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Should the Residency Programs Train International Medical Graduates in Certain Communication Skills?

To the Editor: International medical graduates (IMGs) form an integral part of health care delivery in America. One in four physicians in the United States is an IMG (1). IMGs are more likely to be trained in internal medicine, psychiatry, and other primary care specialties (2), and play a significant role in providing health care in rural underserved areas. More than 30% of residents in psychiatry are IMGs and the largest number of IMGs come from India (1, 3).

One of the key aspects of assessing residents by supervising faculty is the manner with which a patient’s symptoms, signs, laboratory tests, assessment, and management plan are communicated to the attending and other team members. Additionally, communication plays a key role in psychiatry while interviewing a patient. Communication involves several aspects in addition to language, such as quality or accent of language, eye contact, and body language.

IMGs in general have diverse language capabilities and are sensitive to caring for members from other ethnic groups. In fact, the diverse experience that the IMGs bring with them could enhance the overall learning experience of the residency program. However, when IMGs arrive from their respective countries they are often in a totally different environment, which might itself lead to anxiety related to culture shock. In Western culture expressing one’s opinion in group discussion, especially during ward rounds, is encouraged. In contrast, some of the IMGs coming from countries like India are accustomed to a hierarchy in terms of providing their input, and may politely wait for a direct query to answer or provide information. Thus, an IMG from a country with this system may not be assertive enough while presenting cases or in discussion during rounds.

Few residency programs attempting to improve the communication skills of IMGs have focused primarily on teaching essential English-language skills, including accent, to IMGs (4, 5). However, certain aspects of communication, such as eye contact or other body language, might vary between different cultures or ethnic groups. All these aspects could lead to improper or inadequate communication between the IMG and other residents, supervisors, or patients and their families. As a result these shortcomings could lead to difficulty in day-to-day clinical activities, which in turn could be interpreted as a lack of sufficient clinical skills rather than addressing the underlying issue. These factors significantly influence the first year of an IMG’s residency training period. In some cases the initial impression may lead to a premature negative evaluation of the resident, often causing anguish and stress during the first few months of training. This can potentially have a negative impact on the self-esteem and adaptability of the resident.

Even though cultural awareness and diversity training programs are increasing in both community hospital and university-based training programs, the focus is usually on the diversity and cultural aspects of the patient. These aspects of cultural diversity training could be expanded to enhance the understanding of IMGs’ cultural backgrounds among staff, residents, and faculty. It is possible that taking these cultural aspects of IMGs into consideration while evaluating an IMG during the first 6-month to 1-year period of their residency training may help the program train IMGs more effectively. It may be beneficial to have a seminar or a discussion on effective communication during the initial orientation with an emphasis on communication with team members, patients, and their families. This may help the IMG understand the expectation right from the beginning and not hold back his or her contribution to the clinical discussion. Additionally, training the IMGs in certain aspects of proper and appropriate communication of clinical aspects, or possibly having some kind of mentorship experience to improve these skills, may be beneficial (6). The Accreditation Council for Graduate Medical Education (ACGME) requires that all residency programs train their residents to be competent in communication skills for effective information exchange with patients, their families, and other health professionals (7). Nurturing these skills in the early part of the training may benefit the residency program to a great extent.

Further, the live patient interview, which is currently part of the American Board of Psychiatry and Neurology oral examination (Part 2), will be abolished and will be replaced by three observed and evaluated live patient interviews during residency training. We believe that the mentioned communication factors (eye contact, body language, addressing patients) and assertiveness level should become standard parts of the evaluation and discussion of the observed interviews.

In conclusion, appropriate and timely training of IMGs in comprehensive communication skills and educating staff, residents, and faculty about IMGs’ diverse cultural backgrounds may benefit the residency training programs. Perhaps organizations such as AADPRT could provide guidance in this area.

REFERENCES

TOP REFERENCES

 

1. American Medical Association: Physician Characteristics and Distribution in the U.S. Chicago, Ill., American Medical Association, 2007
2. Salsberg ES: American Medical Association Section on Medical Schools Presentation, 2001. Available at http://www.ama-assn.org/ama1/pub/upload/mm/44/speakersumi-01.doc
3. Rao NR: Psychiatric workforce: past legacies, current dilemmas, and future prospects. Acad Psychiatry 2003; 27:238–240[Free Full Text]
4. Goldszmidt M, Kortas C, Meehan S: Advanced medical communications: support for international residents. Med Education 2007; 41:522–522
5. Rosner F, Dantzker DR, Walerstein S, et al: Intensive one-week orientation for foreign medical graduates entering an internal medicine residency program. J Gen Intern Med 1993; 8:264–265[Medline]
6. Kramer MN: The educational needs of international medical graduates in psychiatric residencies. Acad Psychiatry 2005; 29:322–324[Free Full Text]
7. ACGME Outcome Project: ACGME General Competencies Version 1.3 (9.28.99), 2000

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