Communication skills, cultural challenges andindividual support: challenges of international medicalgraduates in a Canadian healthcare environment

PIPPA HALL, ERIN KEELY, SUZAN DOJEIJI, ANNA BYSZEWSKI & MERIDITH MARKSUniversity of Ottawa, Faculty of Medicine, Department of Medicine, Ottawa, Ontario, Canada

SUMMARY Physicians require good communication skills to

develop effective patient–physician relationships. Externally funded

international medical graduates (IMGs) move directly from their

home countries to complete residency training at the University

of Ottawa, Canada. They must learn quickly how to work with

patients, families and colleagues. A detailed needs assessment was

designed to assess IMGs’ communication skill needs through focus

groups, interviews and surveys with IMGs, program directors,

allied healthcare professionals and experts in communication skills.

There was a high degree of consensus amongst all participants

concerning specific educational needs for communication skills and

training issues related to the healthcare system for externally funded

IMGs. Specific recommendations include (1) English-language

skills; (2) how to get things done in the hospital/healthcare

system; (3) opportunities to practise specific skills, e.g. negotiating

treatment, (4) adequate support system for IMGs; (5) faculty and

staff education on the cultural challenges faced by IMGs.

Introduction

All physicians require good communication skills to develop

effective physician–patient relationships. A review of the

communication skills literature confirms that North American

patients and families expect physicians to provide reliable

information in an effective and compassionate way with

priority given to the bioethical principle of patient autonomy

(Stewart, 1995). Doctors, however, receive very little formal

training in these skills (McNinch, 2001). Dr Daniel Klass

of the College of Physicians and Surgeons of Ontario states

that ‘‘physicians cannot be fully competent if they don’t

communicate effectively with their patients . . . ’’ (Klass,

2001). International medical graduates (IMGs) face addi-

tional communication skill challenges, as they must learn

quickly to work with patients, families and colleagues in

North America.

An Australian study (Rolfe & Pearson, 1994) suggested

that IMGs showed deficiencies in communication skills not

being remedied in their current training programmes when

compared with Australian-trained residents. The countries

where these IMGs received their training are not described.

Kidd and Zulman (1994) described the educational needs

they observed in IMGs migrating to Australia and note that

many overseas-trained doctors have never received formal

training in communication skills. They recommend this

training be incorporated into all training programmes. If

communication skills are not perceived as important in the

country of training, it will be difficult to shift the residents’

perception of priorities on arrival in the North American

setting. Kidd and Zulman also suggest that an understanding

of ethical and medico-legal issues is essential to safe medical

practice in any country. Fiscella and Frankel (2000) discuss

English-language skills as one component of the challenges

encountered by IMGs coming to the United States.

Three articles from residents in psychiatry programmes

discussed IMGs’ perspectives. All identified the challenges of

mastering the English language. Also, Cheng (1974), Brody

et al. (1971) and Haveliwala (1979) note the cultural stresses

faced by the IMGs, including how cultural issues can impact

on the residents’ understanding of the patient’s reality, citing

examples of different parenting traditions, sexual roles and

behaviour. Cheng discusses differences in role identity

and attitudes towards authority figures, which can cause

problems in working with the North American professional

team. From his own experiences, Cheng suggests that many

IMGs may discount their language difficulties and accuse the

host population of prejudice. Cheng also notes that cultural

norms cause IMGs to appear too inhibited, passive and

rigid to the North American medical teams.

Haveliwala shares a personal perspective on the needs of

Indian, Philippine and Asian graduates working in psychiatry.

He identifies that the resident’s knowledge often must be

adapted to differences in diagnostic emphasis, medication

names and availability, medical literature and reference

materials, i.e. a local medical culture. Haveliwala notes that

discrimination arises against IMGs, not only at the individual

level but also at the administrative levels dealing with issues

related to licensing and suggests that the stress of accultura-

tion can precipitate significant mental health problems for

IMGs.

Communication skills development was identified as one

of the topics of instruction to be included in the Pre-entry

Assessment Program (PEAP) for externally funded IMGs

at the University of Ottawa. This paper discusses the results

of a detailed needs assessment designed to assess the com-

munication skill needs of IMGs starting a PEAP. Particular

attention was paid to the skills they need to acquire to be

successful in the Canadian healthcare system.

Methods

The University of Ottawa has two groups of IMGs that

participate in residency training programmes. The first group

Correspondence: Pippa Hall, University of Ottawa, Faculty of Medicine,

Department of Medicine, Smyth Road, Ottawa, Ontario, Canada. email:

phall@scohs.on.ca

Medical Teacher, Vol. 26, No. 2, 2004, pp. 120–125

120 ISSN 0142–159X print/ISSN 1466–187X online/03/030120-6 � 2004 Taylor & Francis LtdDOI: 10.1080/01421590310001653982

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is funded by the Ontario Ministry of Health’s (MOH)

re-entry programme. They are typically landed immigrants

or Canadian citizens who completed medical school outside

Canada or the United States. These residents have resided in

Ontario for extended periods of time, often working in many

different types of employment, waiting for the opportunity

to restart their medical careers in Canada. On completing

residency training, they intend to work in the Canadian

healthcare system.

The second group of IMGs is externally funded residents,

moving directly from their home countries to complete

residency training. The majority come from Middle East

countries and will be returning to their native countries

on completion of their training. In 2000, the University

of Ottawa had 119 externally funded IMGs: 106 men;

13 women. The externally funded IMGs must complete a

PEAP of six to eight weeks before starting residency training.

Approximately 20 residents participate in the PEAP each

year. The primary purpose of the PEAP is to assess the level

of medical knowledge of these potential residents. It is also

a period in which IMGs may participate in further instruc-

tion to ease their transition into the Canadian healthcare

system.

This study was completed as a case study, using

qualitative research methods. Data collection occurred with

focus groups, semi-structured interviews and questionnaires.

Multiple sources of data were obtained to ensure triangula-

tion of the results (Mays & Pope, 2000) and to provide a

comprehensive understanding of the communication skills

needs and cultural challenges of IMGs participating in

PEAP.

Data collection methods included:

� Focus group with an expert group of communication skills

educators practising in Ontario (referred to as ‘experts’).

Participants completed a written assessment of the com-

munication skill needs they identified IMGs as requiring

and then participated in a group discussion. The two

facilitators recorded field notes during the session,

identifying recurring issues emerging from the discussion.� Semi-structured interviews with healthcare professionals

who have experienced working with IMGs during PEAP.

Participants included Faculty of Medicine Residency

Program Directors and allied healthcare professionals

(AHP). The interviews were audiotaped and transcribed

verbatim.� Interviews and focus groups with IMGs who had completed

PEAP. As most of the IMGs were from the Middle East,

separate groups were held for male and female residents.

The men had a male facilitator and the women a female

facilitator. Although both facilitators were faculty mem-

bers, they were not directly involved in the IMGs

training programme. The interviews were audiotaped and

transcribed verbatim.� Survey of IMG residents by mailed questionnaire. The survey

questions were designed to further probe the perceived

needs of IMGs related to communication skills. The

survey was voluntary and anonymous. The questions

were based on the results of all the components of the

needs assessment. Respondents were asked to rate the

importance of the issues that had been identified, using a

five-point Likert scale.

� Review of the literature. Communication skills for physi-

cians working with patients and families in North America

were identified by a review of the literature.

The study received approval from the Ottawa Hospital

Research Ethics Board in March 2001.

Analysis

Identifying information was removed from the data prior

to data analysis. All textual data (transcripts, field notes

and questionnaires) were analysed using the process of

open coding to identify recurring themes and associations.

Consistent with grounded theory, the data were reviewed

iteratively until all trends and variations were accounted

(Strauss & Corbin, 1998). The qualitative analysis was

completed by two of the authors (PH and MM), one of

whom was not directly involved in data collection or in

the provision of a communication skills programme (MM).

Discrepancies in coding were resolved by consensus.

Results

Participants

A total of 30 individuals participated in the study. Four

IMGs responded to the invitation to participate in the focus

group/interviews: three men and one woman. The men

participated in a focus group, and the woman was interviewed

individually. Twelve IMGs returned the surveys (10 men;

2 women). Over 70% of the participating IMGs were from

Saudi Arabia, the others coming from Libya, United Arab

Emirates and Ireland. The respondents included residents

at all levels of training (PGY1-5 and Fellows). The actual

programmes were not identified in order to protect the

residents’ confidentiality.

Three program directors and two social workers were

interviewed individually. Nine communication skills experts

participated in the focus group: seven physicians; one nurse;

one individual who worked as a standardized patient.

Communication skills needs, cultural and support challenges of

IMGs identified by the participants

(1) Language and specific skills. The IMGs involved in this

study had no specific training in patient–physician commu-

nication skills prior to arriving in Canada. At the most,

their experience was limited to didactic presentations in

the context of religious ethics. IMGs listed the opportunity

to practise communication skills as the most important

element to include in an educational programme.

Table 1 lists issues identified by interviews and ques-

tionnaires related to language and specific communication

skills. All groups identified the need to improve patient-

centred interviewing skills, as well as the skill of receiving

and giving feedback. Noted as a key area for improvement

by programme directors and experts, the residents rated

giving and receiving feedback as the third most important

communication skill they needed opportunities to practise.

The residents, allied health professionals and experts all

noted that IMGs tend not to ask for clarification and rarely

will question the attending physician.

Challenges of international medical graduates

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Better understanding of the English language, particularly

the use of idioms, nuances and vernacular terms, was

identified as a need by the IMGs, programme directors

and expert focus group. The IMGs gave particular examples

of confusing terms (e.g. belly button) and said they often

became confused by the use of unfamiliar terms and phrases.

The programme directors and experts specified that IMGs

should also have particular instruction in non-verbal com-

munication skills (e.g. body language), the use of medical

terminology, and the more common or ordinary terms used

by patients and families as well as skills to deal with telephone

conversations. In addition, the programme directors, allied

health professionals and experts identified the need for

English grammar instruction, and written language and

writing skills.

Another communication skills area where the IMGs,

programme directors and experts concurred was dealing

with ‘Do Not Resuscitate’ (DNR) and end-of-life issues.

As one IMG stated:

. . . people in my culture, they don’t want to know

a lot about their problems, especially if they are

dying . . .. Tell the family!

The IMGs rated this as the second most important skill they

needed to practise. They rated negotiating treatment plans

as the most important. Experts suggested specific training

in psychosocial interviewing skills should be considered.

(2) Culture-related issues. Culture related issues included

both differences in the delivery of healthcare, i.e. system

issues and differences in patient/family expectations, and

the role of religion in healthcare decisions. Table 2 lists the

issues identified that related more specifically to the cultural

challenges faced by the IMGs. It must be emphasized that

the majority of these individuals had no exposure to Western

culture until arriving to do their medical training.

(a) System issues. (i) Teamwork. All groups identified a

need for IMGs to better understand the functioning of a

healthcare team and the roles and responsibilities of the

team members. The majority of IMGs had only worked

with nurses, who rarely questioned a physician’s request

or opinion. IMGs were not familiar with the roles of other

healthcare team members, in particular social workers, or the

role of the physician on a team.

The Canadian health system is less hierarchical in its

organization than the system where the IMGs trained. Issues

related to gender, hierarchy and power were suggested to

be important factors contributing to IMGs’ challenges in

teamwork. The IMG respondents felt discriminated against

by some allied healthcare professionals, faculty and patients.

This contributed to communication difficulties within the

team. There was discomfort in challenging supervisors and

concern that relative lack of language skills was interpreted

as a sign of lack of medical knowledge and skill. Similar

communication issues and discrimination were identified

between IMGs and their medical colleagues. Comments

from Canadian staff such as ‘‘ . . . if you cut this, I will send

you back to Saudi . . . ’’ were reported by IMGs.

There was a perception among IMG residents that

Canadian residents often perceived them as ‘fillers’ for the

on-call schedule rather than recognizing them as fellow

learners.

(ii) Canadian healthcare system. The importance of under-

standing the Canadian healthcare system, especially the

Table 1. Issues identified related to language and specific communication skills

Language and specific skill issues IMGs PD AHP Expert focus group

Language:

� Accents make it difficult for staff & patients to understand X X

� Understanding importance of body language X X

� Use of common language rather than medical jargon, use of idioms X X X

� Tendency not to ask for more information, clarifications,

will not disagree or question attending MD

X X X

� Discriminatory comments from staff, other residents & AHP X X

� Difficulties with contextualized language X

� Lack of language skills misinterpreted as

lack of medical knowledge & skills

X X

Skills:

� Patient-centred interview skills need improvement X X X X

� Difficulty in giving & accepting feedback X X X X

� Need to improve listening skills & psychosocial interviewing skills X X

� Discussing DNR X X X

� Negotiating treatment plans X

Written communication:

� Difficult to read X X

� Not always complete X X

� Chart is a legal document—must be legible &

complete, requirements not always met

X X

� Orders are a particular difficulty X

� Would benefit from more training for written skills X X X

Notes: IMGs ¼ international medical graduates; PD ¼ program directors; AHP ¼ allied health professionals.

Pippa Hall et al.

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focus on home care and discharge planning, was identified as

another important area for education by programme directors

and IMGs. In the IMGs’ training, the physician has very little

role in discharge planning, and therefore identifying com-

munity resources and completing certain tasks to facilitate a

discharge are unfamiliar challenges. This can cause commu-

nication difficulties between team members. One IMG

stated:

. . .we don’t have enough information about how

your system is run . . .. We don’t have social work-

ers . . .. We don’t have to spend time doing

[paperwork] . . .. We just discharge people and

that’s it . . .

IMGs also identified a strong need to better understand

legal and ethical issues in the Canadian healthcare system,

rating this as the second most important issue to address

in a communications skills education programme.

(b) Cultural issues. (i) Patient and family expectations. Better

understanding of patient and family expectations in the

Canadian system was also a common theme. One focus

group participant stated: ‘‘Canadians don’t act the way you

see Americans on TV and in movies . . ..’’

The patient-centred model of care, considered a standard

of practice in North America (Kalamazoo, 2001), was

unfamiliar to the IMGs. It was more common in their

experience to discuss diagnosis, treatment and care plans

with families, particularly male family members, than directly

with the patient.

(ii) Culture and religion. The heterogeneity of Canadian

culture, the role of religion in decision making and the

residents’ perception now being viewed as a minority were all

highlighted as issues in communicating with patients and

families. Interestingly, a clash of views/moral dilemmas was

not highlighted.

All suggested a better understanding of the multicultural

nature of the community with whom IMGs will be working

would be helpful, as cross-cultural misinterpretations can

be made by all parties. The variable role of religion in

decision-making in the Canadian setting required more

understanding by IMGs. As one IMGs stated:

In my culture, we have the same religion, so . . . it

will be easy . . . how you approach these people

[in situations of conflict] . . .. Here you have to be

more practical . . .

Being prepared for unexpected reactions to their customs and

culture by their Canadian colleagues, patients and families

was listed by IMGs as the third most important issue to

address in a communication skills education programme.

One IMG stated: ‘‘I didn’t feel that I am different—except

when people treat me different . . ..’’

(c) Support issues. All groups identified the need for

supportive networks for the IMGs. Table 3 identifies issues

related to the support IMGs require as they embark on

training in Canada.

Single female residents were particularly vulnerable.

There are few faculty role models. IMGs often feel isolated

and women IMGs have unique stresses. One IMG stated:

. . . some of them [male residents] do not want

women to work. Some of them think women should

stay at home. We have an internal struggle that we

Table 2. Issues identified related to cultural challenges for IMGs

Culture-related issues IMGs PD AHP

Expert

focus group

System issues:

� Understanding roles of AHP: who to consult for what & when X X X X

� Canadian healthcare system more egalitarian than hierarchical X X X X

� Do not understand how to get things done X X X

– Discharge planning X X X

– Ordering procedures, completing forms X X X

� Understanding how the Ontario health

system works: levels of care, community care

X X

� Understanding legal & ethical issues in Canadian medicine X X

� Difficulties understanding patient & family expectations of MD X

� Faculty lack understanding of IMG skills X X

Cultural issues:

� Need to learn how to deal with non-medical/psychosocial issues,

as patient care includes more holistic perspective here

X X X X

� Understanding multicultural nature of community X X X X

� Discussing end-of-life issues in context of religious beliefs X X X

� Disclosure of medical information to patient versus family X X

� Differences in gender roles & interactions—peers & staff X X

� Differences in attitudes & values

(e.g. hierarchy, role of elderly, life & death issues)

X X

� Discriminatory attitudes of patients to IMGs X X

� Understanding the taboos in Canadian culture X

Notes: IMGs ¼ international medical graduates; PD ¼ program directors; AHP ¼ allied health professionals.

Challenges of international medical graduates

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should say we are here, we exist and a male making

you feel that you should go home . . .

This tension makes it difficult for women IMGs to seek

support from men IMGs. The IMGs want to know their

rights and the resources available to offer them support and

advice. In addition, staff and faculty should know to whom

they could refer the IMGs if there are problems and who is

actually responsible for them.

Experts, allied healthcare professionals and IMGs

identified a need for faculty and staff to better under-

stand the clinical experience and training of the IMGs as well

as to appreciate at least some of their behaviours, attitudes

and values which have been culturally defined and may cause

some misunderstandings. For example, a woman IMG is

expected to be quiet and shy in her own culture. This can be

misinterpreted as being unhappy or as lacking confidence by

her Canadian colleagues. With this perspective, issues related

to gender, power/hierarchy structures, differences in work

ethics, expectations of degrees of autonomy in practice,

responsibilities and accountability could be more directly

addressed.

Discussion

Externally funded residents arriving in Canada to participate

in specialty training programmes have specific educational

needs for communication skills as well as specific training

issues related to working in an unfamiliar healthcare system.

There is a high degree of consensus amongst the residents

themselves, programme directors, experts in communica-

tions skills and allied healthcare professionals about these

needs. Patients’ expectations were drawn from the literature,

rather than through interviews, owing to limited resources.

Only a minimum number of IMGs (16/119 or 13%)

participated in the study, but their contributions offer a

significant input to our understanding of their needs.

Attempts to repeat the survey to increase the response rate

were thwarted by the terrorist events of September 2001.

The literature review failed to identify other studies that

systematically assessed the needs of this group of trainees.

This study confirms that understanding dialect, colloquial-

isms and nuances of spoken language, as well as local

humour and non-verbal communication, requires high

levels of language skills.

This study found that difficulties in working with the

professional team around issues such as discharge planning

could be related to differences in role identity, attitudes

towards authority figures and experience. Similarly, cultural

norms did have an impact on the medical team’s perspective

of the IMGs’ behaviour. The residents in this study were

very sensitive to misunderstandings due to language and

they confirmed the additional challenges of learning the local

medical culture. This study identified the need for supports

to help the IMGs cope with these stresses.

For IMGs, the needs assessment identified issues related

to cultural adaptation to Canadian society as well as issues

specifically related to communication skills. The Ontario

International Medical Graduates (OIMGs) programme,

which focuses on MOH-funded residents who have perma-

nently moved to Canada, recognized that communication

proficiencies, cultural issues and English proficiency were a

weak point in the training offered to IMGs (Rothman &

Cusimano, 2000). This has led to an enhancement of the

OIMGs programme structure to allow appropriate training

to occur, assisting these individuals to assimilate into the

Canadian scene. No such programme has yet been described

for externally funded residents. Rosner et al. (1993) describe

an intensive one-week orientation programme implemented

for IMGs entering an internal medicine programme in the

United States, reporting fewer personal and professional

adjustment problems for IMGs after implementation. This

programme was based on the observed need of IMGs

to become rapidly acclimatized to the American medical

system. The residents participating in the programme are

not described.

Attention is being paid to setting standards and license

procedures for IMGs (Freidman et al., 1993; Friedman

Ben-David et al., 1999) but there remains a dearth of

information on the IMGs’ specific communication skill

learning needs. Many of the communication skills educa-

tional needs identified in this study are similar to those of

Canadian trained residents (e.g. practical experience, skills

to negotiate treatment plans with patients, breaking bad

news, discussing DNR and end-of-life issues with patients

and families, ethical and legal issues). The patient-centred

interview techniques and skilled negotiation of treatment

plans, not familiar to the IMGs in this study, are considered

the standard of practice through which these expectations

can best be met (Kalamazoo, 2001).

Summary and recommendations

In conclusion, we were able to identify consensus on many

important issues affecting externally funded residents arriving

Table 3. Issues identified related to supports for IMGs

Support issues IMGs PD AHP Expert focus group

Lack of support systems:

� Limited networks—especially for single female residents X X X X

� Who should they go to when having problems?

Who is responsible for them?

X X X

� What are our expectations? X X X

� What are their rights? X X

� Attending staff need to better understand the culture

of these residents, misunderstood by many

X X X

� Lot of pressure to perform, lot of pressure not to show any weaknesses X X X

Notes: IMGs ¼ international medical graduates; PD ¼ program directors; AHP ¼ allied health professionals.

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for postgraduate training in Canada. Educational priorities

for a communications programme identified through this

needs assessment include:

(1) English-language skills, oral and written;

(2) how to get things done in the hospital/healthcare system,

including understanding the roles of allied health

professionals, faculty and other physicians, including

their peers and colleagues-in-training;

(3) opportunities to practise specific skills, such as discussing

end-of-life issues with patients and families, negotiating

treatment plans and conflict resolution;

(4) ensuring an adequate support system is available and

easily accessible for IMGs;

(5) faculty and staff education on the cultural challenges

faced by the IMGs, as well as clarifying the roles and

responsibilities of the IMGs and the expectations the

medical team has of them.

The externally funded IMG residents are valued members of

the healthcare teams in our institution. This needs assess-

ment resulted in the development of a pilot communication

skills programme, instituted in June 2001. Faculty at the

University of Ottawa are now developing a more formalized

communication skills curriculum for the externally funded

residents arriving for the 2003 PEAP.

Acknowledgements

This work was supported by grants from the University of

Ottawa Central Residency Education fund and the Canadian

Cancer Society/Educating Future Physicians of Ontario

Communications Project.

Notes on contributors

PIPPA HALL, MD CCFP MEd FCFP, is Assistant Professor, Department

of Family Medicine at the University of Ottawa Institute of Palliative

Care, SCO Health Service.

ERINKEELY, MD FRCP, is Associate Professor, Department of Medicine,

Obstetrics & Gynaecology at the University of Ottawa.

SUZANDOJEIJI, MD FRCPMEd, is Assistant Professor, Physical Medicine

& Rehabilitation at the University of Ottawa.

ANNA BYSZEWSKI, MD FRCP, is Associate Professor, Medicine, at the

University of Ottawa. She is also with the Division of Geriatric Medicine,

the Ottawa Hospital and teaches in the undergraduate and postgraduate

training programmes.

MERIDITH MARKS, MD FRCP MEd, is Associate Professor, Medicine,

at the University of Ottawa.

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