Patient Education and Counseling 84 (2011) 98104

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Medical Education

Moving beyond the language barrier: The communication strategies used by

international medical graduates in intercultural medical encounters
Parul Jain *, Janice L. Krieger
School of Communication, The Ohio State University, USA

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 26 August 2009
Received in revised form 11 June 2010
Accepted 16 June 2010

Objective: To understand the communication strategies international medical graduates use in medical
interactions to overcome language and cultural barriers.
Methods: In-depth interviews were conducted with 12 international physicians completing their
residency training in internal medicine in a large hospital in Midwestern Ohio. The interview explored
(a) barriers participants encountered while communicating with their patients regarding language,
affect, and culture, and (b) communication convergence strategies used to make the interaction
meaningful.
Results: International physicians use multiple convergence strategies when interacting with their
patients to account for the intercultural and intergroup differences, including repeating information,
changing speaking styles, and using non-verbal communication.
Practice implications: Understanding barriers to communication faced by international physicians and
recognizing accommodation strategies they employ in the interaction could help in training of future
international doctors who come to the U.S. to practice medicine. Early intervention could reduce the time
international physicians spend navigating through the system and trying to learn by experimenting with
different strategies which will allow these physicians to devote more time to patient care. We
recommend developing a training manual that is instructive of the socio-cultural practices of the region
where international physician will start practicing medicine.
2010 Elsevier Ireland Ltd. All rights reserved.

Keywords:
International medical graduates
Physician patient communication
Foreign doctors
Communication accommodation
Convergence
Communication challenges
Communication barriers
Communication strategies

1. Introduction
Effective communication skills are essential to a successful
physicianpatient interaction [1,2]. Culture has an important, but
often understudied, inuence on medical encounters [3]. Patients
report more satisfaction, participation, and positive affect when
interacting with a physician from their same ethnic/racial group
[46]. This suggests shared beliefs are an important aspect of
providerpatient relationships that likely inuence patient outcomes [46]. Furthermore, differences in race, ethnicity, and other
aspects of culture are signicant factors in determining the impact
of communication skills training programs on patient participation
[1,4]. To date, research that has considered the inuence of culture
on physicianpatient communication has focused on interactions
between U.S. American physicians and foreign-born patients [7,8].
This exclusive focus has inhibited academic understanding of
intercultural medical interactions between foreign-born physicians and U.S. American patients.

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

E-mail address: jain.122@osu.edu (P. Jain).
0738-3991/$ see front matter 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2010.06.022

One in every four physicians in the United States is an

international medical graduate (IMGs hereafter) and almost 30%
of IMGs are involved in providing care in various primary care
specialties [9]. Many IMGs receive their medical training in
countries where it is common for physicians to exert a great deal of
control, authority, and power in the medical interaction and rely on
paternalistic mode of communication as compared to the United
States where physicians have been found to employ a wide range
of communication styles [1012]. 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 nd it difcult to understand the concepts of
patient involvement and patient autonomy and have limited to no
experience with physicianpatient communication skills training
[1012]. Although previous research has identied the communication challenges that many IMGs face [1017], there is no
previous research that describes what communication strategies
they use to overcome these challenges. Thus, the purpose of this
study is to explore the communication strategies IMG physicians
use to adjust to interpersonal and socio-cultural differences they
encounter when practicing medicine in the U.S.

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1.1. Communication strategies used in medical interactions

Medical interactions are considered to be an intergroup
communication context because the behaviors of both physicians
and patients are governed by the norms attached to their role in the
encounter [18]. The intergroup nature of the interaction may be even
more salient in intercultural medical situations because of
differences in language or physical appearance. One theoretical
perspective for understanding how intergroup differences are
managed in interactions is Communication Accommodation Theory
(CAT) [19,20]. One of the core tenets of CAT is that people will adjust
their communication style in intergroup interactions. Convergence
is a form of adjustment in which person tries to minimize the
differences in communication between themselves and others. For
example, a physician who avoids using medical jargon with a patient
would be engaging in convergence. The ability to successfully
converge is associated with greater patient satisfaction [19]. Thus, it
is particularly important to understand the communication strategies used by IMGs who have the difcult task of negotiating medical
interactions that are intercultural as well as intergroup.
1.2. Negotiating communication challenges in physicianpatient
interaction
There are a number of communication challenges inherent in
intercultural providerpatient interactions, especially when the
physician is foreign-born. The three most common sources of
difculty for IMGs include language, emotion, and cultural norms
for medical interaction [8,1014,21]. International physicians, like
their U.S. counterparts, undergo rigorous evaluation of their
English prociency 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 fulll 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 prociency. However, it is possible to score
well on this exam but IMGs may experience difculty with
advanced aspects of language use including colloquialisms, idioms,
vernacular terms, accents, regional dialects, voice inection, 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 difcult
to ask questions about a patients 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 signicant role in
emotional expressiveness and the maintenance of relationshipcentered patient care [25]. A physicians ability to competently
manage affect has numerous benets to patients, such as improved
information exchange, greater participation in decision-making, and
increased efcacy 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.

99

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 difculties IMGs face, it is unknown to what extent
they adjust to the various cultural norms of patients in the U.S.
1.3. Objectives
Previous research has identied the linguistic, affective, and
cultural difculties IMG physicians encounter when practicing in
the U.S. What still remains to be explored, however, is the ways in
which IMGs try to adapt their communication to overcome these
barriers. Thus, the following general research question is proposed:
RQ: What communication strategies do IMG physicians use to
minimize differences in language, emotion, and culture when
communicating with their US born patients?
2. Method
2.1. Participants
Participants in the study were internal medicine residents in a
large teaching hospital in Midwestern U.S. Twelve participants,
recruited using snowball sampling, completed a voluntary
interview and a brief survey exploring physician demographics.
Participants ranged in age from 28 to 42 years (M = 32.41,
SD = 3.89). Most of the participants were male (n = 8). Participants
had lived in the U.S. between 1 and 9 years (M = 4.41, SD = 2.25)
and were from six different countries. Six out of 12 interviewees
were originally from India, 2 were from China, and the remaining 4
came from the following countries: Jordan, Lebanon, Nigeria, and
Philippines. At the time of the interview, ve interviewees were in
their rst year of residency training in the U.S., four were in their
second year and three participants were in third year of residency.
2.2. Data collection
The rst author conducted face-to-face interviews with 12
residents completing their residency at an internal medicine
residency program in a hospital in Midwestern part of the U.S. The
interviews were conducted between December 2007 and May
2008. Interviews were appropriate for addressing the research
question in this study because they allowed participants the
opportunity to narrate their experiences and reect on how they
accommodate differences that they experience in the interaction
situations [10,12,24,29,30]. Data saturation occurred after 12
interviews, meaning that no new information or themes emerged
from data analysis [29,30].
Interviews were conducted in a public location outside the
hospital to ensure participant condentiality and to provide them
with a setting where they could comfortably share their opinions.
The interviews were audio-recorded for transcription with the
consent of participants and lasted 35 min on average (range of 18
52 min). We used previous research [13,21] to create semistructured interview guide which served mainly as a framework to
make sure all the themes that we wanted to explore were covered
with each respondent (Table 1). The interviews explored basic
themes such as most difcult issues that IMG physicians encounter
while interacting with patients, communication strategies they
adopt to navigate through those issues, strategies for adjustments
to life as a resident, and suggestions for improving the residency
experiences for IMG physicians. Participants in the study provided
care in both in-hospital settings and ofce settings and thus
recounted both types of experiences.

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Table 1
Interview guide.

1. Describe what it is like to be a resident in (name of hospital). Could you elaborate on some of the experiences that you nd memorable during the residency
period? Prompts: general struggles, how are these different for you because you an international medical graduate? Are there specic challenges that IMGs face
compared to other residents? How is the experience similar/different that what you expected?
2. Describe the process of adjusting to living in the U.S.? Working in the U.S.? Prompts: How did you manage the things during the rst few months of the
residency (explore about support systems, friends, and mentor)? How did you learn to navigate the hospital system?
3. How is being a doctor in the US different from being a doctor in your home country?
4. In ways does being an IMG inuence how you communicate with patients? In what ways does it inuence how patients communicate with you?
5. What do you think is the biggest problem when you communicate with the patients? Prompts: Probe on trust, adherence, language, culture. What strategies
have you found to be helpful that make you, as well as your patient, comfortable during the medical interaction?
6. What type of things you do to help patients understand you (prompts: repeat, change voice inections). Are there times when you dont use those strategies that
you just described? Could you elaborate on certain instances when you did not knowingly or unknowingly used the abovementioned strategies?
7. In what ways do you change the way you speak or behave to be more like your patient? What are the ways that you adopt so that patients could identify
with you and become more comfortable with you during the discussion?
8. To what extent would you have beneted from a training program focusing on communication with patients? If there is a training program, in your opinion
what are some of the main issues that such a program should address?
9. What are some of the most important issues that need to be addressed in order to improve IMGs experiences in the U.S.?
10. Is there anything else that you would like to share regarding healthcare system in the United States that has potential implications on your interaction with
the patients?

2.3. Data analysis

A paid transcriptionist transcribed each audio-recorded interview verbatim. All participant identiers were then removed and
replaced by a code number. Using grounded theory methodology,
both the authors carefully read and open coded each of the 12
transcripts individually, focusing on barriers to communication
with patients and the communication strategies used to overcome
these barriers. Next, both the authors reexamined the open codes
to determine how they related to one another, a process referred to
as axial coding [29,30]. Finally, the rst author reread all the
transcripts and nalized coding, focusing on collapsing codes to
create themes.
We employed several steps to ensure internal validity and rigor
of the analysis. First, we also employed triangulation within
method by asking questions in different ways that explored the
same concept [29,30]. Second, we conducted member checks. At
the end of each interview, the interviewer summarized her notes
for the participants to check for accuracy. Third, we engaged in
peer debrieng by sharing our nding with an IMG physician who
was not part of the study.
3. Results
3.1. Language
We sought to understand language related difculties encountered by IMG physicians, the strategies they used to overcome
these difculties, and if the strategies were indicative of
communication convergence. Language was conceptualized as
verbal and non-verbal communication used in face-to-face
interaction with patients. Consolidation of open codes revealed
that IMG doctors encountered differences in both linguistic and
paralinguistic issues, as illustrated by Table 2. Consistent with
previous research [16,21], about one-fourth of the interviewees
found it difcult to understand the English words used by the
patients. As one physician noted:
The spoken English we dont know very well and how to
express. In your mind you think you know this well but actually
to express or to say it or to interact with the patient is different.
That is a big challenge how you can express yourself and your
clinical judgment well to the patient. (A physician from India)
More commonly, IMGs had difculty with more subtle aspects
of language, such as paralinguistic cues, pronunciation, and use of
colloquialism. Paralinguistic cues were coded as references to

accents, tone, voice inection, and pace. Pronunciation was

conceptualized as the extent to which IMG doctors perceived
that their patients had difculty with the manner in which they
uttered specic words. Colloquial language usage referred to the
use of slang words, idioms, and other popular lingo. Most
interviewees reported difculties with either one or all of these
factors. A third year resident from India explained, Our English is
the British English and the American English is different but after
you come here you start to learn how people pronounce things.
Many IMG physicians indicated a number of accommodation
strategies indicative of convergence to manage differences in
language between them and their patients. Some strategies
indicated by the participants were learning to pronounce words
in usual North American manner and trying to understand and
learn meanings of slang words with the help of media and their
North American friends. Many of the doctors noted that they also
tried to accommodate for differences in accents by either repeating
their sentences or by changing the pace or volume of speech. A
third year IMG resident from the Middle East acknowledged that
he usually spoke quickly, I usually repeat everything I say because
I speak too fast, so I make sure my patients understand what I say. I
try to make 100% sure that my patients understand what I said.
In addition to checking with patients if they understood what
was said, participants also tried to compensate for linguistic
differences through the use of non-verbal gestures. IMGs frequently
reported making a conscious effort to maintain good eye contact,
have a friendly disposition, smile, and vocally convey warmth and
care. The following quote from one participant illustrates this: my
strength is trying to be a good communicator and even though my
English is not perfect but my eye contact is very good.
Although accents did contribute to difculties in the physician
patient interaction, IMG physicians did not perceive this as a
hindrance. One physician, in particular, felt her accent positively
contributed to interactions with patients. She explained that her

Table 2
Convergence strategies and barriers to convergence.
Convergence strategies
 Verbal (e.g. repetition)
 Non-verbal (e.g. eye contact)
 Emotions (e.g. supportive touch)
Barriers to convergence
 Accent (e.g. British pronunciation)
 Vocabulary (e.g. 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

patients were often intrigued by her accent, which usually led to

questions about her origin. In this way, even though differences in
accent sometimes created initial distance between patient and
their provider, in some instances these differences also facilitated
the process of building rapport because they led to initiation of
informal conversation between patient and provider before
provider initiated clinical talk. It should be noted that we only
interviewed IMG physicians in this study and not the patients. It is
the perception of IMG physicians that differences in their accent do
not pose a signicant barrier. Future studies should seek patients
perspectives to understand if different accents of IMGs do pose
difculties for the patients. Thus linguistically our data is
indicative of convergent accommodation strategies used by IMG
physicians to account for differences.
3.2. Handling emotions
The issue of handling emotions was conceptualized by asking
IMG physicians how they managed patient despair and crying,
patient expressed fear and other negative emotions, and general
support needed by patients in moments of uncertainty and
distress. IMG physicians reported using both verbal and non-verbal
strategies for emotion management. Non-verbal strategies included empathetic gestures such as supportive touch, eye contact, and
respectful silence. Verbal strategies included attempts to calm and
reassure the patient. One physician noted that,
Whenever a patient starts to experience immense negative
emotions, I try to listen actively, giving my full attention; once I
feel that it is appropriate I start to comfort the patient verbally
but I never say I can understand because no one but only the
person undergoing the illness could understand the issue. (A
physician from India)
IMGs frequently associated emotions with disclosure of
medical information, particularly delivering bad news. For most
of the IMGs, delivering bad news to a patient is the responsibility of
the family, not the physician. Thus, many of the physicians
reported that they had to learn how to give patients bad news and
how to handle the resulting emotions. This indicates communication convergence, because IMGs strove to adapt to the perceived
cultural norms of their patients. One IMG gave the following advice
for handling negative emotions, . . . Try to be as understanding as
you can and try not to interrupt him and try to be compassionate
and apologize if you think that you made a mistake . . .
3.3. Differences in norms related to medical interaction
During the interview we also asked IMG physicians how they
managed differences in cultural norms with respect to medical
interaction. Data analysis revealed three sub-themes relating to
conversational scripts, power, and medical information disclosure.
3.3.1. Conversational norms and scripts
We found that in general, certain preformed expectations,
scripts, and norms govern medical interviews just as they do any
other interaction. To ease the patient anxiety and stress, physicians
often talked about topics unrelated to the purpose of the medical
visit, such as weather, sports, and holidays. Small talk gave both
physician and the patient a chance to get acclimated in the
interaction and reduces the anxiety from an otherwise tense
environment. IMG physicians however reported that carrying out
small talk was a key difculty with their patients. One physician
mentioned that he would try to talk about a local, professional
football team to start the conversation. However, this convergent
strategy would backre when patients responded by talking about

101

particular players because he possessed only supercial knowledge about the team that he learned specically to help start
conversations with patients, not out of personal interest. Other
physicians expressed similar uncertainty about discussing American holidays, such as Halloween and Thanksgiving. Thus although
physicians were trying to use convergent communication to
accommodate for the difference between them and their patients,
their efforts sometime led to more divergence. Another difculty
with conversational norms and scripts related to the use of
abbreviations when working in medical teams to treat a patient.
Most IMG interns interviewed in the study reported dissatisfaction
with the use of abbreviations by medical teams because they are
still not acculturated enough to learn the medical lingo. A rst year
resident recounted the following incident:
Initially when I came here and when I started my residency, the
rst month was very hard for me in the sense that medically it
was not hard, but there was the way they use short terms here
like CBCs or like one of the word they say . . . what are the CMP?
Lets get a nger stick. What is nger stick? It was actually a
nger stick with loopholes. So, these are like some quick terms
like what was a CRIT which was hematocrit. So, some of the
language this was a problem for me.
3.3.2. Power/patient-centered communication
The second sub-theme that emerged consisted of comments
made about power dynamics in the physicianpatient interaction. Power was conceptualized in this study as the distribution
of control and authority in the interaction. Although no IMG
physician explicitly stated that egalitarian relationship between
the physician and the patient was unjust, there were still subtle
and nuanced expressions that clearly delineated the concern and
confusions that many IMG physicians experienced in terms of
differences in patient care in the US from their home country.
One physician from India very eloquently described the
differences in communication patterns between the U.S. and
his home country and the associated surprise and confusion that
might be encountered while rst starting the medical practice in
the U.S. He stated, I think in India physicians think they know
what is best for the patient; here physicians take into account the
patients opinion as well. A rst year intern from a Middle
Eastern country commented, Here the patient has to know
everything on his disease, our country is different. Most
physicians noted that they converged to accommodate for
power differences between them and their patients by providing
patients a chance to be actively involved in their treatment. Some
also indicated that convergence was because of the norms and
expectations by U.S. patients and the U.S. medical system and not
just by their choice.
3.3.3. Medical information disclosure
Medical information disclosure was conceptualized as to whom
the information related to the disease will be disclosed the patient
or the family. In many countries outside the U.S. and specically in
many collectivist cultures, most of the disease and prognosis-related
information is given to the patients family and friends rather than
the patients. In the U.S. however, due to condentiality and
malpractice reasons, information is delivered directly to the patient
(or patient surrogate). Thus it is no surprise that most IMG
physicians interviewed in the study found it difcult when it came
to disclosure of sensitive information directly to the patient. One
physician in his third year of residency noted:
The one thing I dont like about the American system is that you
are telling the patient face-to-face that he is going to die, which
is something that I dont like. You are telling a dying patient that

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102

he only has a few weeks or months left, . . . [if I was the patient] I
wouldnt want to know that.
Not only did physicians recognize that the norms for information disclosure were different, they also expressed feelings that the
culture of medical system in the U.S. did not permit the physician
enough power to make such decisions. For example, several
physicians expressed the frustration with disclosing everything to
the patient, and one physician referred to it as treating patients as
kings. Thus, attempts at convergence in these interactions
consisted of disclosing more information to a patient than the
physician felt necessary and appropriate.
Fig. 1. Different dimensions of IMG physician patient communication.

4. Discussion and conclusion

4.1. Discussion
The IMG physicians in this study identied 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 ndings are consistent
with the previous research on the barriers that IMGs must
overcome [1017,21]. This study contributes to the literature by
identifying the strategies IMG physicians use to minimize the
differences in communication during consultations with their U.S.
patients. Our ndings are unique in that, contrary to the
assumption that accommodation is always desirable in medical
interactions [18] we found instances where maintenance of
differences was more benecial to the interaction. For example,
one of the IMG physicians in our interview noted that she
maintains her accent during the conversation because she sees her
accent as a potential conversation starter with the patient. Some
IMG physicians in our study maintained cultural and linguistic
differences between themselves and their patients, to maintain
their own cultural identity, or for more pragmatic reasons, such as
establishing rapport with patients.
IMG physician interaction is such that it involves elements of
intercultural, interpersonal, and intergroup communication because it involves communication between people of two different
cultures who are also members of two distinct groups, but who
communicate on a personal level. Most previous research assumes
that IMG physicians try to move from intercultural to intergroup to
interpersonal dimension of communication to relate to their
patients. In other words, IMG physicians start at an intercultural
communication position because of interaction between people of
two different cultures [10]. In addition to having intercultural
elements, IMG physician patient interaction can also be characterized as intergroup communication because physicians and
patients have prescribed roles in medical interaction [18].
However, IMG physicians may attempt to deemphasize the
traditional physicianpatient power dynamics by accommodating
to unique linguistics or behavioral characteristics of the patient. In
treating the patient as an individual, and not solely as a member of
the patient population or a representative of his/her culture, the
interaction becomes one that can be characterized as interpersonal
in nature (see Fig. 1).
We are arguing that while the above holds true, there are many
instances when IMG physicians do not want to accommodate and
maintain the differences between them and their patients (as in
the case of the physician who uses her usual accent). In such cases,
these physicians use the intercultural form of communication to
enhance interpersonal communication between them and their
patients. That is, these physicians use differences in culture to
facilitate interpersonal form of communication.
Such strategies are not new in interaction situation involving
people of different cultures. For example, Giles et al. found that

divergent strategies can be used to express attitudes and to bring

meaning and understanding to the interaction [20]. They further
note that delineation of differences in some form indicate to the
opposite party that the interactant does not belong to the host
culture which can be helpful in achieving mutual understanding.
IMG physicians can take advantage of such expectations to initiate
small talk with the patients and to build rapport and long-term
relationship. Of course this strategy could also backre, but
perhaps patients might appreciate differences and use those to
develop relationship with the IMG physician. IMG physicians
might also use these differences to maintain their cultural identity.
Moreover, they might nd the maintenance of differences more
pragmatic than converging as these differences sometimes provide
them a way to start conversation with their patients. Therefore, the
research needs to move beyond the overarching assumption that
physicians should accommodate to their patients and explore how
can physicians use differences between them and their patients to
make the interaction more interpersonal and fruitful in nature.
One of the strengths of this study is that it gives voice to a
population that is very difcult to access and is signicantly
understudied, but who constitutes a critical component of the
American healthcare system. To our knowledge, this is one of the
rst studies in the eld of communication that tries to explore how
IMG physicians in residency programs learn to respond to the
communication barriers posed by their status as an international
medical graduate. Specically, this study extends previous research
by not only describing the communication barriers of IMGs, but by
also illuminating the strategies they use to overcome those barriers
including both accommodation and maintenance. Although cultural
differences do pose certain challenges for IMGs, it is important for
the medical community to be aware of the ways that these
physicians are using their background to benet their practice.
It should be noted that, this study relied on physicians from one
healthcare system in one geographical region of the U.S. Thus, the
ndings of the study should not be generalized to all IMGs, but
rather offer an initial step in understanding the accommodation
strategies of international medical graduates practicing medicine
in the U.S. We are not implying that our ndings speak to the
experiences of all the IMG physicians in the U.S. These ndings
offer an insight into a group of IMG physicians who came from
different countries to practice medicine in a hospital in the U.S.
Perhaps experiences of IMGs would differ depending upon the
place they are completing their residency, composition of the
patient population in that institution, as well as other factors.
Future research on this topic should examine the inuence of
regional sub-cultures on communication strategies used by IMG
physicians, and the perceptions of patients of IMG physicians.
Another area of future research could be comparison of communication strategies used by IMGs who are in their residency practice
in the U.S. to the IMG physicians who have experienced practicing
medicine in the U.S. This study provides a rich understanding of the

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accommodation processes involved in intercultural exchange in

medical interaction where physician rather than patient belongs to
a cultural minority group.
To our knowledge, previous research has not looked into how the
accommodation processes work when power dynamics are shared
in the interaction. For example, in terms of ethnic identity, IMG
physicians typically belong to cultural minority groups; in other
words groups that have been historically marginalized in the society.
In the medical interaction, however, physicians are perceived to
have more power than patients [18]. Therefore, by understanding
how IMG physicians accommodate in interactions when they have
high professional status but belong to a culturally marginalized
group is important because perhaps some of the views expressed by
these physicians regarding the feelings of the loss of power might
have been derived by the feelings of lacking the power in the societal
context. Moreover, by illustrating when IMG physicians do not
accommodate in the interaction, we challenge the previous research
and training guidelines for IMG physicians that emphasize
acculturating IMGs to the culture of the U.S. so that they can
communicate effectively with North American patients.
This study provides a rich understanding of communication
strategies used by IMG physicians when they start practicing
medicine in the U.S. However, there were some limitations. For
example, we did not explore the issues related to organizational
differences that IMG physicians encounter when starting their
medical practice in the U.S. The medical system in the U.S. is one of
the most sophisticated but also extremely complicated entities.
Thus it is important to explore the organizational accommodation
processes that many IMG physicians might undergo when they
start residency training in the U.S. because adjustment and
acculturation into organizational climate could impact their
performance and in turn impact the patient care that these
physicians impart. Future research should also focus on the
lifestyle differences that IMG physicians experience when they
come to the U.S. for residency and impact of these differences on
their work productivity and quality of medical care provided.
Finally, we support the recommendations proposed by previous
research that a rigorous, multifaceted training program be
instituted that helps IMG physicians in acculturating to the U.S.
work culture from different angles, especially when they rst begin
the residency training [11,16,17,24,3133]. Although some institutions such as Albert Einstein Medical Center in Philadelphia
already have a component of cultural competence built in their
residency programs [34], such programs are far from the norm. We
suggest that these training programs should be culturally sensitive
to the needs of the IMGs so that they can also maintain their
cultural identity. They should emphasize the strategies IMG
physicians could use, including convergence, maintenance, and
divergence that might be benecial for these physicians. Finally,
institutions can perhaps look at ways different than just training to
help in transition of these physicians. For example IMG physicians
could be matched up with a more experienced IMG physician from
similar culture, standardized patients, or patient advocates who
could help the IMG physicians in transition to the U.S. healthcare
system. Increasing cultural sensitivity during the residency
program will not only improve the quality of care provided by
IMGs, but could also improve patients overall satisfaction with the
medical system.
4.2. Conclusion
In sum, this study enhanced our understanding of the issues that
IMG physicians face in communicating with their patients and the
strategies they adopt to accommodate those differences. These
descriptions of how IMGs communicatively negotiate intercultural
patient encounters form the groundwork for designing future

103

studies to further explore this issue. Since IMG physicians bring

different cultural perspectives to the patient care and the healthcare
system, educating them regarding cultural norms of the U.S. in
general, including regional norms associated with the location of
their practice could help them in becoming more culturally
sensitive. Furthermore, the new IMG residents might also benet
from learning about medical culture in the U.S., including physician
patient communication practices. This training might force them to
reconsider the norms they might have regarding physicianpatient
relationship based on their medical education in their country of
origin. Educating IMG physicians regarding the norms of medicine in
the U.S. might help these physicians improve communication with
their patients which would enable them to deliver quality care. It is
not only benecial for the self-development of IMG doctors and the
healthcare system in general, but helping these physicians to be
competent communicator is crucial to the well-being and health
outcomes of the most important entity in this entire gamut of
healthcare: the patients.
4.3. Practice implications
There are many practical implications of these ndings. Most
participants were acutely aware of the cultural differences
between themselves and their patients. For example, all the IMGs
reported differences in language in terms of different accents,
paralingustics, and use of slang words as a difcult situation.
None of the IMGs felt that their knowledge of English language
was so limited that they had difculties communicating with the
patients or their colleagues. However, a number of physicians felt
that sometimes language posed as a barrier. In the absence of
comfortable linguistic ability and other cultural differences,
long-term goals of establishing rapport with patients and gaining
their trust might suffer. International physicians in this study
found it difcult to engage in small talk with their patients and
sometimes felt at a loss in terms of topics of conversation with
patients other than discussing their clinical information. The
results of this study support the recommendations of [21] and
[28] that language classes be made available for international
doctors. The main focus of the language classes should be upon
teaching culturally appropriate language and acculturation with
respect to usage of slang words, idiomatic English, and other
colloquial terms prevalent in that part of the U.S. where the IMG
practices.
Our results are similar to the previous research in the area that
suggests that IMGs experience cultural and social differences,
which could impact the patient care [1017,21]. Many physicians
for example noted their frustration in terms of medical information
disclosure and DNR procedures. These kind of difcult decisions
could be stressful for both patients and the physicians and hence
IMGs who practice medicine in this country should be made aware
of such cultural norm and condentiality practices not just from an
organizational standpoint, but also from a more humane and
emotional perspective.
Acknowledgement
The authors are grateful to Dr. Vinayak Shukla for his assistance
with data collection, Don Cegala and Rick Street for their valuable
feedback on a previous version of this manuscript, and the editor
and anonymous reviewers for their helpful input.
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