . . Try to be as understanding as you can and try not to interrupt him and try to be compassionate and apologize if you think that you made a mistake . . .’’ 3.3. Differences in norms related to medical interaction During the interview we also asked IMG physicians how they managed differences in cultural norms with respect to medical interaction. Data analysis revealed three sub-themes relating to conversational scripts, power, and medical information disclosure. 3.3.1. Conversational norms and scripts We found that in general, certain preformed expectations, scripts, and norms govern medical interviews just as they do any other interaction. To ease the patient anxiety and stress, physicians often talked about topics unrelated to the purpose of the medical visit, such as weather, sports, and holidays. Small talk gave both physician and the patient a chance to get acclimated in the interaction and reduces the anxiety from an otherwise tense environment. IMG physicians however reported that carrying out small talk was a key difficulty with their patients. One physician mentioned that he would try to talk about a local, professional football team to start the conversation. However, this convergent strategy would backfire when patients responded by talking about
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particular players because he possessed only superficial knowledge about the team that he learned specifically to help start conversations with patients, not out of personal interest. Other physicians expressed similar uncertainty about discussing American holidays, such as Halloween and Thanksgiving. Thus although physicians were trying to use convergent communication to accommodate for the difference between them and their patients, their efforts sometime led to more divergence. Another difficulty with conversational norms and scripts related to the use of abbreviations when working in medical teams to treat a patient. Most IMG interns interviewed in the study reported dissatisfaction with the use of abbreviations by medical teams because they are still not acculturated enough to learn the medical lingo. A first year resident recounted the following incident: Initially when I came here and when I started my residency, the first month was very hard for me in the sense that medically it was not hard, but there was the way they use short terms here like CBCs or like one of the word they say . . . what are the CMP? Let’s get a finger stick. What is finger stick? It was actually a finger stick with loopholes. So, these are like some quick terms like what was a CRIT which was hematocrit. So, some of the language this was a problem for me. 3.3.2. Power/patient-centered communication The second sub-theme that emerged consisted of comments made about power dynamics in the physician–patient interaction. Power was conceptualized in this study as the distribution of control and authority in the interaction. Although no IMG physician explicitly stated that egalitarian relationship between the physician and the patient was unjust, there were still subtle and nuanced expressions that clearly delineated the concern and confusions that many IMG physicians experienced in terms of differences in patient care in the US from their home country. One physician from India very eloquently described the differences in communication patterns between the U.S. and his home country and the associated surprise and confusion that might be encountered while first starting the medical practice in the U.S. He stated, ‘‘I think in India physicians think they know what is best for the patient; here physicians take into account the patients’ opinion as well.’’ A first year intern from a Middle Eastern country commented, ‘‘Here the patient has to know everything on his disease, our country is different.’’ Most physicians noted that they converged to accommodate for power differences between them and their patients by providing patients a chance to be actively involved in their treatment. Some also indicated that convergence was because of the norms and expectations by U.S. patients and the U.S. medical system and not just by their choice. 3.3.3. Medical information disclosure Medical information disclosure was conceptualized as to whom the information related to the disease will be disclosed – the patient or the family. In many countries outside the U.S. and specifically in many collectivist cultures, most of the disease and prognosis-related information is given to the patient’s family and friends rather than the patients. In the U.S. however, due to confidentiality and malpractice reasons, information is delivered directly to the patient (or patient surrogate). Thus it is no surprise that most IMG physicians interviewed in the study found it difficult when it came to disclosure of sensitive information directly to the patient. One physician in his third year of residency noted: The one thing I don’t like about the American system is that you are telling the patient face-to-face that he is going to die, which is something that I don’t like. You are telling a dying patient that
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he only has a few weeks or months left, . . . [if I was the patient] I wouldn’t want to know that. Not only did physicians recognize that the norms for information disclosure were different, they also expressed feelings that the culture of medical system in the U.S. did not permit the physician enough power to make such decisions. For example, several physicians expressed the frustration with disclosing everything to the patient, and one physician referred to it as treating ‘‘patients as kings.’’ Thus, attempts at convergence in these interactions consisted of disclosing more information to a patient than the physician felt necessary and appropriate. Fig. 1. Different dimensions of IMG physician patient communication.
4. Discussion and conclusion 4.1. Discussion The IMG physicians in this study identified three major areas that posed a barrier to communicating effectively with patients namely language, affect related issues, and differences in cultural norms regarding medical interaction. These findings are consistent with the previous research on the barriers that IMGs must overcome [10–17,21]. This study contributes to the literature by identifying the strategies IMG physicians use to minimize the differences in communication during consultations with their U.S. patients. Our findings are unique in that, contrary to the assumption that accommodation is always desirable in medical interactions [18] we found instances where maintenance of differences was more beneficial to the interaction. For example, one of the IMG physicians in our interview noted that she maintains her accent during the conversation because she sees her accent as a potential conversation starter with the patient. Some IMG physicians in our study maintained cultural and linguistic differences between themselves and their patients, to maintain their own cultural identity, or for more pragmatic reasons, such as establishing rapport with patients. IMG physician interaction is such that it involves elements of intercultural, interpersonal, and intergroup communication because it involves communication between people of two different cultures who are also members of two distinct groups, but who communicate on a personal level. Most previous research assumes that IMG physicians try to move from intercultural to intergroup to interpersonal dimension of communication to relate to their patients. In other words, IMG physicians start at an intercultural communication position because of interaction between people of two different cultures [10]. In addition to having intercultural elements, IMG physician patient interaction can also be characterized as intergroup communication because physicians and patients have prescribed roles in medical interaction [18]. However, IMG physicians may attempt to deemphasize the traditional physician–patient power dynamics by accommodating to unique linguistics or behavioral characteristics of the patient. In treating the patient as an individual, and not solely as a member of the patient population or a representative of his/her culture, the interaction becomes one that can be characterized as interpersonal in nature (see Fig. 1). We are arguing that while the above holds true, there are many instances when IMG physicians do not want to accommodate and maintain the differences between them and their patients (as in the case of the physician who uses her usual accent). In such cases, these physicians use the intercultural form of communication to enhance interpersonal communication between them and their patients. That is, these physicians use differences in culture to facilitate interpersonal form of communication. Such strategies are not new in interaction situation involving people of different cultures. For example, Giles et al. found that
divergent strategies can be used to express attitudes and to bring meaning and understanding to the interaction [20]. They further note that delineation of differences in some form indicate to the opposite party that the interactant does not belong to the host culture which can be helpful in achieving mutual understanding. IMG physicians can take advantage of such expectations to initiate small talk with the patients and to build rapport and long-term relationship. Of course this strategy could also backfire, but perhaps patients might appreciate differences and use those to develop relationship with the IMG physician. IMG physicians might also use these differences to maintain their cultural identity. Moreover, they might find the maintenance of differences more pragmatic than converging as these differences sometimes provide them a way to start conversation with their patients. Therefore, the research needs to move beyond the overarching assumption that physicians should accommodate to their patients and explore how can physicians use differences between them and their patients to make the interaction more interpersonal and fruitful in nature. One of the strengths of this study is that it gives voice to a population that is very difficult to access and is significantly understudied, but who constitutes a critical component of the American healthcare system. To our knowledge, this is one of the first studies in the field of communication that tries to explore how IMG physicians in residency programs learn to respond to the communication barriers posed by their status as an international medical graduate. Specifically, this study extends previous research by not only describing the communication barriers of IMGs, but by also illuminating the strategies they use to overcome those barriers including both accommodation and maintenance. Although cultural differences do pose certain challenges for IMGs, it is important for the medical community to be aware of the ways that these physicians are using their background to benefit their practice. It should be noted that, this study relied on physicians from one healthcare system in one geographical region of the U.S. Thus, the findings of the study should not be generalized to all IMGs, but rather offer an initial step in understanding the accommodation strategies of international medical graduates practicing medicine in the U.S. We are not implying that our findings speak to the experiences of all the IMG physicians in the U.S. These findings offer an insight into a group of IMG physicians who came from different countries to practice medicine in a hospital in the U.S. Perhaps experiences of IMGs would differ depending upon the place they are completing their residency, composition of the patient population in that institution, as well as other factors. Future research on this topic should examine the influence of regional sub-cultures on communication strategies used by IMG physicians, and the perceptions of patients of IMG physicians. Another area of future research could be comparison of communication strategies used by IMGs who are in their residency practice in the U.S. to the IMG physicians who have experienced practicing medicine in the U.S. This study provides a rich understanding of the
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accommodation processes involved in intercultural exchange in medical interaction where physician rather than patient belongs to a cultural minority group. To our knowledge, previous research has not looked into how the accommodation processes work when power dynamics are shared in the interaction. For example, in terms of ethnic identity, IMG physicians typically belong to cultural minority groups; in other words groups that have been historically marginalized in the society. In the medical interaction, however, physicians are perceived to have more power than patients [18]. Therefore, by understanding how IMG physicians accommodate in interactions when they have high professional status but belong to a culturally marginalized group is important because perhaps some of the views expressed by these physicians regarding the feelings of the loss of power might have been derived by the feelings of lacking the power in the societal context. Moreover, by illustrating when IMG physicians do not accommodate in the interaction, we challenge the previous research and training guidelines for IMG physicians that emphasize acculturating IMGs to the culture of the U.S. so that they can communicate effectively with North American patients. This study provides a rich understanding of communication strategies used by IMG physicians when they start practicing medicine in the U.S. However, there were some limitations. For example, we did not explore the issues related to organizational differences that IMG physicians encounter when starting their medical practice in the U.S. The medical system in the U.S. is one of the most sophisticated but also extremely complicated entities. Thus it is important to explore the organizational accommodation processes that many IMG physicians might undergo when they start residency training in the U.S. because adjustment and acculturation into organizational climate could impact their performance and in turn impact the patient care that these physicians impart. Future research should also focus on the lifestyle differences that IMG physicians experience when they come to the U.S. for residency and impact of these differences on their work productivity and quality of medical care provided. Finally, we support the recommendations proposed by previous research that a rigorous, multifaceted training program be instituted that helps IMG physicians in acculturating to the U.S. work culture from different angles, especially when they first begin the residency training [11,16,17,24,31–33]. Although some institutions such as Albert Einstein Medical Center in Philadelphia already have a component of cultural competence built in their residency programs [34], such programs are far from the norm. We suggest that these training programs should be culturally sensitive to the needs of the IMGs so that they can also maintain their cultural identity. They should emphasize the strategies IMG physicians could use, including convergence, maintenance, and divergence that might be beneficial for these physicians. Finally, institutions can perhaps look at ways different than just training to help in transition of these physicians. For example IMG physicians could be matched up with a more experienced IMG physician from similar culture, standardized patients, or patient advocates who could help the IMG physicians in transition to the U.S. healthcare system. Increasing cultural sensitivity during the residency program will not only improve the quality of care provided by IMGs, but could also improve patients overall satisfaction with the medical system. 4.2. Conclusion In sum, this study enhanced our understanding of the issues that IMG physicians face in communicating with their patients and the strategies they adopt to accommodate those differences. These descriptions of how IMGs communicatively negotiate intercultural patient encounters form the groundwork for designing future
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studies to further explore this issue. Since IMG physicians bring different cultural perspectives to the patient care and the healthcare system, educating them regarding cultural norms of the U.S. in general, including regional norms associated with the location of their practice could help them in becoming more culturally sensitive. Furthermore, the new IMG residents might also benefit from learning about medical culture in the U.S., including physician– patient communication practices. This training might force them to reconsider the norms they might have regarding physician–patient relationship based on their medical education in their country of origin. Educating IMG physicians regarding the norms of medicine in the U.S. might help these physicians improve communication with their patients which would enable them to deliver quality care. It is not only beneficial for the self-development of IMG doctors and the healthcare system in general, but helping these physicians to be competent communicator is crucial to the well-being and health outcomes of the most important entity in this entire gamut of healthcare: the patients. 4.3. Practice implications There are many practical implications of these findings. Most participants were acutely aware of the cultural differences between themselves and their patients. For example, all the IMGs reported differences in language in terms of different accents, paralingustics, and use of slang words as a difficult situation. None of the IMGs felt that their knowledge of English language was so limited that they had difficulties communicating with the patients or their colleagues. However, a number of physicians felt that sometimes language posed as a barrier. In the absence of comfortable linguistic ability and other cultural differences, long-term goals of establishing rapport with patients and gaining their trust might suffer. International physicians in this study found it difficult to engage in small talk with their patients and sometimes felt at a loss in terms of topics of conversation with patients other than discussing their clinical information. The results of this study support the recommendations of [21] and [28] that language classes be made available for international doctors. The main focus of the language classes should be upon teaching culturally appropriate language and acculturation with respect to usage of slang words, idiomatic English, and other colloquial terms prevalent in that part of the U.S. where the IMG practices. Our results are similar to the previous research in the area that suggests that IMGs experience cultural and social differences, which could impact the patient care [10–17,21]. Many physicians for example noted their frustration in terms of medical information disclosure and DNR procedures. These kind of difficult decisions could be stressful for both patients and the physicians and hence IMGs who practice medicine in this country should be made aware of such cultural norm and confidentiality practices not just from an organizational standpoint, but also from a more humane and emotional perspective. Acknowledgement The authors are grateful to Dr. Vinayak Shukla for his assistance with data collection, Don Cegala and Rick Street for their valuable feedback on a previous version of this manuscript, and the editor and anonymous reviewers for their helpful input. References [1] Cegala DJ, Post DM. On addressing racial and ethnic health disparities: the potential role of patient communication skills interventions. Am Behav Sci 2006;49:853–67.
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[19] Street Jr RL. Accommodation in medical consultations. In: Giles HW, Coupland N, Coupland J, editors. Contexts of accommodation: developments in applied sociolinguistics. New York: Cambridge University Press; 1991. p. 131–56. [20] Giles H, Coupland N, Coupland J. Accommodation theory: communication, context and consequence. In: Giles HW, Coupland N, Coupland J, editors. Contexts of accommodation: developments in applied sociolinguistics. New York: Cambridge University Press; 1991. p. 1–68. [21] Hall P, Keely E, Dojeiji S, Byszewski A, Marks M. Communication skills, cultural challenges and individual support: challenges of international medical graduates in a Canadian healthcare environment. Med Teach 2004;26: 120–5. [22] Zoghbi WA, Algeria JR, Doty WD, Jones RH, Labovitz AJ, Reeder GS, et al. Working Group 4: international medical graduates and the cardiology workforce. J Am Coll Cardiol 2004;44:245–51. [23] Laidlaw TS, Kaufman DM, MacLeod H, van Zanten S, Simpson D, Dorgan WW. Relationship of resident characteristics, attitudes, prior training and clinical knowledge to communication skills performance. Med Educ 2006;40:18–25. [24] Fiscella K, Roman-Diaz M, Lue B, Botelho R, Frankel R. ‘Being a foreigner, I may be punished if I make a small mistake’: assessing transcultural experiences in caring for patients. Fam Pract 1997;14:112–6. [25] Roter DL, Frankel RM, Hall JA, Sluyter D. The expression of emotion through nonverbal behavior in medical visits. J Gen Intern Med 2006;21:28–34. [26] Larson EB, Yao X. Clinical empathy as emotional labor in the patient–physician relationship. J Am Med Assoc 2005;293:1100–6. [27] Eid M, Diener E. Norms for experiencing emotions in different cultures: interand international differences. J Pers Soc Psychol 2001;81:869–85. [28] Holland JC, Geary N, Marchini A, Tross S. An international survey of physician attitudes and practice in regard to revealing the diagnosis of cancer. Cancer Invest 1987;5:151–4. [29] Lindlof TR, Taylor BC. Qualitative communication research methods. Sage Publications; 2002. [30] Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. Sage Publications; 2006. [31] Green AR, Betancourt JR, Park ER, Greer JA, Donahue EJ, Weissman JS. Providing culturally competent care: residents in HRSA Title VII funded residency programs feel better prepared. Acad Med 2008;83:1071–9. [32] Lax LR, Russell ML, Nelles LJ, Smith CM. Scaffolding knowledge building in a web-based communication and cultural competence program for international medical graduates. Acad Med 2009;84:S5–8. [33] Whelan GP. Commentary: Coming to America: the integration of international medical graduates into the American medical culture. Acad Med 2006;81:176–8. [34] Bernstein HP. International medical graduates (IMGs): building cultural competence into the curriculum. Health Policy Newsletter; 2006. Available at: http:// jdc.jefferson.edu/cgi/viewcontent.cgi?article=1581&context=hpn#page=3.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Medical Education
Moving beyond the language barrier: The communication strategies used by international medical graduates in intercultural medical encounters Parul Jain *, Janice L. Krieger School of Communication, The Ohio State University, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 August 2009 Received in revised form 11 June 2010 Accepted 16 June 2010
Objective: To understand the communication strategies international medical graduates use in medical interactions to overcome language and cultural barriers. Methods: In-depth interviews were conducted with 12 international physicians completing their residency training in internal medicine in a large hospital in Midwestern Ohio. The interview explored (a) barriers participants encountered while communicating with their patients regarding language, affect, and culture, and (b) communication convergence strategies used to make the interaction meaningful. Results: International physicians use multiple convergence strategies when interacting with their patients to account for the intercultural and intergroup differences, including repeating information, changing speaking styles, and using non-verbal communication. Practice implications: Understanding barriers to communication faced by international physicians and recognizing accommodation strategies they employ in the interaction could help in training of future international doctors who come to the U.S. to practice medicine. Early intervention could reduce the time international physicians spend navigating through the system and trying to learn by experimenting with different strategies which will allow these physicians to devote more time to patient care. We recommend developing a training manual that is instructive of the socio-cultural practices of the region where international physician will start practicing medicine. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: International medical graduates Physician patient communication Foreign doctors Communication accommodation Convergence Communication challenges Communication barriers Communication strategies
1. Introduction Effective communication skills are essential to a successful physician–patient interaction [1,2]. Culture has an important, but often understudied, influence on medical encounters [3]. Patients report more satisfaction, participation, and positive affect when interacting with a physician from their same ethnic/racial group [4–6]. This suggests shared beliefs are an important aspect of provider–patient relationships that likely influence patient outcomes [4–6]. Furthermore, differences in race, ethnicity, and other aspects of culture are significant factors in determining the impact of communication skills training programs on patient participation [1,4]. To date, research that has considered the influence of culture on physician–patient communication has focused on interactions between U.S. American physicians and foreign-born patients [7,8]. This exclusive focus has inhibited academic understanding of intercultural medical interactions between foreign-born physicians and U.S. American patients.
* Corresponding author. Tel.: +1 614 292 3400. E-mail address: [email protected] (P. Jain). 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.06.022
One in every four physicians in the United States is an international medical graduate (IMGs hereafter) and almost 30% of IMGs are involved in providing care in various primary care specialties [9]. Many IMGs receive their medical training in countries where it is common for physicians to exert a great deal of control, authority, and power in the medical interaction and rely on paternalistic mode of communication as compared to the United States where physicians have been found to employ a wide range of communication styles [10–12]. Furthermore, many IMG physicians complete their undergraduate medical education in countries where models of medicine practice are very different from that in the U.S. For example, a recent study focused on developing an acculturation curriculum for IMG physicians notes that foreign residents find it difficult to understand the concepts of patient involvement and patient autonomy and have limited to no experience with physician–patient communication skills training [10–12]. Although previous research has identified the communication challenges that many IMGs face [10–17], there is no previous research that describes what communication strategies they use to overcome these challenges. Thus, the purpose of this study is to explore the communication strategies IMG physicians use to adjust to interpersonal and socio-cultural differences they encounter when practicing medicine in the U.S.
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1.1. Communication strategies used in medical interactions Medical interactions are considered to be an intergroup communication context because the behaviors of both physicians and patients are governed by the norms attached to their role in the encounter [18]. The intergroup nature of the interaction may be even more salient in intercultural medical situations because of differences in language or physical appearance. One theoretical perspective for understanding how intergroup differences are managed in interactions is Communication Accommodation Theory (CAT) [19,20]. One of the core tenets of CAT is that people will adjust their communication style in intergroup interactions. Convergence is a form of adjustment in which person tries to minimize the differences in communication between themselves and others. For example, a physician who avoids using medical jargon with a patient would be engaging in convergence. The ability to successfully converge is associated with greater patient satisfaction [19]. Thus, it is particularly important to understand the communication strategies used by IMGs who have the difficult task of negotiating medical interactions that are intercultural as well as intergroup. 1.2. Negotiating communication challenges in physician–patient interaction There are a number of communication challenges inherent in intercultural provider–patient interactions, especially when the physician is foreign-born. The three most common sources of difficulty for IMGs include language, emotion, and cultural norms for medical interaction [8,10–14,21]. International physicians, like their U.S. counterparts, undergo rigorous evaluation of their English proficiency and communication skills before getting accepted into the residency programs. To enter any residency program in the U.S., both IMG and USMG physicians are expected to fulfill many requirements including different steps of United States Medical Licensing (USMLE) examination. USMLE step 2 includes a subcomponent of the Clinical Skills (CS) exam in which standardized patients evaluate IMGs on three main aspects: integrated clinical encounter (ICE), communication and interpersonal skills, and English proficiency. However, it is possible to score well on this exam but IMGs may experience difficulty with advanced aspects of language use including colloquialisms, idioms, vernacular terms, accents, regional dialects, voice inflection, and body language [13,21,22]. As would be expected, problems communicating with patients are most pronounced among physicians whose primary language is not English [14,23]. For example, IMGs report that language problems can make it difficult to ask questions about a patient’s medical history in a way that the patient can understand [24]. A second challenge to IMGs is managing affect in medical interaction. Non-verbal communication plays a significant role in emotional expressiveness and the maintenance of relationshipcentered patient care [25]. A physician’s ability to competently manage affect has numerous benefits to patients, such as improved information exchange, greater participation in decision-making, and increased efficacy to engage in preventive care [26]. However, cultures differ greatly in what emotional displays are considered appropriate in the medical context, as well as what type of comforting a physician should provide. Previous research has suggested that norms for experiencing emotions are different in collectivist and individualistic societies [27]. Since many IMGs come from collectivist cultures such as India, Pakistan, and China [9], they may handle emotions quite differently than would be expected by patients in comparatively individualistic societies such as the U.S. All aspects of medical interaction are guided by norms and expectations, which are shaped by culturally acquired attitudes and beliefs [8]. To illustrate, norms for medical privacy in the U.S.
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dictate that physicians reveal medical information directly to patients. However, a survey of 90 doctors from 20 countries found that physicians from countries outside the U.S. feel most comfortable giving the diagnosis of a life-threatening illness (e. g., cancer) to the family of the patient [28]. As with other common communication difficulties IMGs face, it is unknown to what extent they adjust to the various cultural norms of patients in the U.S. 1.3. Objectives Previous research has identified the linguistic, affective, and cultural difficulties IMG physicians encounter when practicing in the U.S. What still remains to be explored, however, is the ways in which IMGs try to adapt their communication to overcome these barriers. Thus, the following general research question is proposed: RQ: What communication strategies do IMG physicians use to minimize differences in language, emotion, and culture when communicating with their US born patients? 2. Method 2.1. Participants Participants in the study were internal medicine residents in a large teaching hospital in Midwestern U.S. Twelve participants, recruited using snowball sampling, completed a voluntary interview and a brief survey exploring physician demographics. Participants ranged in age from 28 to 42 years (M = 32.41, SD = 3.89). Most of the participants were male (n = 8). Participants had lived in the U.S. between 1 and 9 years (M = 4.41, SD = 2.25) and were from six different countries. Six out of 12 interviewees were originally from India, 2 were from China, and the remaining 4 came from the following countries: Jordan, Lebanon, Nigeria, and Philippines. At the time of the interview, five interviewees were in their first year of residency training in the U.S., four were in their second year and three participants were in third year of residency. 2.2. Data collection The first author conducted face-to-face interviews with 12 residents completing their residency at an internal medicine residency program in a hospital in Midwestern part of the U.S. The interviews were conducted between December 2007 and May 2008. Interviews were appropriate for addressing the research question in this study because they allowed participants the opportunity to narrate their experiences and reflect on how they accommodate differences that they experience in the interaction situations [10,12,24,29,30]. Data saturation occurred after 12 interviews, meaning that no new information or themes emerged from data analysis [29,30]. Interviews were conducted in a public location outside the hospital to ensure participant confidentiality and to provide them with a setting where they could comfortably share their opinions. The interviews were audio-recorded for transcription with the consent of participants and lasted 35 min on average (range of 18– 52 min). We used previous research [13,21] to create semistructured interview guide which served mainly as a framework to make sure all the themes that we wanted to explore were covered with each respondent (Table 1). The interviews explored basic themes such as most difficult issues that IMG physicians encounter while interacting with patients, communication strategies they adopt to navigate through those issues, strategies for adjustments to life as a resident, and suggestions for improving the residency experiences for IMG physicians. Participants in the study provided care in both in-hospital settings and office settings and thus recounted both types of experiences.
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100 Table 1 Interview guide.
1. Describe what it is like to be a resident in (name of hospital). Could you elaborate on some of the experiences that you find memorable during the residency period? Prompts: general struggles, how are these different for you because you an international medical graduate? Are there specific challenges that IMGs face compared to other residents? How is the experience similar/different that what you expected? 2. Describe the process of adjusting to living in the U.S.? Working in the U.S.? Prompts: How did you manage the things during the first few months of the residency (explore about support systems, friends, and mentor)? How did you learn to navigate the hospital system? 3. How is being a doctor in the US different from being a doctor in your home country? 4. In ways does being an IMG influence how you communicate with patients? In what ways does it influence how patients communicate with you? 5. What do you think is the biggest problem when you communicate with the patients? Prompts: Probe on trust, adherence, language, culture. What strategies have you found to be helpful that make you, as well as your patient, comfortable during the medical interaction? 6. What type of things you do to help patients understand you (prompts: repeat, change voice inflections). Are there times when you don’t use those strategies that you just described? Could you elaborate on certain instances when you did not knowingly or unknowingly used the abovementioned strategies? 7. In what ways do you change the way you speak or behave to be more like your patient? What are the ways that you adopt so that patients could identify with you and become more comfortable with you during the discussion? 8. To what extent would you have benefited from a training program focusing on communication with patients? If there is a training program, in your opinion what are some of the main issues that such a program should address? 9. What are some of the most important issues that need to be addressed in order to improve IMGs experiences in the U.S.? 10. Is there anything else that you would like to share regarding healthcare system in the United States that has potential implications on your interaction with the patients?
2.3. Data analysis A paid transcriptionist transcribed each audio-recorded interview verbatim. All participant identifiers were then removed and replaced by a code number. Using grounded theory methodology, both the authors carefully read and open coded each of the 12 transcripts individually, focusing on barriers to communication with patients and the communication strategies used to overcome these barriers. Next, both the authors reexamined the open codes to determine how they related to one another, a process referred to as axial coding [29,30]. Finally, the first author reread all the transcripts and finalized coding, focusing on collapsing codes to create themes. We employed several steps to ensure internal validity and rigor of the analysis. First, we also employed triangulation within method by asking questions in different ways that explored the same concept [29,30]. Second, we conducted member checks. At the end of each interview, the interviewer summarized her notes for the participants to check for accuracy. Third, we engaged in peer debriefing by sharing our finding with an IMG physician who was not part of the study. 3. Results 3.1. Language We sought to understand language related difficulties encountered by IMG physicians, the strategies they used to overcome these difficulties, and if the strategies were indicative of communication convergence. Language was conceptualized as verbal and non-verbal communication used in face-to-face interaction with patients. Consolidation of open codes revealed that IMG doctors encountered differences in both linguistic and paralinguistic issues, as illustrated by Table 2. Consistent with previous research [16,21], about one-fourth of the interviewees found it difficult to understand the English words used by the patients. As one physician noted: The spoken English we don’t know very well and how to express. In your mind you think you know this well but actually to express or to say it or to interact with the patient is different. That is a big challenge how you can express yourself and your clinical judgment well to the patient.’’ (A physician from India) More commonly, IMGs had difficulty with more subtle aspects of language, such as paralinguistic cues, pronunciation, and use of colloquialism. Paralinguistic cues were coded as references to
accents, tone, voice inflection, and pace. Pronunciation was conceptualized as the extent to which IMG doctors perceived that their patients had difficulty with the manner in which they uttered specific words. Colloquial language usage referred to the use of slang words, idioms, and other popular lingo. Most interviewees reported difficulties with either one or all of these factors. A third year resident from India explained, ‘‘Our English is the British English and the American English is different but after you come here you start to learn how people pronounce things.’’ Many IMG physicians indicated a number of accommodation strategies indicative of convergence to manage differences in language between them and their patients. Some strategies indicated by the participants were learning to pronounce words in usual North American manner and trying to understand and learn meanings of slang words with the help of media and their North American friends. Many of the doctors noted that they also tried to accommodate for differences in accents by either repeating their sentences or by changing the pace or volume of speech. A third year IMG resident from the Middle East acknowledged that he usually spoke quickly, ‘‘I usually repeat everything I say because I speak too fast, so I make sure my patients understand what I say. I try to make 100% sure that my patients understand what I said.’’ In addition to checking with patients if they understood what was said, participants also tried to compensate for linguistic differences through the use of non-verbal gestures. IMGs frequently reported making a conscious effort to maintain good eye contact, have a friendly disposition, smile, and vocally convey warmth and care. The following quote from one participant illustrates this: ‘‘my strength is trying to be a good communicator and even though my English is not perfect but my eye contact is very good.’’ Although accents did contribute to difficulties in the physician– patient interaction, IMG physicians did not perceive this as a hindrance. One physician, in particular, felt her accent positively contributed to interactions with patients. She explained that her
Table 2 Convergence strategies and barriers to convergence. Convergence strategies Verbal (e.g. repetition) Non-verbal (e.g. eye contact) Emotions (e.g. supportive touch) Barriers to convergence Accent (e.g. British pronunciation) Vocabulary (e.g. difficulty understanding acronyms, slang words) Power Conversational norms Medical information disclosure (e.g. family versus patient)s
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patients were often intrigued by her accent, which usually led to questions about her origin. In this way, even though differences in accent sometimes created initial distance between patient and their provider, in some instances these differences also facilitated the process of building rapport because they led to initiation of informal conversation between patient and provider before provider initiated clinical talk. It should be noted that we only interviewed IMG physicians in this study and not the patients. It is the perception of IMG physicians that differences in their accent do not pose a significant barrier. Future studies should seek patient’s perspectives to understand if different accents of IMGs do pose difficulties for the patients. Thus linguistically our data is indicative of convergent accommodation strategies used by IMG physicians to account for differences. 3.2. Handling emotions The issue of handling emotions was conceptualized by asking IMG physicians how they managed patient despair and crying, patient expressed fear and other negative emotions, and general support needed by patients in moments of uncertainty and distress. IMG physicians reported using both verbal and non-verbal strategies for emotion management. Non-verbal strategies included empathetic gestures such as supportive touch, eye contact, and respectful silence. Verbal strategies included attempts to calm and reassure the patient. One physician noted that, Whenever a patient starts to experience immense negative emotions, I try to listen actively, giving my full attention; once I feel that it is appropriate I start to comfort the patient verbally but I never say I can understand because no one but only the person undergoing the illness could understand the issue. (A physician from India) IMGs frequently associated emotions with disclosure of medical information, particularly delivering bad news. For most of the IMGs, delivering bad news to a patient is the responsibility of the family, not the physician. Thus, many of the physicians reported that they had to learn how to give patients bad news and how to handle the resulting emotions. This indicates communication convergence, because IMGs strove to adapt to the perceived cultural norms of their patients. One IMG gave the following advice for handling negative emotions, ‘‘. . . Try to be as understanding as you can and try not to interrupt him and try to be compassionate and apologize if you think that you made a mistake . . .’’ 3.3. Differences in norms related to medical interaction During the interview we also asked IMG physicians how they managed differences in cultural norms with respect to medical interaction. Data analysis revealed three sub-themes relating to conversational scripts, power, and medical information disclosure. 3.3.1. Conversational norms and scripts We found that in general, certain preformed expectations, scripts, and norms govern medical interviews just as they do any other interaction. To ease the patient anxiety and stress, physicians often talked about topics unrelated to the purpose of the medical visit, such as weather, sports, and holidays. Small talk gave both physician and the patient a chance to get acclimated in the interaction and reduces the anxiety from an otherwise tense environment. IMG physicians however reported that carrying out small talk was a key difficulty with their patients. One physician mentioned that he would try to talk about a local, professional football team to start the conversation. However, this convergent strategy would backfire when patients responded by talking about
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particular players because he possessed only superficial knowledge about the team that he learned specifically to help start conversations with patients, not out of personal interest. Other physicians expressed similar uncertainty about discussing American holidays, such as Halloween and Thanksgiving. Thus although physicians were trying to use convergent communication to accommodate for the difference between them and their patients, their efforts sometime led to more divergence. Another difficulty with conversational norms and scripts related to the use of abbreviations when working in medical teams to treat a patient. Most IMG interns interviewed in the study reported dissatisfaction with the use of abbreviations by medical teams because they are still not acculturated enough to learn the medical lingo. A first year resident recounted the following incident: Initially when I came here and when I started my residency, the first month was very hard for me in the sense that medically it was not hard, but there was the way they use short terms here like CBCs or like one of the word they say . . . what are the CMP? Let’s get a finger stick. What is finger stick? It was actually a finger stick with loopholes. So, these are like some quick terms like what was a CRIT which was hematocrit. So, some of the language this was a problem for me. 3.3.2. Power/patient-centered communication The second sub-theme that emerged consisted of comments made about power dynamics in the physician–patient interaction. Power was conceptualized in this study as the distribution of control and authority in the interaction. Although no IMG physician explicitly stated that egalitarian relationship between the physician and the patient was unjust, there were still subtle and nuanced expressions that clearly delineated the concern and confusions that many IMG physicians experienced in terms of differences in patient care in the US from their home country. One physician from India very eloquently described the differences in communication patterns between the U.S. and his home country and the associated surprise and confusion that might be encountered while first starting the medical practice in the U.S. He stated, ‘‘I think in India physicians think they know what is best for the patient; here physicians take into account the patients’ opinion as well.’’ A first year intern from a Middle Eastern country commented, ‘‘Here the patient has to know everything on his disease, our country is different.’’ Most physicians noted that they converged to accommodate for power differences between them and their patients by providing patients a chance to be actively involved in their treatment. Some also indicated that convergence was because of the norms and expectations by U.S. patients and the U.S. medical system and not just by their choice. 3.3.3. Medical information disclosure Medical information disclosure was conceptualized as to whom the information related to the disease will be disclosed – the patient or the family. In many countries outside the U.S. and specifically in many collectivist cultures, most of the disease and prognosis-related information is given to the patient’s family and friends rather than the patients. In the U.S. however, due to confidentiality and malpractice reasons, information is delivered directly to the patient (or patient surrogate). Thus it is no surprise that most IMG physicians interviewed in the study found it difficult when it came to disclosure of sensitive information directly to the patient. One physician in his third year of residency noted: The one thing I don’t like about the American system is that you are telling the patient face-to-face that he is going to die, which is something that I don’t like. You are telling a dying patient that
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he only has a few weeks or months left, . . . [if I was the patient] I wouldn’t want to know that. Not only did physicians recognize that the norms for information disclosure were different, they also expressed feelings that the culture of medical system in the U.S. did not permit the physician enough power to make such decisions. For example, several physicians expressed the frustration with disclosing everything to the patient, and one physician referred to it as treating ‘‘patients as kings.’’ Thus, attempts at convergence in these interactions consisted of disclosing more information to a patient than the physician felt necessary and appropriate. Fig. 1. Different dimensions of IMG physician patient communication.
4. Discussion and conclusion 4.1. Discussion The IMG physicians in this study identified three major areas that posed a barrier to communicating effectively with patients namely language, affect related issues, and differences in cultural norms regarding medical interaction. These findings are consistent with the previous research on the barriers that IMGs must overcome [10–17,21]. This study contributes to the literature by identifying the strategies IMG physicians use to minimize the differences in communication during consultations with their U.S. patients. Our findings are unique in that, contrary to the assumption that accommodation is always desirable in medical interactions [18] we found instances where maintenance of differences was more beneficial to the interaction. For example, one of the IMG physicians in our interview noted that she maintains her accent during the conversation because she sees her accent as a potential conversation starter with the patient. Some IMG physicians in our study maintained cultural and linguistic differences between themselves and their patients, to maintain their own cultural identity, or for more pragmatic reasons, such as establishing rapport with patients. IMG physician interaction is such that it involves elements of intercultural, interpersonal, and intergroup communication because it involves communication between people of two different cultures who are also members of two distinct groups, but who communicate on a personal level. Most previous research assumes that IMG physicians try to move from intercultural to intergroup to interpersonal dimension of communication to relate to their patients. In other words, IMG physicians start at an intercultural communication position because of interaction between people of two different cultures [10]. In addition to having intercultural elements, IMG physician patient interaction can also be characterized as intergroup communication because physicians and patients have prescribed roles in medical interaction [18]. However, IMG physicians may attempt to deemphasize the traditional physician–patient power dynamics by accommodating to unique linguistics or behavioral characteristics of the patient. In treating the patient as an individual, and not solely as a member of the patient population or a representative of his/her culture, the interaction becomes one that can be characterized as interpersonal in nature (see Fig. 1). We are arguing that while the above holds true, there are many instances when IMG physicians do not want to accommodate and maintain the differences between them and their patients (as in the case of the physician who uses her usual accent). In such cases, these physicians use the intercultural form of communication to enhance interpersonal communication between them and their patients. That is, these physicians use differences in culture to facilitate interpersonal form of communication. Such strategies are not new in interaction situation involving people of different cultures. For example, Giles et al. found that
divergent strategies can be used to express attitudes and to bring meaning and understanding to the interaction [20]. They further note that delineation of differences in some form indicate to the opposite party that the interactant does not belong to the host culture which can be helpful in achieving mutual understanding. IMG physicians can take advantage of such expectations to initiate small talk with the patients and to build rapport and long-term relationship. Of course this strategy could also backfire, but perhaps patients might appreciate differences and use those to develop relationship with the IMG physician. IMG physicians might also use these differences to maintain their cultural identity. Moreover, they might find the maintenance of differences more pragmatic than converging as these differences sometimes provide them a way to start conversation with their patients. Therefore, the research needs to move beyond the overarching assumption that physicians should accommodate to their patients and explore how can physicians use differences between them and their patients to make the interaction more interpersonal and fruitful in nature. One of the strengths of this study is that it gives voice to a population that is very difficult to access and is significantly understudied, but who constitutes a critical component of the American healthcare system. To our knowledge, this is one of the first studies in the field of communication that tries to explore how IMG physicians in residency programs learn to respond to the communication barriers posed by their status as an international medical graduate. Specifically, this study extends previous research by not only describing the communication barriers of IMGs, but by also illuminating the strategies they use to overcome those barriers including both accommodation and maintenance. Although cultural differences do pose certain challenges for IMGs, it is important for the medical community to be aware of the ways that these physicians are using their background to benefit their practice. It should be noted that, this study relied on physicians from one healthcare system in one geographical region of the U.S. Thus, the findings of the study should not be generalized to all IMGs, but rather offer an initial step in understanding the accommodation strategies of international medical graduates practicing medicine in the U.S. We are not implying that our findings speak to the experiences of all the IMG physicians in the U.S. These findings offer an insight into a group of IMG physicians who came from different countries to practice medicine in a hospital in the U.S. Perhaps experiences of IMGs would differ depending upon the place they are completing their residency, composition of the patient population in that institution, as well as other factors. Future research on this topic should examine the influence of regional sub-cultures on communication strategies used by IMG physicians, and the perceptions of patients of IMG physicians. Another area of future research could be comparison of communication strategies used by IMGs who are in their residency practice in the U.S. to the IMG physicians who have experienced practicing medicine in the U.S. This study provides a rich understanding of the
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accommodation processes involved in intercultural exchange in medical interaction where physician rather than patient belongs to a cultural minority group. To our knowledge, previous research has not looked into how the accommodation processes work when power dynamics are shared in the interaction. For example, in terms of ethnic identity, IMG physicians typically belong to cultural minority groups; in other words groups that have been historically marginalized in the society. In the medical interaction, however, physicians are perceived to have more power than patients [18]. Therefore, by understanding how IMG physicians accommodate in interactions when they have high professional status but belong to a culturally marginalized group is important because perhaps some of the views expressed by these physicians regarding the feelings of the loss of power might have been derived by the feelings of lacking the power in the societal context. Moreover, by illustrating when IMG physicians do not accommodate in the interaction, we challenge the previous research and training guidelines for IMG physicians that emphasize acculturating IMGs to the culture of the U.S. so that they can communicate effectively with North American patients. This study provides a rich understanding of communication strategies used by IMG physicians when they start practicing medicine in the U.S. However, there were some limitations. For example, we did not explore the issues related to organizational differences that IMG physicians encounter when starting their medical practice in the U.S. The medical system in the U.S. is one of the most sophisticated but also extremely complicated entities. Thus it is important to explore the organizational accommodation processes that many IMG physicians might undergo when they start residency training in the U.S. because adjustment and acculturation into organizational climate could impact their performance and in turn impact the patient care that these physicians impart. Future research should also focus on the lifestyle differences that IMG physicians experience when they come to the U.S. for residency and impact of these differences on their work productivity and quality of medical care provided. Finally, we support the recommendations proposed by previous research that a rigorous, multifaceted training program be instituted that helps IMG physicians in acculturating to the U.S. work culture from different angles, especially when they first begin the residency training [11,16,17,24,31–33]. Although some institutions such as Albert Einstein Medical Center in Philadelphia already have a component of cultural competence built in their residency programs [34], such programs are far from the norm. We suggest that these training programs should be culturally sensitive to the needs of the IMGs so that they can also maintain their cultural identity. They should emphasize the strategies IMG physicians could use, including convergence, maintenance, and divergence that might be beneficial for these physicians. Finally, institutions can perhaps look at ways different than just training to help in transition of these physicians. For example IMG physicians could be matched up with a more experienced IMG physician from similar culture, standardized patients, or patient advocates who could help the IMG physicians in transition to the U.S. healthcare system. Increasing cultural sensitivity during the residency program will not only improve the quality of care provided by IMGs, but could also improve patients overall satisfaction with the medical system. 4.2. Conclusion In sum, this study enhanced our understanding of the issues that IMG physicians face in communicating with their patients and the strategies they adopt to accommodate those differences. These descriptions of how IMGs communicatively negotiate intercultural patient encounters form the groundwork for designing future
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studies to further explore this issue. Since IMG physicians bring different cultural perspectives to the patient care and the healthcare system, educating them regarding cultural norms of the U.S. in general, including regional norms associated with the location of their practice could help them in becoming more culturally sensitive. Furthermore, the new IMG residents might also benefit from learning about medical culture in the U.S., including physician– patient communication practices. This training might force them to reconsider the norms they might have regarding physician–patient relationship based on their medical education in their country of origin. Educating IMG physicians regarding the norms of medicine in the U.S. might help these physicians improve communication with their patients which would enable them to deliver quality care. It is not only beneficial for the self-development of IMG doctors and the healthcare system in general, but helping these physicians to be competent communicator is crucial to the well-being and health outcomes of the most important entity in this entire gamut of healthcare: the patients. 4.3. Practice implications There are many practical implications of these findings. Most participants were acutely aware of the cultural differences between themselves and their patients. For example, all the IMGs reported differences in language in terms of different accents, paralingustics, and use of slang words as a difficult situation. None of the IMGs felt that their knowledge of English language was so limited that they had difficulties communicating with the patients or their colleagues. However, a number of physicians felt that sometimes language posed as a barrier. In the absence of comfortable linguistic ability and other cultural differences, long-term goals of establishing rapport with patients and gaining their trust might suffer. International physicians in this study found it difficult to engage in small talk with their patients and sometimes felt at a loss in terms of topics of conversation with patients other than discussing their clinical information. The results of this study support the recommendations of [21] and [28] that language classes be made available for international doctors. The main focus of the language classes should be upon teaching culturally appropriate language and acculturation with respect to usage of slang words, idiomatic English, and other colloquial terms prevalent in that part of the U.S. where the IMG practices. Our results are similar to the previous research in the area that suggests that IMGs experience cultural and social differences, which could impact the patient care [10–17,21]. Many physicians for example noted their frustration in terms of medical information disclosure and DNR procedures. These kind of difficult decisions could be stressful for both patients and the physicians and hence IMGs who practice medicine in this country should be made aware of such cultural norm and confidentiality practices not just from an organizational standpoint, but also from a more humane and emotional perspective. Acknowledgement The authors are grateful to Dr. Vinayak Shukla for his assistance with data collection, Don Cegala and Rick Street for their valuable feedback on a previous version of this manuscript, and the editor and anonymous reviewers for their helpful input. References [1] Cegala DJ, Post DM. On addressing racial and ethnic health disparities: the potential role of patient communication skills interventions. Am Behav Sci 2006;49:853–67.
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