Medical EducationMoving beyond the language barrier: The communication strategies used by international medical graduates in intercultural medical encounters
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], [5], [6]. This suggests shared beliefs are an important aspect of provider–patient relationships that likely influence patient outcomes [4], [5], [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.
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], [11], [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], [11], [12]. Although previous research has identified the communication challenges that many IMGs face [10], [11], [12], [13], [14], [15], [16], [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.
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.
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], [11], [12], [13], [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 relationship-centered 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. 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.
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:
Section snippets
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
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
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], [11], [12], [13], [14], [15], [16], [17], [21]. This study contributes to the literature by identifying the strategies IMG physicians use to minimize the differences
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.
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