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Overcoming Cultural Barriers: International Medical Graduates in the United States
Kevin Fiscella, MD, MPH;
Richard Frankel, PhD
University of Rochester School of Medicine and Dentistry, Rochester, NY
JAMA. 2000;283:1751.
It is widely accepted that cultural differences between physicians and patients can shape medical encounters and affect quality of care. A large body of research documents the effect of patients' race or ethnicity on physician decision-making and demonstrates that health-related beliefs affect health outcomes.1-2 While many training programs have focused attention on teaching US medical graduates (USMGs) to overcome cultural barriers, little attention has been given to the effect of cultural difference on encounters between international medical graduates (IMGs) and their patients.
As a framework for discussing the major cultural challenges facing IMGs in providing care to patients in the United States, we use a model3 that describes 3 core tasks of the health care provider—gathering data, developing rapport, and educating and motivating the patient—each of which can present difficulties to IMGs who are not fully acculturated to US society.
Residency programs trying to improve IMGs' data-gathering skills have focused primarily on teaching essential English-language skills to IMGs educated in non–English-speaking countries.4 Considerably less attention has been given to teaching IMGs to recognize regional patient dialects, colloquial speech, body language, and speech inflection, yet studies show that even IMGs who are proficient in standard English may find it difficult to understand patients' more subtle or informal means of communication.5 Formal English classes may not prepare an IMG to recognize a patient's use of the phrase "high blood" to refer to hypertension, for example, or to understand a substance user who says "one day at a time" to allude to the philosophy of Alcoholics Anonymous.
Developing rapport and responding to patients' emotions may also be a challenging task for medical graduates from non-Western countries. A 1999 study of the role of race and gender in the patient-physician relationship indicated that patients report more satisfaction in a given medical encounter when their physician is of the same race and/or ethnicity.6 Both IMGs and US medical graduates who belong to ethnic or racial minorities may find it difficult to establish rapport with patients who do not share their appearance or background.
Furthermore, many IMGs come from developing countries where epidemic disease, physician shortages, and disparities in education leave little room for exploration of the patient's story as a focus for clinical training. As a result, some educators have suggested that communication skills are not a primary concern of these countries' undergraduate medical curriculum.7 Graduates may find it difficult to shift priorities once they arrive in the United States.
Further complicating IMGs' efforts to establish rapport with their patients is the widely held but infrequently substantiated perception that IMGs are not as well-trained or as qualified as their US-trained counterparts.8 A 1997 study of residents in a primary care training program identified "fear of patient bias" as a major factor shaping IMGs' approach to their US patients.9 These fears of rejection or of being singled out may cause IMGs to be appear more aloof in their interactions with patients, or to insist more unyieldingly on their own authority as physicians.
Finally, differences between IMGs' and patients' health-related beliefs may affect patients' adherence to these physicians' medical advice. A 1990 study of foreign-born IMGs found significant disparities between patients' and IMGs' attitudes toward health-related issues such as family involvement in health care, the meaning of facial expressions, and the use of life-sustaining technology.10 Although it is not clear whether these differences were owing to residents' foreign upbringing or their education in a foreign medical school, they had the potential to change patients' trust in their physicians' instructions.
In the future, medical educators will need to take cultural differences into account when training IMGs for practice in the United States. Tools such as mixed IMG and USMG support groups, international student retreats, cultural-sensitivity training, and standardized patients may prove useful in achieving this goal.
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