10: Training of International Medical Graduates

This chapter will review issues involved in the training and education of international medical graduates (IMGs), including differing views of psychiatric conditions and treatment; differences in educational experiences; clinical issues involving interactions with patients and nonphysician staff; technology and documentation; psychosocial issues; and medical ethics. General suggestions are offered regarding possible modifications to residency education to address the special needs of these trainees. As in any discussion of cross-cultural differences, the tremendous variability in the backgrounds of IMGs must be acknowledged. Generalizations will always be qualified and may not reflect the experience of all IMGs.

International medical graduates are filling an increasing proportion of openings in US primary care specialties. Match results from 2013 indicate that 13% of postgraduate year (PGY)1 family medicine residents were non-US citizen IMGs with comparable figures of 27% for internal medicine and 11% of pediatrics. The percentage of IMGs entering internal medicine residencies has remained fairly constant over the past several years while percentages of non-US citizen IMGs entering family medicine and pediatric residencies has declined slightly. In 2013, the top three countries for IMGs’ medical education were India, the Philippines, and Mexico. At present, about 30% of practicing physicians in primary care specialties come from outside the United States. A similar pattern exists for Canada, Britain, and Australia. For example, in Britain, one-third of all practicing physicians are IMGs. As noted above, in the United States, IMGs are well represented in primary care specialties (family medicine, internal medicine, and pediatrics) and it is estimated that they will soon represent 35% of the primary care physician workforce. International Medical Graduates currently provide a disproportionate share of health care in medically underserved areas.

As noted by geographic data, a high proportion of US and Canadian noncitizen physicians come from less developed countries that are poor in resources. In addition to the differences in educational content and pedagogy, many IMGs come from cultures in which norms differ from the United States regarding communication style, male–female relationships, and views of children and the elderly. Given this increased internationalization of medical residents, assumptions about prior medical training, based on US-educated physicians, are likely to be inaccurate.

In the United States, the biopsychosocial model has strongly influenced primary care and community medicine. While the diverse backgrounds of IMGs are valuable in caring for a multiethnic and increasingly diverse US population, the extent to which IMGs have been trained in the biopsychosocial model differs tremendously depending on the country in which the resident was trained. For instance, with a few exceptions, such as Canada, England, Australia, South Africa, and the Netherlands, applied behavioral science and psychology is much better developed in the United States than elsewhere in the world. One recent study examined whether differences in medical training affected IMGs’ recognition of late-life depression in standardized vignettes of older patients. Among 178 primary care physicians and 321 psychiatrists, IMGs were significantly less likely than the US medical graduates (USMGs) to make the correct diagnosis of depression or recommend treatment with a first-line antidepressant. The authors proposed that the decreased diagnosis and treatment of late-life depression by IMGs may be attributable to decreased familiarity with depressive symptoms due to different training or cultural paradigms of depression.

A biopsychosocial framework also implicitly underlies sexual medicine and pain management, topics also largely absent in non-Western medical school curricula. In the case of sexual medicine, cultural factors associated with prohibitions regarding premarital sex, sexual orientation, and sexual activity in later life may make it less likely that IMGs will broach these topics with patients. This reluctance is likely to extend to assessing and treating medication-induced sexual dysfunction. With respect to pain management, a recent report found that only 5 out of 300 medical schools in India included pain management and/or palliative care in their curricula.

Our experiences in family medicine residency training are consistent with these observations. As our programs matched greater numbers of IMGs, physician faculty increasingly commented that many of these residents did not appear to appreciate the psychological and social components of primary care. For example, without prompting and even with direct modeling, an IMG resident might interview a 17-year-old pregnant patient without inquiring about the patient’s feelings about the pregnancy; the father of the child; parental/family support; whether and how she plans to continue her education; and the availability of other social supports.

Moreover, comments by the IMGs with whom we worked suggested that many of the common mental health conditions seen in the United States were not commonly diagnosed or treated in their home countries. These comments are supported by cross-cultural research. For example, in Japan major depressive disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V), is only currently gaining acceptance. Historically, Utsobyo was the term for clinically significant depression; however, this condition is severe and involved debilitating psychotic symptoms requiring inpatient care. A related condition, Yuutsu, a melancholic state having moral connotations, was often prized in Japanese culture. Kokoro no kaze, the Western construct of depression, is beginning to gain acceptance as a “cold of the soul.”

Many IMGs that we trained viewed attention deficit hyperactivity disorder (ADHD), as misbehavior rather than a medical condition requiring medication. These differences in practice appeared to stem both from differences in previous training (i.e., limited education in behavioral medicine) as well as acculturation factors (i.e., the way mental health was conceptualized in the resident’s home country).

While medical schools vary widely internationally, residents from non-Western countries describe vastly different educational experiences than the typical US graduate. First, in many Asian countries, entrance into medical school occurs directly after completion of high school. While there are some 6-year medical school programs in the United States that take students at a similar point in their educational career, most students in the United States earn a bachelor’s degree before applying to medical school. While meeting medical school requirements in the sciences, many US medical school applicants major in fields such as English literature, history, psychology, foreign language, or even art history. In contrast, in those countries in which students enter medical school at 17 years of age, a direct career trajectory heavily loaded with education in the biological sciences precludes broadening the student’s scope of knowledge and intellectual exploration in the humanities.

Approaches to teaching and evaluation of students’ knowledge also frequently differ by country. In many international schools, rote memorization of information from textbooks and lectures is the principle learning style. In the United States, there is more emphasis on the application of medical knowledge and on small group learning experiences such as “problem-based learning” (PBL), rather than pure memorization of information. The current US medical school emphasis on evidence-based medicine (EBM), combined with PBL, encourages critical analysis of knowledge and its applicability to a given context rather than retention of facts. The interactional style of many US educators, often including games requiring learner participation (e.g., “Pharmacotherapy Jeopardy”), is a new experience for many IMGs. Ironically, however, the United States relies heavily on multiple-choice exams to evaluate medical students, residents (in training exams), and practicing physicians (board exams)—thereby reinforcing the memorization of facts. Outside of the United States, essay and oral exams are more commonly used to assess medical students’ knowledge. In addition, Objective Structured Clinical Examinations (OSCEs) featuring role playing by standardized patients are not widely used outside of the United States, Canada, and Western Europe. In many developing countries, rather than being observed by faculty, it is assumed that directly observing faculty mentors’ interactions with patients will provide adequate training to medical students. In these societies, the relationship component of the clinical encounter is often minimized.

International medical graduates frequently come from societies in which there is a rigid hierarchy between students and teachers. International graduates often demonstrate much greater deference toward faculty than their US-trained counterparts. An ongoing Canadian study concluded that an IMGs’ medical school experience is characterized by “… an authoritarian didactic professor in large group settings.” In these countries, two-way exchanges of ideas are also very rare—a learner openly questioning a faculty member would be considered impolite, if not disrespectful. These differences are particularly evident when learners are asked to evaluate their teachers. The US-trained residents and students have considerable experience evaluating faculty; student evaluations are commonly used for promotion and tenure decisions in undergraduate colleges and universities. International Medical Graduates often indicate that they are very uncomfortable evaluating their US faculty and consider it inappropriate.

This reticence to speak up in the presence of authority often extends to rounds and precepting interactions, frequently leading the US-trained faculty member to conclude erroneously that the IMG has a deficient knowledge base. While limited, available patient outcome data suggest otherwise. Norcini and colleagues examined a large pool of patients with congestive heart failure and/or myocardial infarction. The US-licensed IMGs had significantly lower mortality rates compared with patients cared for by the American-educated or the US-citizen IMGs. However, the IMG’s knowledge may not be evident in precepting encounters. Rather than providing to preceptors the presenting problem, evaluation results, diagnosis, and plan as USMGs are trained to do, some IMG’s may provide only the patient evaluation findings, and not offer problem lists, diagnoses, or treatment recommendations. This reticence is often mistaken for a deficient knowledge base by the US-trained faculty. International Medical Graduates from some cultures may perceive that offering this concluding information without specific prompting from the supervising physician is “showing off” and a sign of disrespect for a faculty member. In many Asian countries, teachers are held in very high esteem and a learner who “knows too much” would be seen as offending a supervising clinician. Even when presenting diagnoses and treatment recommendations, this information may be tentatively communicated out of respect. Similarly, when desiring assistance with a patient, the IMG resident may not make a direct request but expect that the omniscient faculty member will recognize their difficulties and spontaneously provide the necessary help.

Patient Care & Physician–Patient Interaction

Many IMGs come from third-world countries and have a wealth of experience with diseases that their US counterparts rarely see. For example, early childhood death due to diarrhea and parasitic diseases are relatively uncommon in the United States compared with the developing world. The physician–patient relationship also differs across cultures. Many IMGs come from countries in which a paternalistic style of medical practice still predominates. Under the basic tenets of informed consent, patients have a right to know what is wrong with them, what treatments are being recommended, the risks and benefits of the treatment(s), and alternatives—including no treatment. The ultimate decision maker is the patient with the physician acting more as an expert facilitator. This model is in stark contrast to the approach in India described by a family medicine resident from that country:

Similar to the authority-based instructional style characteristic of medical schools in many developing countries, IMGs are often accustomed to respectful, deferential patients. Coming from this background, IMGs are likely to be disoriented and perhaps insulted by American patients coming to them requesting specific tests or medications that they have seen on television and the Internet, or that have been recommended by friends. Because much of primary care in the United States emphasizes chronic disease management rather than treatment of acute illness, patient adherence has become a particularly challenging issue. Some IMGs were brought up in systems that have little respect for patients who do not take their antihypertensive medications or follow their diabetic regimen. The concept of having a repertoire of communication skills for enhancing patient adherence is new to IMGs trained in a country where physician authority, power, and control are unquestioned. The idea of a difficult patient, requiring specialized interpersonal management skills, may not have been viewed as part of the physician’s responsibility. Models such as the transtheoretical approach in which patient adherence is conceptualized by stages of change (e.g., precontemplation, contemplation, preparation, and action) are unlikely to be part of the IMG’s knowledge base. Health behavior change requires active listening, negotiation, setting initially small goals, and providing social support for the patient (see Chapter 19). These skills are unlikely to be taught outside the United States, nor are health behavior models that provide a conceptual framework for counseling these patients.

Even if the IMG begins practice with an appreciation of the American patient as a consumer, there are still concrete challenges, such as language barriers. Often IMGs who have spoken English much of their lives still find conversations with US patients challenging:

Particularly those IMGs who have learned English as a second language find it confusing that their patients do not speak “proper” English. American English is strongly impacted by regional and ethnic factors influencing word choice, idioms, intonation, and emphasis. Similarly, US patients may be unfamiliar with the accent and terminology (some of which includes British words) of IMGs who acquired much of their English outside the United States. Finally, social psychologists suggest that 90% of communication is nonverbal. As anthropologists and international businessmen have noted, gestures and other physical styles of communication are culture bound. For example, the shaking of the head from side-to-side, while meaning “no” to most Westerners is often an expression of agreement among persons from India.

Interactions with the Nonphysician Staff

US medical care is multidisciplinary. International Medical Graduates need to learn to work with and respect social workers, pharmacists, nurses, care managers, nurse practitioners, physicians’ assistants, physical therapists, and other professions who are all involved in the care of patients. These teams often have a horizontal rather than hierarchical power configuration. Physicians frequently manage patients as a member of a complex team, and though in many cases they coordinate care, in other instances (e.g., hospice care), nonphysician providers take the lead in many aspects of patient care. As one IMG said: “I can’t believe the number of people who tell me how to do things their way—and I’m the one who went to medical school.”

In many countries, the interdisciplinary nature of health care is not as well developed, if recognized at all. Physicians are the lead decision makers, and their orders are obeyed unquestioningly. Additionally, in countries with social and economic distinctions, ancillary workers are typically from different social strata than physicians. In US outpatient settings, the easy familiarity existing between staff, including calling physicians by their first names, is often seen as disrespectful and overly familiar by those trained in a more formal, hierarchical system.

Medical Ethics

Many IMGs come from societies where physician paternalism is still the rule. In countries in which physician paternalism predominates, ethical principles such as autonomous informed consent are often not culturally normative. Ethical dilemmas can be evaluated from the perspective of four principles: autonomy, benevolence, nonmaleficence (do no harm), and justice. Over the past 50 years, US health care has deemphasized beneficence and increasingly valued autonomy as a preeminent principle. Changes in disclosing a cancer diagnosis to patients clearly illustrate this historical shift. In 1961, 90% of American oncologists indicated that they would not disclose a cancer diagnosis to a patient. Twenty years later, this pattern had been reversed, in that oncologists routinely informed patients of their condition. The US emphasis on autonomy, which takes the form of giving patients choices about how to treat their condition (e.g., “You could take any of these three medicines; which one would you like to try?”), is likely to be disorienting to IMGs from countries where the physician remains an unchallenged authority.

For a number of years, the first author routinely polled groups of internal medicine residents (comprised of approximately 75% IMGs) about whether physicians in their home countries routinely disclosed serious or terminal conditions to patients. Many, if not most, residents from India, Pakistan, and Eastern Europe responded “no.” Cross-cultural research suggests that beneficence typically guides nondisclosure. In these societies, it is seen as cruel to inflict emotional distress on an already ill person through such a disclosure. In Jain and Krieger’s study of IMGs’ communication strategies, a third year resident expressed distress about American medicine’s standard of honesty:

In societies in which patients are not informed of their diagnosis, the locus of decision making is likely to differ from the US norm. Family members, often within a network that includes the physician, make medical decisions for the patient. In Pakistan, where family decision making is common, the physician may become adopted into the family and addressed as “parent,” “aunt,” “uncle,” or “sibling.”

This collectivist value may conflict with US laws and ethics emphasizing individual autonomy. International Medical Graduates from traditional societies, particularly when treating a patient in the United States from their own ethnic background, may feel caught between the legal requirements for disclosure and their own culture’s ethics about proper physician conduct.

Technology

Many IMGs are from countries with far less access to sophisticated laboratory and radiologic testing or choices for pharmacotherapy. As a result, they are often particularly skilled in obtaining maximum information from the history and physical examination, since other data sources are limited. The educational system in many international medical schools rewards acumen in physical exam skills, which is heavily emphasized in evaluating the competence of medical students and residents. The routine of ordering multiple tests is initially surprising to many IMGs: “When I first started my training in the US, I was stunned by the number of tests that we ordered. I wish I had the luxury of ordering an echocardiogram for every heart murmur or a CT scan for every head injury back home!”

The influence of technology has spread to the medical record, commonly used pharmaceutical reference sources, and treatment guidelines—all of which are increasingly digitized in the United States. Personal digital assistants (PDAs) and electronic medical records further challenge physicians trained in systems with significantly less technology.

Meghani and Vijay noted that many IMGs had rarely or never prescribed opioid analgesics. This lack of experience often reflects the limited availability of these drugs in their home countries. For example, the amount of fentanyl available to one person in the United States is the same quantity available to 2323 individuals in the Philippines.

Documentation & Litigation

Depending on their training, IMGs have varying degrees of exposure to medical documentation formats common in the United States. While some are aware of the Subjective, Objective, Assessment, and Plan (SOAP) format, others, once exposed to this approach, cannot understand its significance. The vast majority indicate that the amount of detail required in patient notes far exceeds customary practice in their home countries. Additionally, the presence of third parties “looking over the physician’s shoulder” at the chart notes creates some anxiety. One IMG resident observed: “Documentation is a huge issue here. Not just documenting in a professional way, but in a legal way. Every word is important.”

Malpractice litigation is a relatively new concept in many developing countries. Concerns such as patient abandonment, negligence, and the dictum “if it isn’t written in the chart, it didn’t happen,” are new to many IMGs. Some report frequently being worried that they have “missed something” in a patient’s care that could lead to a lawsuit.

IMGs’ Views of Psychiatric Conditions

International medical graduates often have different views of psychiatric conditions compared to US-trained residents and faculty. In a qualitative study investigating the behavioral science training of IMG residents prior to coming to the United States, the majority of respondents commented that rates of mental disorders appeared to be higher in the United States than in their home countries. International Medical Graduate residents will sometimes attribute these higher rates to differences in the US social structure—such as the widespread use of nursing homes, elders without visitors in the hospital, and mothers raising several children alone—as the primary reasons there is more depression in the United States. These residents perceive family support to be stronger in their home countries, buffering against mental illness. The well-established finding by the World Health Organization of better outcomes for persons diagnosed with schizophrenia in less-developed versus more-westernized countries provides some indirect support for these observations.

International medical graduates also tend to perceive strong religious faith as a valuable coping skill. These residents suggest that Americans often become “depressed” in response to chronic or daily struggles, in contrast with their international counterparts who may be more likely to accept their fate and avoid converting emotional distress into a medical condition:

Other cultures share with the United States the belief that psychiatric mental disorders are a form of illness, but the perceived causes of mental illness may differ. For example, in Karachi, Pakistan, Qidwai and Azam found that 30% of primary care patients believed that psychiatric illness was caused by supernatural powers and spirits. These patients commonly sought treatment from a Hakim (12%), spiritual healer (12%), and family support (2.5%).

The stigma of mental illness also affects how these issues are addressed by IMG residents in primary care. In many cultures, mental health issues are viewed as shameful and taboo: “You practically never do this … [in my country] … psychiatry is for the mad man.” Due to their own culturally based misgivings about mental health issues, many residents fear they will offend patients and therefore avoid such questioning.

Views of Mental Health Treatment

Not surprisingly, many IMGs report minimal exposure to behavioral medicine prior to residency education in the United States. Many cultures view anxiety and milder mood disorders as variations on normal functioning rather than as illnesses. In these societies, the prototype of a psychiatric condition is a severe illness such as psychotic depression, bipolar I disorder or schizophrenia. Clinical training often involves observerships or walking rounds in institutions for patients manifesting debilitating psychiatric conditions. One resident from India reported:

Even in countries in which primary care physicians inquire about and treat psychiatric symptoms, there may be little diagnostic specificity. For example, one IMG from Bosnia stated:

The sociopolitical history in IMGs’ home countries may influence how they approach mental disorders. Family physicians in Russia revealed a reluctance to refer for mental health care, in part due to a history, in which psychology and psychiatry were used by the State to control political dissidents. In the Stalinist era it was said, “No person, no problem.” Diagnoses such as schizophrenia meant that there was “no person,” and the “patient” could be locked up indefinitely in a mental hospital, which was little different than a prison. (This practice has recently been resurrected in Russia by the Putin government.) People became afraid of psychiatrists. As one of the interviewees said, “The fear of that kind of specialist is probably somewhere in the genetic code.”

Family Life

International medical graduates, particularly from East Asian countries and the Philippines, are startled by many aspects of US family life, including single-parent families, cohabiting relationships, and serial monogamy. Before beginning residency, IMGs obtain their knowledge about the U.S. families from several sources, including television “talk” shows as well as from listening to the discussions of the personal lives of office staff in settings where they were completing observerships.

Usually, IMGs are stunned by the permissive parenting practices in the United States and the childhood behavior problems that they believe result from this approach. Many find it odd that conditions like childhood ADHD, not commonly diagnosed in their home countries, are so common in the United States. As one resident from Eastern Europe said:

International medical graduates tend to view parental discipline, even when physically harsh, as important for preventing oppositional and disrespectful behavior among children. The notion of child physical abuse is new to many IMGs. They are surprised that the state becomes involved when parents physically discipline their children. Child protective services’ power to remove children from their parents’ custody is very troubling to many of these residents. What is considered abusive in the United States may be seen as responsible parenting that builds character in their home countries. A resident from India noted that the children of strict parents do very well in school and college. In addition to influencing the clinical context, many IMGs have children of their own that they are raising in a new country with different parenting practices. They may themselves be experiencing conflicts regarding appropriate discipline.

Sexual Behavior

Early sexual experiences are particularly troubling to IMGs raised in traditional societies governed by strong religious and collectivist values. Sciolla and colleagues suggest that IMGs raised in many non-Western cultures may view sexuality as intensely private or even shameful. Premarital sex, while occurring, is a taboo subject.

Our observations of IMG residents suggest two common patient management styles. One approach is to avoid discussing sexuality with adolescents seen in the office. Preceptors often need to remind residents repeatedly to raise these issues (see Chapter 32). Even then, residents often appear uncomfortable with the topic—speaking awkwardly while looking at the floor rather than the patient. The other approach is to accept that the West is a sexually permissive society. The resident may address sexuality in a matter-of-fact, almost business-like manner. For example, an IMG seeing a 14-year-old girl who recently had her first sexual intercourse approached the patient in much the same way as an adult. A Pap smear and pelvic examinations were conducted, and customary guidance about pregnancy, contraception, and safe sex provided. There was no discussion about the circumstances under which the girl had intercourse (e.g., was it coerced?), the age of the partner, or the patient’s perspective on the experience. Despite research evidence that early sexual activity is associated with sexual abuse history, smoking cigarettes, and using marijuana, the resident raised none of these issues until some of them were suggested by the behavioral scientist observing the encounter.

Nonmarital cohabitation is also a unique experience for many IMGs. In one instance, a resident from the Asia-Pacific region was seeing a hospitalized patient with injuries reportedly sustained through an assault by her boyfriend. The supervising physician had urged the resident to address the issue with the patient and provide her with resources for victims of domestic violence (see Chapter 38). The IMG was confused and didn’t follow through at first. When asked about her reluctance, she responded: “It’s not domestic violence. They are just boyfriend and girlfriend; they’re dating. Each of them has their own house.” The resident was surprised to learn that adult “boyfriends” and “girlfriends” often live together, and domestic violence can indeed occur in these situations.

The increased nuclearization and isolation of generations among the US kinship networks is troubling for IMGs from non-Western cultures, where extended families are common. To those from East Asia, for example, domestic violence in their home country was not a dyadic event with a perpetrator and a victim, but a situation in which the wife’s family members would rightfully intrude into the marriage to protect her. The family should handle this problem rather than the medical–legal system:

Caring for geriatric patients in institutional settings contributes to a view of American families as isolated and cut-off from their extended kinship network. Residents from societies that care for aging family members at home have difficulty comprehending the practice of placing senior family members in impersonal nursing homes: “Nursing homes do not exist in India—because no son or daughter would ever lose the honor of caring for his or her elders, especially a parent.” Similarly, hospitalized patients receiving no visitors—even when family members live nearby—are troubling to IMGs. One resident commented that he could now understand why he saw so many depressed patients here in the United States compared with his home country: “Back home families are crucial. Here, people are left alone. You have a chance to get depressed much more here.”

Challenges In Learning Behavioral Science

At a fundamental level, many IMGs are challenged by the inclusion of psychiatry and psychosocial aspects of the patient’s life as a significant component of Western medical practice. Coming from societies where diagnosis of mental health problems was often less common and those syndromes that were diagnosed were typically severe, many resident IMGs initially feel inadequate to diagnose and treat these conditions. Early in residency, some IMGs respond by referring nearly all depressed and anxious patients to psychiatrists. It is important that preceptors establish early in training that diagnosis and treatment of common mood and anxiety disorders, dementias, childhood behavior and adjustment problems, as well as sexual dysfunction, are expected competencies. Unless the case is complicated and beyond the scope of a nonspecialist (e.g., schizophrenia), the resident should learn to manage the patient.

Diagnostic interviewing for mental health conditions is particularly challenging for IMGs. After taking the United States Medical Licensing Exam (USMLE), most IMGs are familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM) system and the use of explicit criteria for diagnosis. It may be difficult for them, however, to convert these dimensions to conversational questions. Often the questions tend to be verbatim recitations of the DSM criteria and have a stilted quality that confuses the patient (e.g., “Are you having feelings of worthlessness or inappropriate guilt?” Or “Do you have chronic feelings of emptiness?”). IMGs often recognize that they do not know how to ask about these types of symptoms and consequently omit them. This reluctance may be particularly pronounced for questions about self-harm, suicide, abuse, and illegal acts. One IMG resident describes his experience of learning how to ask sensitive questions:

Another IMG said:

During their behavioral science training, we have noticed unspoken discomfort when IMG residents are asked to interview, for example, a 14-year-old unwed mother, an openly lesbian couple, or divorced parents—each present with their new spouse. The resident who has done quite well interviewing other patients with psychosocial issues often seems at a loss about how to proceed with these family configurations. After sensing that they are uncomfortable asking the patient(s) further questions, the behavioral science faculty member will take over the interview for awhile. Later in the interview, we typically try to turn it back over to the resident who often at this point appears less confused and can follow the faculty member’s lead. After the encounter, when asked about their reaction and reason for not continuing the interview, a common response is something like:

General Suggestions

More recently, several programs of educational research and training recommendations for IMGs have emerged. The ECFMG has produced a series of brief video physician–patient vignettes addressing confidentiality, patient requests for specific therapies based on Internet information, interaction with pediatric patients and adolescents, customer service, child abuse, informed consent, and working with nursing staff.

A consistent theme arising in recent research on IMGs is their experience of being “second class citizens.” Having been educationally and often professionally successful in their home countries, proving oneself in a new country and health care system is frustrating and onerous. This issue is particularly sensitive for those IMGs who had practiced independently in their home countries and now are having to undergo re-training. Alienation, loneliness, and anger are common emotional reactions to these challenges. Some residents have shared their fear that they may be unsuccessful in the long sought-after US residency program and be required to return to their home countries. Fears of revealing any knowledge deficiencies may prevent IMGs from directly asking for appropriate faculty assistance. When providing clinical supervision to IMGs, educators should maintain awareness of these underlying dynamics.

International medical graduates would benefit from early acclimatization. Instead of the typical July 1 start date, it would be helpful if some preparatory experiences could begin at least 8–12 weeks before the formal residency year begins. English immersion, and when possible including information on common US medical abbreviations as well as idiomatic English experiences, would be helpful for IMGs with uneven abilities in written and/or spoken English. For those residents who learned English late in life and whose accent is a barrier to understanding, there are specialists in accent reduction who can be quite helpful. There are CD-ROMs and other resources for learning specialized medical terminology.

Other areas that could become part of a preresidency curriculum include medical documentation, the mechanics of ordering lab work and radiographic studies, writing prescriptions, and how to use a PDA. An overview of the US health care system including legal, ethical, and insurance issues would also be valuable. Basic medical interviewing skills can be taught through use of videotapes, simulated patients and role-plays. One resource that may be helpful is the Doc.com interactive web-based curriculum on clinician–patient communication, produced by the American Academy on Communication in Healthcare (see “Other Resources” at the end of chapter). The general “style” that a primary care physician uses when relating to patients, however, is difficult to reduce to a set of skills. IMGs might benefit from shadowing faculty or seasoned primary care physicians as they see patients.

The individualist–collectivist distinction that plays a significant role in ethics and determining moral responsibilities should be discussed explicitly in the context of ethical decision making, end-of-life care, and other relevant areas in medicine. For both US-trained physicians as well as IMGs, an open exploration of these issues, including their cultural and religious background, would allow all physicians to be more sensitive with a broader cultural array of patients.

When IMG residents are having apparent difficulty meeting performance criteria, faculty should consider both cultural and language issues. As anyone who has learned a second language knows, people can appear to understand even if they are only picking up bits and pieces of what is being said. The deference that IMGs show toward faculty may be misinterpreted as a lack of assertiveness, an absence of independent thinking, inadequate knowledge base, or poor motivation. Before drawing conclusions, it would be helpful to have several supportive, noncritical conversations with these residents to better understand their background. During observation of clinical interactions with patients, we noted that an IMG from Pakistan never sat down during any of four to five encounters. In our discussion afterward, the resident indicated that she knew that sitting was the correct thing to do in terms of carrying out an effective interview, but thought it would be disrespectful to sit while the supervisor was present. If we had not clarified this point, we would have “graded” her interview skills as less than optimal.

Suggestions For Teaching Psychiatry & Psychosocial Medicine

Psychosocial content should be introduced early in the first year of residency. To address educational and training needs in behavioral science, a formal block rotation can be scheduled during the resident’s first year. At our program, we added a first-year rotation in addition to the second-year rotation that had been in place for many years. The first-year behavioral science rotation focused more on effective interview skills and several common psychiatric conditions, while the second-year block focuses exclusively on diagnosing and treating mental disorders.

To help residents with wording questions about psychiatric symptoms, we heeded their advice and developed a series of “cheat sheets.” Specifically, we made up a series of laminated cards (they easily fit into a lab coat) with helpful questions to elicit symptoms for many common psychiatric disorders. These became very popular among residents.

Faculty should be aware that patients with diverse backgrounds, customs, and family configurations are likely to be somewhat disconcerting to the IMG resident. In an individual discussion with a resident, the faculty member may want to begin by asking questions such as, “How often have you had the experience of … interviewing an openly gay male, a teenager being raised by foster parents, or a patient who requests a specific test that you don’t think is indicated? Would physicians see patients or situations like these in your home country? Why do you think it’s different here?” The faculty member should demonstrate genuine interest in the resident’s experiences, respect, and intellectual curiosity during this exchange. These conversations can be useful learning experiences for both parties. Next, the clinical instructor should provide some focused information on the topic (e.g., “In the inner city, up to 50% of children are being raised by grandparents. Research shows that raising grandchildren has a negative effect on the grandparents’ health compared to grandparents not raising grandchildren.” Or, “About a third of the US children are born to unmarried women. What is your reaction to that norm?”)

We typically do joint patient interviews with residents as part of their behavioral science training. This allows observational learning of the faculty’s unspoken acceptance of patients and a way of responding to them “like anyone else.” In discussing these issues with IMGs, faculty should appreciate the extent to which patterns of family organization, views of the physician role, and so forth, are culturally relative. For example, many Westerners who automatically accept the norm of “companionate marriage”—a product of an extended friendship, dating relationship, and often a period of cohabitation—may be disturbed by the East Asian custom of arranged marriage. However, the teacher’s genuine, noncritical interest in the background of arranged marriages often creates a climate in which the IMG is receptive to learning about the US relationship variations.

As many seasoned clinical faculty know, patients can be great teachers. IMGs who have been successful in understanding the US patients in a cultural context approach these patients with respect, intellectual curiosity, concern, and a genuine desire to learn. While obtaining pertinent historical and symptomatic information, these physicians can also encourage patients to “tell their story,” and in so doing provide meaning and satisfaction for both doctor and patient.