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Barbara L. Schuster, MD, MACP
Professor and Chair
Department of Medicine, Wright State University
Former ACP Regent
The United States is a country of immigrants. The vitality and spirit brought by new Americans add texture to daily life. The diversity of cultures creates complexity and challenge for those in healthcare. International medical graduates (IMGs) bring a wealth of knowledge of disease not often seen in the United States in addition to knowledge of the belief systems of the cultures from which they come. Belief systems have significant impact on health and disease. Having diversity within the healthcare team allows for improved care delivery within a multicultural environment.
The challenges of IMGs in postgraduate programs include: 1) biased perceptions from medical students, staff, attending physicians, and patients; 2) communication skills of the international physician; and 3) professional and social acculturation.
In general, patients are more comfortable with caretakers who are the same gender, race, and culture. In most areas of the United States, the international medical graduate faces an additional hurdle in building the patient-physician relationship because of cultural bias. "Different" is often translated as "inferior." A current guide to residency in the United States clearly warns U.S. medical students to consider the number of international graduates in a program when making their own choices. It implies that a program with significant numbers of international graduates is inferior. Because of this bias, residency programs without IMGs are wary about accepting international graduates, and programs with a majority of IMGs have more difficulty recruiting U.S. graduates. In both cases, perceptions of the quality of the program become more powerful than the reality. These perceptions pervade both academic and community faculty and may obstruct the growth and improvement of residency programs.
The ability to communicate goes beyond the ability to speak and write English. Accents, slang terminology, street language, and idioms all influence the communication between physician and patients as well as hospital staff. Humor differs markedly between cultures, and language is often the medium. Non-verbal communication through body language is a more sophisticated yet powerful medium that obstructs or facilitates patient-physician interaction. The extent to which the international graduate can vary his/her own verbal and non-verbal responses, is accepting of feedback about his/her communication skills, and can accept patient differences, the more likely the international physician will be successful in transitioning to a comfortable working relationship.
The international educational system also differs markedly from that in the United States. In many countries, the hierarchical system of instruction is reflected in less questioning of the professors by learners vs. the more "team" learning system in the United States. Transitioning to different educational expectations requires time, patience, and understanding of both the learners and the teachers. Interacting with medical students is one of the hallmarks of graduate education. Helping international graduates to understand the undergraduate medical education system and how to most appropriately interact with students is an additional challenge. U.S. medical students can facilitate the acculturation of the international graduate, if the international graduate accepts the "give and take" style of education.
Academic physician leadership has the responsibility of setting standards for the education of students and residents and the care of patients. The challenge is to help each young physician to grow in all skill areas necessary to be an excellent physician. Educating international graduates who have chosen to immigrate to the United States or to return home after advanced training to upgrade the healthcare in their respective countries, requires leaders who understand their own biases, accept the responsibility for advancing medical care within the growing multicultural environment of the United States, and find interacting with learners most exhilarating.
Barbara L. Schuster graduated from the University of Rochester School of Medicine, Rochester, New York. After completing internal medicine residency in Rochester in one of the first primary care internal medicine residencies in the country, she joined the faculty and subsequently worked in graduate medical education in Rochester until eventually becoming the Program Director for the Primary Care Internal Medicine residency and the Combined Internal Medicine/Pediatrics residency. She served as President of the Association of Program Directors in 1992-93 and was elected a Master of ACP in 1996. She was elected to the Board of Regents of the ACP in 1999 and has served on the Awards Committee, the Nominations Committee, and the Education Committee. Since September 1995, she has held the position of Chairperson of the Department of Internal Medicine at Wright State University School of Medicine, Dayton, Ohio.
This article was prepared for the ACP IMG Web site in 2000.