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Patient Education

jo ur n al h o mep ag e: w ww .e lse1. Introduction

Effective communication skills are essential to a successfulphysicianpatient interaction [1,2]. Culture has an important, butoften understudied, inuence on medical encounters [3]. Patientsreport more satisfaction, participation, and positive affect wheninteracting with a physician from their same ethnic/racial group[46]. This suggests shared beliefs are an important aspect ofproviderpatient relationships that likely inuence patient out-comes [46]. Furthermore, differences in race, ethnicity, and otheraspects of culture are signicant factors in determining the impactof communication skills training programs on patient participation[1,4]. To date, research that has considered the inuence of cultureon physicianpatient communication has focused on interactionsbetween U.S. American physicians and foreign-born patients [7,8].This exclusive focus has inhibited academic understanding ofintercultural medical interactions between foreign-born physi-cians and U.S. American patients.

One in every four physicians in the United States is aninternational medical graduate (IMGs hereafter) and almost 30%of IMGs are involved in providing care in various primary carespecialties [9]. Many IMGs receive their medical training incountries where it is common for physicians to exert a great deal ofcontrol, authority, and power in the medical interaction and rely onpaternalistic mode of communication as compared to the UnitedStates where physicians have been found to employ a wide rangeof communication styles [1012]. Furthermore, many IMGphysicians complete their undergraduate medical education incountries where models of medicine practice are very differentfrom that in the U.S. For example, a recent study focused ondeveloping an acculturation curriculum for IMG physicians notesthat foreign residents nd it difcult to understand the concepts ofpatient involvement and patient autonomy and have limited to noexperience with physicianpatient communication skills training[1012]. Although previous research has identied the communi-cation challenges that many IMGs face [1017], there is noprevious research that describes what communication strategiesthey use to overcome these challenges. Thus, the purpose of thisstudy is to explore the communication strategies IMG physiciansuse to adjust to interpersonal and socio-cultural differences theyencounter when practicing medicine in the U.S.

Keywords:

International medical graduates

Physician patient communication

Foreign doctors

Communication accommodation

Convergence

Communication challenges

Communication barriers

Communication strategies

(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.

2010 Elsevier Ireland Ltd. All rights reserved.

* Corresponding author. Tel.: +1 614 292 3400.

E-mail address: jain.122@osu.edu (P. Jain).

0738-3991/$ see front matter 2010 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.pec.2010.06.022Medical Education

Moving beyond the language barrier: Thinternational medical graduates in inter

Parul Jain *, Janice L. Krieger

School of Communication, The Ohio State University, USA

A R T I C L E I N F O

Article history:

Received 26 August 2009

Received in revised form 11 June 2010

Accepted 16 June 2010

A B S T R A C T

Objective: To understand th

interactions to overcome la

Methods: In-depth intervie

residency training in intern communication strategies used byultural medical encounters

communication strategies international medical graduates use in medical

uage and cultural barriers.

s were conducted with 12 international physicians completing their

medicine in a large hospital in Midwestern Ohio. The interview explored

and Counseling

vier . co m / loc ate /p ated u co u

P. Jain, J.L. Krieger / Patient Education and Counseling 84 (2011) 98104 991.1. Communication strategies used in medical interactions

Medical interactions are considered to be an intergroupcommunication context because the behaviors of both physiciansand patients are governed by the norms attached to their role in theencounter [18]. The intergroup nature of the interaction may be evenmore salient in intercultural medical situations because ofdifferences in language or physical appearance. One theoreticalperspective for understanding how intergroup differences aremanaged in interactions is Communication Accommodation Theory(CAT) [19,20]. One of the core tenets of CAT is that people will adjusttheir communication style in intergroup interactions. Convergenceis a form of adjustment in which person tries to minimize thedifferences in communication between themselves and others. Forexample, a physician who avoids using medical jargon with a patientwould be engaging in convergence. The ability to successfullyconverge is associated with greater patient satisfaction [19]. Thus, itis particularly important to understand the communication strate-gies used by IMGs who have the difcult task of negotiating medicalinteractions that are intercultural as well as intergroup.

1.2. Negotiating communication challenges in physicianpatient

interaction

There are a number of communication challenges inherent inintercultural providerpatient interactions, especially when thephysician is foreign-born. The three most common sources ofdifculty for IMGs include language, emotion, and cultural normsfor medical interaction [8,1014,21]. International physicians, liketheir U.S. counterparts, undergo rigorous evaluation of theirEnglish prociency and communication skills before gettingaccepted into the residency programs. To enter any residencyprogram in the U.S., both IMG and USMG physicians are expectedto fulll many requirements including different steps of UnitedStates Medical Licensing (USMLE) examination. USMLE step 2includes a subcomponent of the Clinical Skills (CS) exam in whichstandardized patients evaluate IMGs on three main aspects:integrated clinical encounter (ICE), communication and interper-sonal skills, and English prociency. However, it is possible to scorewell on this exam but IMGs may experience difculty withadvanced aspects of language use including colloquialisms, idioms,vernacular terms, accents, regional dialects, voice inection, andbody language [13,21,22]. As would be expected, problemscommunicating with patients are most pronounced amongphysicians whose primary language is not English [14,23]. Forexample, IMGs report that language problems can make it difcultto ask questions about a patients medical history in a way that thepatient can understand [24].

A second challenge to IMGs is managing affect in medicalinteraction. Non-verbal communication plays a signicant role inemotional expressiveness and the maintenance of relationship-centered patient care [25]. A physicians ability to competentlymanage affect has numerous benets to patients, such as improvedinformation exchange, greater participation in decision-making, andincreased efcacy to engage in preventive care [26]. However,cultures differ greatly in what emotional displays are consideredappropriate in the medical context, as well as what type ofcomforting a physician should provide. Previous research hassuggested that norms for experiencing emotions are different incollectivist and individualistic societies [27]. Since many IMGs comefrom collectivist cultures such as India, Pakistan, and China [9], theymay handle emotions quite differently than would be expected bypatients in comparatively individualistic societies such as the U.S.

All aspects of medical interaction are guided by norms andexpectations, which are shaped by culturally acquired attitudesand beliefs [8]. To illustrate, norms for medical privacy in the U.S.dictate that physicians reveal medical information directly topatients. However, a survey of 90 doctors from 20 countries foundthat physicians from countries outside the U.S. feel mostcomfortable giving the diagnosis of a life-threatening illness (e.g., cancer) to the family of the patient [28]. As with other commoncommunication difculties IMGs face, it is unknown to what extentthey adjust to the various cultural norms of patients in the U.S.

1.3. Objectives

Previous research has identied the linguistic, affective, andcultural difculties IMG physicians encounter when practicing inthe U.S. What still remains to be explored, however, is the ways inwhich IMGs try to adapt their communication to overcome thesebarriers. Thus, the following general research question is proposed:RQ: What communication strategies do IMG physicians use tominimize differences in language, emotion, and culture whencommunicating with their US born patients?

2. Method

2.1. Participants

Participants in the study were internal medicine residents in alarge teaching hospital in Midwestern U.S. Twelve participants,recruited using snowball sampling, completed a voluntaryinterview 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). Participantshad 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 intervieweeswere originally from India, 2 were from China, and the remaining 4came from the following countries: Jordan, Lebanon, Nigeria, andPhilippines. At the time of the interview, ve interviewees were intheir rst year of residency training in the U.S., four were in theirsecond year and three participants were in third year of residency.

2.2. Data collection

The rst author conducted face-to-face interviews with 12residents completing their residency at an internal medicineresidency program in a hospital in Midwestern part of the U.S. Theinterviews were conducted between December 2007 and May2008. Interviews were appropriate for addressing the researchquestion in this study because they allowed participants theopportunity to narrate their experiences and reect on how theyaccommodate differences that they experience in the interactionsituations [10,12,24,29,30]. Data saturation occurred after 12interviews, meaning that no new information or themes emergedfrom data analysis [29,30].

Interviews were conducted in a public location outside thehospital to ensure participant condentiality and to provide themwith a setting where they could comfortably share their opinions.The interviews were audio-recorded for transcription with theconsent of participants and lasted 35 min on average (range of 1852 min). We used previous research [13,21] to create semi-structured interview guide which served mainly as a framework tomake sure all the themes that we wanted to explore were coveredwith each respondent (Table 1). The interviews explored basicthemes such as most difcult issues that IMG physicians encounterwhile interacting with patients, communication strategies theyadopt to navigate through those issues, strategies for adjustmentsto life as a resident, and suggestions for improving the residencyexperiences for IMG physicians. Participants in the study providedcare in both in-hospital settings and ofce settings and thusrecounted both types of experiences.

te on some of the experiences that you nd memorable during the residency

an international medical graduate? Are there specic challenges that IMGs face

you expected?

mpts: How did you manage the things during the rst few months of the

earn to navigate the hospital system?

ntry?

hat ways does it inuence how patients communicate with you?

ients? Prompts: Probe on trust, adherence, language, culture. What strategies

le during the medical interaction?

hange voice inections). Are there times when you dont use those strategies that

knowingly or unknowingly used the abovementioned strategies?

patient? What are the ways that you adopt so that patients could identify

co

to

i

P. Jain, J.L. Krieger / Patient Education and Counseling 84 (2011) 981041002.3. Data analysis

A paid transcriptionist transcribed each audio-recorded inter-view verbatim. All participant identiers were then removed andreplaced by a code number. Using grounded theory methodology,both the authors carefully read and open coded each of the 12transcripts individually, focusing on barriers to communicationwith patients and the communication strategies used to overcomethese barriers. Next, both the authors reexamined the open codesto determine how they related to one another, a process referred toas axial coding [29,30]. Finally, the rst author reread all thetranscripts and nalized coding, focusing on collapsing codes tocreate themes.

We employed several steps to ensure internal validity and rigorof the analysis. First, we also employed triangulation withinmethod by asking questions in different ways that explored thesame concept [29,30]. Second, we conducted member checks. Atthe end of each interview, the interviewer summarized her notesfor the participants to check for accuracy. Third, we engaged inpeer debrieng by sharing our nding with an IMG physician whowas not part of the study.

3. Results

3.1. Language

We sought to understand language related difculties encoun-tered by IMG physicians, the strategies they used to overcome

Table 1Interview guide.

1. Describe what it is like to be a resident in (name of hospital). Could you elabora

period? Prompts: general struggles, how are these different for you because you

compared to other residents? How is the experience similar/different that what

2. Describe the process of adjusting to living in the U.S.? Working in the U.S.? Pro

residency (explore about support systems, friends, and mentor)? How did you l

3. How is being a doctor in the US different from being a doctor in your home cou

4. In ways does being an IMG inuence how you communicate with patients? In w

5. What do you think is the biggest problem when you communicate with the pat

have you found to be helpful that make you, as well as your patient, comfortab

6. What type of things you do to help patients understand you (prompts: repeat, c

you just described? Could you elaborate on certain instances when you did not

7. In what ways do you change the way you speak or behave to be more like your

with you and become more comfortable with you during the discussion?

8. To what extent would you have beneted from a training program focusing on

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

10. Is there anything else that you would like to share regarding healthcare system

the patients?these difculties, and if the strategies were indicative ofcommunication convergence. Language was conceptualized asverbal and non-verbal communication used in face-to-faceinteraction with patients. Consolidation of open codes revealedthat IMG doctors encountered differences in both linguistic andparalinguistic issues, as illustrated by Table 2. Consistent withprevious research [16,21], about one-fourth of the intervieweesfound it difcult to understand the English words used by thepatients. As one physician noted:

The spoken English we dont know very well and how toexpress. In your mind you think you know this well but actuallyto express or to say it or to interact with the patient is different.That is a big challenge how you can express yourself and yourclinical judgment well to the patient. (A physician from India)

More commonly, IMGs had difculty with more subtle aspectsof language, such as paralinguistic cues, pronunciation, and use ofcolloquialism. Paralinguistic cues were coded as references toaccents, tone, voice inection, and pace. Pronunciation wasconceptualized as the extent to which IMG doctors perceivedthat their patients had difculty with the manner in which theyuttered specic words. Colloquial language usage referred to theuse of slang words, idioms, and other popular lingo. Mostinterviewees reported difculties with either one or all of thesefactors. A third year resident from India explained, Our English isthe British English and the American English is different but afteryou come here you start to learn how people pronounce things.

Many IMG physicians indicated a number of accommodationstrategies indicative of convergence to manage differences inlanguage between them and their patients. Some strategiesindicated by the participants were learning to pronounce wordsin usual North American manner and trying to understand andlearn meanings of slang words with the help of media and theirNorth American friends. Many of the doctors noted that they alsotried to accommodate for differences in accents by either repeatingtheir sentences or by changing the pace or volume of speech. Athird year IMG resident from the Middle East acknowledged thathe usually spoke quickly, I usually repeat everything I say becauseI speak too fast, so I make sure my patients understand what I say. Itry to make 100% sure that my patients understand what I said.

In addition to checking with patients if they understood whatwas said, participants also tried to compensate for linguisticdifferences through the use of non-verbal gestures. IMGs frequentlyreported making a conscious effort to maintain good eye contact,have a friendly disposition, smile, and vocally convey warmth andcare. The following quote from one participant illustrates this: my

mmunication with patients? If there is a training program, in your opinion

improve IMGs experiences in the U.S.?

n the United States that has potential implications on your interaction withstrength is trying to be a good communicator and even though myEnglish is not perfect but my eye contact is very good.

Although accents did contribute to difculties in the physicianpatient interaction, IMG physicians did not perceive this as ahindrance. One physician, in particular, felt her accent positivelycontributed to interactions with patients. She explained that her

Table 2Convergence 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. difculty understanding acronyms, slang words) Power Conversational norms Medical information disclosure (e.g. family versus patient)s

P. Jain, J.L. Krieger / Patient Education and Counseling 84 (2011) 98104 101patients were often intrigued by her accent, which usually led toquestions about her origin. In this way, even though differences inaccent sometimes created initial distance between patient andtheir provider, in some instances these differences also facilitatedthe process of building rapport because they led to initiation ofinformal conversation between patient and provider beforeprovider initiated clinical talk. It should be noted that we onlyinterviewed IMG physicians in this study and not the patients. It isthe perception of IMG physicians that differences in their accent donot pose a signicant barrier. Future studies should seek patientsperspectives to understand if different accents of IMGs do posedifculties for the patients. Thus linguistically our data isindicative of convergent accommodation strategies used by IMGphysicians to account for differences.

3.2. Handling emotions

The issue of handling emotions was conceptualized by askingIMG physicians how they managed patient despair and crying,patient expressed fear and other negative emotions, and generalsupport needed by patients in moments of uncertainty anddistress. IMG physicians reported using both verbal and non-verbalstrategies for emotion management. Non-verbal strategies includ-ed empathetic gestures such as supportive touch, eye contact, andrespectful silence. Verbal strategies included attempts to calm andreassure the patient. One physician noted that,

Whenever a patient starts to experience immense negativeemotions, I try to listen actively, giving my full attention; once Ifeel that it is appropriate I start to comfort the patient verballybut I never say I can understand because no one but only theperson undergoing the illness could understand the issue. (Aphysician from India)

IMGs frequently associated emotions with disclosure ofmedical information, particularly delivering bad news. For mostof the IMGs, delivering bad news to a patient is the responsibility ofthe family, not the physician. Thus, many of the physiciansreported that they had to learn how to give patients bad news andhow to handle the resulting emotions. This indicates communica-tion convergence, because IMGs strove to adapt to the perceivedcultural norms of their patients. One IMG gave the following advicefor handling negative emotions, . . . Try to be as understanding asyou can and try not to interrupt him and try to be compassionateand 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 theymanaged differences in cultural norms with respect to medicalinteraction. Data analysis revealed three sub-themes relating toconversational 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 anyother interaction. To ease the patient anxiety and stress, physiciansoften talked about topics unrelated to the purpose of the medicalvisit, such as weather, sports, and holidays. Small talk gave bothphysician and the patient a chance to get acclimated in theinteraction and reduces the anxiety from an otherwise tenseenvironment. IMG physicians however reported that carrying outsmall talk was a key difculty with their patients. One physicianmentioned that he would try to talk about a local, professionalfootball team to start the conversation. However, this convergentstrategy would backre when patients responded by talking aboutparticular players because he possessed only supercial knowl-edge about the team that he learned specically to help startconversations with patients, not out of personal interest. Otherphysicians expressed similar uncertainty about discussing Ameri-can holidays, such as Halloween and Thanksgiving. Thus althoughphysicians were trying to use convergent communication toaccommodate for the difference between them and their patients,their efforts sometime led to more divergence. Another difcultywith conversational norms and scripts related to the use ofabbreviations when working in medical teams to treat a patient.Most IMG interns interviewed in the study reported dissatisfactionwith the use of abbreviations by medical teams because they arestill not acculturated enough to learn the medical lingo. A rst yearresident recounted the following incident:

Initially when I came here and when I started my residency, therst month was very hard for me in the sense that medically itwas not hard, but there was the way they use short terms herelike CBCs or like one of the word they say . . . what are the CMP?Lets get a nger stick. What is nger stick? It was actually anger stick with loopholes. So, these are like some quick termslike what was a CRIT which was hematocrit. So, some of thelanguage this was a problem for me.

3.3.2. Power/patient-centered communication

The second sub-theme that emerged consisted of commentsmade about power dynamics in the physicianpatient interac-tion. Power was conceptualized in this study as the distributionof control and authority in the interaction. Although no IMGphysician explicitly stated that egalitarian relationship betweenthe physician and the patient was unjust, there were still subtleand nuanced expressions that clearly delineated the concern andconfusions that many IMG physicians experienced in terms ofdifferences in patient care in the US from their home country.One physician from India very eloquently described thedifferences in communication patterns between the U.S. andhis home country and the associated surprise and confusion thatmight be encountered while rst starting the medical practice inthe U.S. He stated, I think in India physicians think they knowwhat is best for the patient; here physicians take into account thepatients opinion as well. A rst year intern from a MiddleEastern country commented, Here the patient has to knoweverything on his disease, our country is different. Mostphysicians noted that they converged to accommodate forpower differences between them and their patients by providingpatients a chance to be actively involved in their treatment. Somealso indicated that convergence was because of the norms andexpectations by U.S. patients and the U.S. medical system and notjust by their choice.

3.3.3. Medical information disclosure

Medical information disclosure was conceptualized as to whomthe information related to the disease will be disclosed the patientor the family. In many countries outside the U.S. and specically inmany collectivist cultures, most of the disease and prognosis-relatedinformation is given to the patients family and friends rather thanthe patients. In the U.S. however, due to condentiality andmalpractice reasons, information is delivered directly to the patient(or patient surrogate). Thus it is no surprise that most IMGphysicians interviewed in the study found it difcult when it cameto disclosure of sensitive information directly to the patient. Onephysician in his third year of residency noted:

The one thing I dont like about the American system is that youare telling the patient face-to-face that he is going to die, whichis something that I dont like. You are telling a dying patient that

strategies of international medical graduates practicing medicinein the U.S. We are not implying that our ndings speak to theexperiences of all the IMG physicians in the U.S. These ndingsoffer an insight into a group of IMG physicians who came fromdifferent countries to practice medicine in a hospital in the U.S.Perhaps experiences of IMGs would differ depending upon theplace they are completing their residency, composition of thepatient population in that institution, as well as other factors.Future research on this topic should examine the inuence ofregional sub-cultures on communication strategies used by IMGphysicians, and the perceptions of patients of IMG physicians.Another area of future research could be comparison of communi-cation strategies used by IMGs who are in their residency practicein the U.S. to the IMG physicians who have experienced practicingmedicine in the U.S. This study provides a rich understanding of the

P. Jain, J.L. Krieger / Patient Education and Counseling 84 (2011) 98104102he only has a few weeks or months left, . . . [if I was the patient] Iwouldnt want to know that.

Not only did physicians recognize that the norms for informa-tion disclosure were different, they also expressed feelings that theculture of medical system in the U.S. did not permit the physicianenough power to make such decisions. For example, severalphysicians expressed the frustration with disclosing everything tothe patient, and one physician referred to it as treating patients askings. Thus, attempts at convergence in these interactionsconsisted of disclosing more information to a patient than thephysician felt necessary and appropriate.

4. Discussion and conclusion

4.1. Discussion

The IMG physicians in this study identied three major areasthat posed a barrier to communicating effectively with patientsnamely language, affect related issues, and differences in culturalnorms regarding medical interaction. These ndings are consistentwith the previous research on the barriers that IMGs mustovercome [1017,21]. This study contributes to the literature byidentifying the strategies IMG physicians use to minimize thedifferences in communication during consultations with their U.S.patients. Our ndings are unique in that, contrary to theassumption that accommodation is always desirable in medicalinteractions [18] we found instances where maintenance ofdifferences was more benecial to the interaction. For example,one of the IMG physicians in our interview noted that shemaintains her accent during the conversation because she sees heraccent as a potential conversation starter with the patient. SomeIMG physicians in our study maintained cultural and linguisticdifferences between themselves and their patients, to maintaintheir own cultural identity, or for more pragmatic reasons, such asestablishing rapport with patients.

IMG physician interaction is such that it involves elements ofintercultural, interpersonal, and intergroup communication be-cause it involves communication between people of two differentcultures who are also members of two distinct groups, but whocommunicate on a personal level. Most previous research assumesthat IMG physicians try to move from intercultural to intergroup tointerpersonal dimension of communication to relate to theirpatients. In other words, IMG physicians start at an interculturalcommunication position because of interaction between people oftwo different cultures [10]. In addition to having interculturalelements, IMG physician patient interaction can also be charac-terized as intergroup communication because physicians andpatients have prescribed roles in medical interaction [18].However, IMG physicians may attempt to deemphasize thetraditional physicianpatient power dynamics by accommodatingto unique linguistics or behavioral characteristics of the patient. Intreating the patient as an individual, and not solely as a member ofthe patient population or a representative of his/her culture, theinteraction becomes one that can be characterized as interpersonalin nature (see Fig. 1).

We are arguing that while the above holds true, there are manyinstances when IMG physicians do not want to accommodate andmaintain the differences between them and their patients (as inthe case of the physician who uses her usual accent). In such cases,these physicians use the intercultural form of communication toenhance interpersonal communication between them and theirpatients. That is, these physicians use differences in culture tofacilitate interpersonal form of communication.

Such strategies are not new in interaction situation involvingpeople of different cultures. For example, Giles et al. found thatdivergent strategies can be used to express attitudes and to bringmeaning and understanding to the interaction [20]. They furthernote that delineation of differences in some form indicate to theopposite party that the interactant does not belong to the hostculture which can be helpful in achieving mutual understanding.IMG physicians can take advantage of such expectations to initiatesmall talk with the patients and to build rapport and long-termrelationship. Of course this strategy could also backre, butperhaps patients might appreciate differences and use those todevelop relationship with the IMG physician. IMG physiciansmight also use these differences to maintain their cultural identity.Moreover, they might nd the maintenance of differences morepragmatic than converging as these differences sometimes providethem a way to start conversation with their patients. Therefore, theresearch needs to move beyond the overarching assumption thatphysicians should accommodate to their patients and explore howcan physicians use differences between them and their patients tomake the interaction more interpersonal and fruitful in nature.

One of the strengths of this study is that it gives voice to apopulation that is very difcult to access and is signicantlyunderstudied, but who constitutes a critical component of theAmerican healthcare system. To our knowledge, this is one of therst studies in the eld of communication that tries to explore howIMG physicians in residency programs learn to respond to thecommunication barriers posed by their status as an internationalmedical graduate. Specically, this study extends previous researchby not only describing the communication barriers of IMGs, but byalso illuminating the strategies they use to overcome those barriersincluding both accommodation and maintenance. Although culturaldifferences do pose certain challenges for IMGs, it is important forthe medical community to be aware of the ways that thesephysicians are using their background to benet their practice.

It should be noted that, this study relied on physicians from onehealthcare system in one geographical region of the U.S. Thus, thendings of the study should not be generalized to all IMGs, butrather offer an initial step in understanding the accommodation

Fig. 1. Different dimensions of IMG physician patient communication.

P. Jain, J.L. Krieger / Patient Education and Counseling 84 (2011) 98104 103accommodation processes involved in intercultural exchange inmedical interaction where physician rather than patient belongs toa cultural minority group.

To our knowledge, previous research has not looked into how theaccommodation processes work when power dynamics are sharedin the interaction. For example, in terms of ethnic identity, IMGphysicians typically belong to cultural minority groups; in otherwords groups that have been historically marginalized in the society.In the medical interaction, however, physicians are perceived tohave more power than patients [18]. Therefore, by understandinghow IMG physicians accommodate in interactions when they havehigh professional status but belong to a culturally marginalizedgroup is important because perhaps some of the views expressed bythese physicians regarding the feelings of the loss of power mighthave been derived by the feelings of lacking the power in the societalcontext. Moreover, by illustrating when IMG physicians do notaccommodate in the interaction, we challenge the previous researchand training guidelines for IMG physicians that emphasizeacculturating IMGs to the culture of the U.S. so that they cancommunicate effectively with North American patients.

This study provides a rich understanding of communicationstrategies used by IMG physicians when they start practicingmedicine in the U.S. However, there were some limitations. Forexample, we did not explore the issues related to organizationaldifferences that IMG physicians encounter when starting theirmedical practice in the U.S. The medical system in the U.S. is one ofthe most sophisticated but also extremely complicated entities.Thus it is important to explore the organizational accommodationprocesses that many IMG physicians might undergo when theystart residency training in the U.S. because adjustment andacculturation into organizational climate could impact theirperformance and in turn impact the patient care that thesephysicians impart. Future research should also focus on thelifestyle differences that IMG physicians experience when theycome to the U.S. for residency and impact of these differences ontheir work productivity and quality of medical care provided.Finally, we support the recommendations proposed by previousresearch that a rigorous, multifaceted training program beinstituted that helps IMG physicians in acculturating to the U.S.work culture from different angles, especially when they rst beginthe residency training [11,16,17,24,3133]. Although some insti-tutions such as Albert Einstein Medical Center in Philadelphiaalready have a component of cultural competence built in theirresidency programs [34], such programs are far from the norm. Wesuggest that these training programs should be culturally sensitiveto the needs of the IMGs so that they can also maintain theircultural identity. They should emphasize the strategies IMGphysicians could use, including convergence, maintenance, anddivergence that might be benecial for these physicians. Finally,institutions can perhaps look at ways different than just training tohelp in transition of these physicians. For example IMG physicianscould be matched up with a more experienced IMG physician fromsimilar culture, standardized patients, or patient advocates whocould help the IMG physicians in transition to the U.S. healthcaresystem. Increasing cultural sensitivity during the residencyprogram will not only improve the quality of care provided byIMGs, but could also improve patients overall satisfaction with themedical system.

4.2. Conclusion

In sum, this study enhanced our understanding of the issues thatIMG physicians face in communicating with their patients and thestrategies they adopt to accommodate those differences. Thesedescriptions of how IMGs communicatively negotiate interculturalpatient encounters form the groundwork for designing futurestudies to further explore this issue. Since IMG physicians bringdifferent cultural perspectives to the patient care and the healthcaresystem, educating them regarding cultural norms of the U.S. ingeneral, including regional norms associated with the location oftheir practice could help them in becoming more culturallysensitive. Furthermore, the new IMG residents might also benetfrom learning about medical culture in the U.S., including physicianpatient communication practices. This training might force them toreconsider the norms they might have regarding physicianpatientrelationship based on their medical education in their country oforigin. Educating IMG physicians regarding the norms of medicine inthe U.S. might help these physicians improve communication withtheir patients which would enable them to deliver quality care. It isnot only benecial for the self-development of IMG doctors and thehealthcare system in general, but helping these physicians to becompetent communicator is crucial to the well-being and healthoutcomes of the most important entity in this entire gamut ofhealthcare: the patients.

4.3. Practice implications

There are many practical implications of these ndings. Mostparticipants were acutely aware of the cultural differencesbetween themselves and their patients. For example, all the IMGsreported differences in language in terms of different accents,paralingustics, and use of slang words as a difcult situation.None of the IMGs felt that their knowledge of English languagewas so limited that they had difculties communicating with thepatients or their colleagues. However, a number of physicians feltthat sometimes language posed as a barrier. In the absence ofcomfortable linguistic ability and other cultural differences,long-term goals of establishing rapport with patients and gainingtheir trust might suffer. International physicians in this studyfound it difcult to engage in small talk with their patients andsometimes felt at a loss in terms of topics of conversation withpatients other than discussing their clinical information. Theresults of this study support the recommendations of [21] and[28] that language classes be made available for internationaldoctors. The main focus of the language classes should be uponteaching culturally appropriate language and acculturation withrespect to usage of slang words, idiomatic English, and othercolloquial terms prevalent in that part of the U.S. where the IMGpractices.

Our results are similar to the previous research in the area thatsuggests that IMGs experience cultural and social differences,which could impact the patient care [1017,21]. Many physiciansfor example noted their frustration in terms of medical informationdisclosure and DNR procedures. These kind of difcult decisionscould be stressful for both patients and the physicians and henceIMGs who practice medicine in this country should be made awareof such cultural norm and condentiality practices not just from anorganizational standpoint, but also from a more humane andemotional perspective.

Acknowledgement

The authors are grateful to Dr. Vinayak Shukla for his assistancewith data collection, Don Cegala and Rick Street for their valuablefeedback on a previous version of this manuscript, and the editorand anonymous reviewers for their helpful input.

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Moving beyond the language barrier: The communication strategies used by international medical graduates in intercultural medical encountersIntroductionCommunication strategies used in medical interactionsNegotiating communication challenges in physician-patient interactionObjectives

MethodParticipantsData collectionData analysis

ResultsLanguageHandling emotionsDifferences in norms related to medical interactionConversational norms and scriptsPower/patient-centered communicationMedical information disclosure

Discussion and conclusionDiscussionConclusionPractice implications

AcknowledgementReferences