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: